MEDICAID SERVICES MANUAL TRANSMITTAL LETTER June 12, 2014

Transcription

MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
June 12, 2014
TO:
CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM:
MARTA E. STAGLIANO, CHIEF OF PROGRAM INTEGRITY
SUBJECT:
MEDICAID SERVICES MANUAL CHANGES
CHAPTER 100 – MEDICAID PROGRAM
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 100 are proposed to establish
definitions, safeguards, and sanctions regarding confidential information as required by 42 Code
of Federal Regulations (CFR) § 431.301, the State Plan, Section 4.3, and Nevada Revised Statute
(NRS) 422.290. A new section defining confidential information, regulatory references,
limitations on use and disclosure, authorized uses and disclosures, penalties, and data ownership
is proposed.
These changes are effective July 1, 2014.
MATERIAL TRANSMITTED
CL 27936
MATERIAL SUPERSEDED
MTL 48/10
Background and Explanation of Policy Changes,
Clarifications and Updates
Manual Section
Section Title
100.1.d
Authority
Added United States Code (USC), Health Insurance
Portability and Accountability Act (HIPAA),
Health Information and Technology for Economic
and Clinical Health (HITECH), State Plan, and
NRS references. Consolidated confidentiality
references and penalties into a single item.
100.1.e
Authority
Removed language regarding the State Plan and
penalties for the unauthorized disclosure of
confidential information found in NRS 193.170.
100.1.f
Authority
Removed language regarding disclosure of
information regulated by 42 CFR 455.106 Sections
11289(b)(9) and 102(a)(38) of the Social Security
Act, and Nevada Medicaid State Plan Section 4.31.
Page 1 of 2
Manual Section
Section Title
100.2
Confidential
Information
Added a new section defining confidential
information, regulatory references, limitations on
use and disclosure, authorized uses and disclosures,
penalties, and data ownership.
103.5
Safeguarding
Information on
Applicants and
Recipients
Added language regarding confidentiality standards
within 42 CFR § 431.301 – 431.305.
Added language that the provider must safeguard
information.
Added language regarding other disclosures of
information requiring a signed authorization for
disclosure from the participant or designated
representative.
Deleted language regarding authorizations, policies
and procedures, information sharing with the
Department of Health and Human Services (DHHS)
and penalties which were incorporated into Section
100.2.
Added language to reference Section 100.2 (d) for
penalties associated with impermissible use and
disclosure of recipient information.
103.5A
Medical and
Psychological
Information
Deleted language pertaining to sharing information
with the Federal DHHS for purposes directly
related to the furtherance of any Medicaid
programs.
Page 2 of 2
MTL 48/10CL 27936
DRAFT
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY
100
Subject:
100
INTRODUCTION
INTRODUCTION
The mission of the Nevada Division of Health Care Financing and Policy (DHCFP) (Nevada
Medicaid) is to:
a.
purchase and provide quality health care services to low-income Nevadans in the most
efficient manner;
b.
promote equal access to health care at an affordable cost to the taxpayers of Nevada;
c.
restrain the growth of health care costs; and
d.
review Medicaid and other State health care programs to maximize potential federal
revenue.
The purpose of this chapter is to provide an overview and description of the Nevada Medicaid
program administered under the authority of the Department of Health and Human Services
(DHHS), the DHCFP and to establish program policies and procedures.
100.1
AUTHORITY
The Medicaid program in Nevada is authorized to operate under the DHHS, the DHCFP per
Nevada Revised Statutes (NRS), Chapter 422. Nevada Medicaid has a federally approved State
Plan to operate a Medicaid program under Title XIX of the Social Security Act. Regulatory and
statutory oversight of the program is found in Chapter 42 of the Code of Federal Regulations
(CFRs) as well as Chapter 422 of the NRS.
This Medicaid Services Manual (MSM) along with the Medicaid Operations Manual (MOM) is
the codification of regulations adopted by Nevada Medicaid based on the authority of NRS
422.2368, following the procedure at NRS 422.2369. These regulations supplement other
Medicaid program requirements including laws, all applicable Federal requirements and
requirements in the Nevada State Plan for Medicaid. The regulations provide the additional
conditions which limit Medicaid providers’ program participation and payment. The regulations
also provide additional limitations on services provided to Medicaid recipients. The Division
administrator has authority under NRS 422.2356 to establish policies and exceptions to policy for
administration of the programs under Medicaid.
a.
Eligibility for Medicaid assistance is regulated by Section 1901(a) of the Social Security
Act, 42 CFR, Part 435, and Nevada Medicaid State Plan Section 2.1.
b.
Payment for Medicaid services is regulated by Sections 1902(a) and 1923 of the Social
Security Act, 42 CFR, Part 447, and Nevada Medicaid State Plan Sections 4.19 and 4.21
December 15, 2010
MEDICAID PROGRAM
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DRAFT
Section:
100
Subject:
INTRODUCTION
c.
Provider contracts/relations are regulated by 42 CFR 431, Subpart C; 42 CFR Part 483,
and Nevada Medicaid State Plan Section 4.13.
d.
Safeguarding and disclosure of information on applicants and recipients is regulated by 42
United States Code (USC) 1396a(a)(7), and the associated regulations: 42 CFR 431,
Subpart F; the Health Insurance Portability and Accountability Act (HIPAA), and
associated regulations: 45 CFR 160, 162 and 164 and the Health Information Technology
for Economic and Clinical Health (HITECH) Act of 2009; Nevada Medicaid State Plan
Section 4.3, and NRS 422.290; and. Penalties for unauthorized use of disclosure of
confidential information are found within the HITECH Act and NRS 193.170.
e.
Nevada Medicaid State Plan Section 4.3. Penalties for the unauthorized disclosure of
confidential information are found in NRS 193.170.
f.
Disclosure of information is regulated by 42 CFR 455.106, Sections 11289(b)(9) and 102
(a)(38) of the Social Security Act, and Nevada Medicaid State Plan Section 4.31.
g.e.
Prohibition against reassignment of provider claims is found in 42 CFR 447.10 and
Nevada Medicaid State Plan Section 4.21.
h.f.
Exclusion and suspension of providers is found in 42 CFR 1002.203 and Nevada
Medicaid State Plan 4.30.
i.g.
Submission of accurate and complete claims is regulated by CFR 42 CFR 455.18 and
444.19.
j.h.
Nevada Medicaid assistance is authorized pursuant to State of NRS, Title 38, Public
Welfare, Chapter 422, Administration of Welfare Programs.
k.i.
Third Party Liability (TPL) policy is regulated by Section 1902 of the Social Security Act;
42 CFR, Part 433, Subpart D, and the Nevada Medicaid State Plan Section 4.22.
l.j.
Assignment of insurance benefits by insurance carriers is authorized pursuant to State in
NRS, Title 57, Insurance, based on the type of policy.
m.k.
Subrogation of medical payment recoveries is authorized pursuant to NRS 422.293.
n.l.
“Advance Directives” are regulated by 42 CFR 489, Subpart I.
o.m.
Worker’s compensation insurance coverage is required for all providers pursuant to NRS
Chapter 616A through 616B.
December 15, 2010
MEDICAID PROGRAM
Section 100 Page 2
MTL 48/10CL 27936
DRAFT
Section:
100
Subject:
100.2
INTRODUCTION
p.n.
Section 1902(a)(68) of the Social Security Act establishes providers as ‘entities’ and the
requirement to educate their employees, contractors, and agents on false claims recovery,
fraud, and abuse.
q.o.
Offering gifts and other inducements to beneficiaries is prohibited pursuant to Section
1128A(a)(5) of the Social Security Act, enacted as part of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).
r.
HIPAA Privacy Regulations 45 CFR 160 and 164.
s.
HIPAA Security Regulations 45 CFR 142.
t.
HIPAA Standards for Electronic Transaction 45 CFR 160 and 162.
CONFIDENTIAL INFORMATION
All individuals have the right to a confidential relationship with the DHCFP. All information
maintained on Medicaid and CHIP applicants and recipients (“recipients”) is confidential and
must be safeguarded.
Handling of confidential information on recipients is restricted by 42 CFR § 431.301 – 431.305,
The Health Insurance Portability and Accountability Act (HIPAA) of 1996, the HITECH Act of
2009, NRS 422.290, and the Medicaid State Plan, Section 4.3.
Any ambiguity in regarding the definition of confidential information or the release thereof will
be resolved by the DHCFP, which will interpret the above regulations as broadly as necessary to
ensure privacy and security of recipient information.
a.
Definition of Confidential Information
For the purposes of this manual, confidential information includes:
1.
Protected Health Information (PHI)
a.
All individually identifiable health information held or transmitted by the
DHCFP or its business associates, in any form or media, whether
electronic, paper, or oral.
1.
December 15, 2010
“Individually identifiable health information” is information,
including demographic data, that relates to:
•
the individual’s past, present or future physical or mental
health or condition;
•
the provision of health care to the individual;
MEDICAID PROGRAM
Section 100 Page 3
MTL 48/10CL 27936
DRAFT
Section:
100
Subject:
b.
b.
INTRODUCTION
•
the past, present, or future payment for the provision of
health care to the individual; or
•
identifies the individual or for which there is a reasonable
basis to believe it can be used to identify the individual.
Information which does not meet the requirements of de-identified data
defined in 45 CFR 164 § 514(b). This includes all elements of dates (such
as date of service, data dispensed, claim paid date) and identifiers
(including internal control numbers (ICN)).
2.
Information on social and economic condition or circumstances.
3.
Division/Department evaluation of personal information.
4.
Any information received for verifying income eligibility and amount of medical
assistance payments.
5.
Any information received in connection with the identification of legally liable
third party resources.
6.
Medicaid Provider Numbers or other identifiers defined by NRS 603A.040.
Limitations on Use and Disclosure
Disclosures of identifiable information are limited to purposes directly related to State
Plan administration. These activities include, but are not limited to:
December 15, 2010
1.
Establishing eligibility;
2.
Determining the amount of medical assistance; payment activities as defined by
HIPAA;
3.
Determining third party liability;
4.
Providing services (medical and non-medical) for recipients; treatment as defined
by HIPAA;
5.
Conducting or assisting an investigation, prosecution, or civil or criminal
proceeding related to the administration of the Plan;
6.
Health care operations as defined by HIPAA, which includes, but is not limited
to: quality assessment and improvement activities, including case management
and care coordination, competency assurance activities, medical reviews, audits,
MEDICAID PROGRAM
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DRAFT
Section:
100
Subject:
INTRODUCTION
fraud and abuse detection, rate setting, business management and general
administration;
c.
7.
For public interest and benefit activities within limits set under HIPAA, including,
but not limited to, disclosures required by law, public health activities, health
oversight activities, judicial and administrative proceedings, essential government
functions, to comply with worker’s compensation laws, and to avoid serious
threats to the health and safety of recipients and others.
8.
Per authorizations (as defined by HIPAA) from the recipient or their designated
representative.
Release of Information
Except as otherwise provided in these rules, no person shall obtain, disclose or use, or
authorize, permit or acquiesce the use of any client information that is directly or
indirectly derived from the records, files, or communications of the DHCFP, except for
purposes directly connected with the administration of the Plan or as otherwise provided
by federal and state law.
1.
Disclosure is permitted for purposes directly connected with the administration of
Medicaid between covered entities (as defined by HIPAA) for the purposes of
treatment, payment, and health care operations and may, in certain circumstances,
be done in the absence of an authorization or agreement. Such situations include,
but are not limited to: verifying information with Medicaid program staff in other
states to verify eligibility status, disclosure to Medicare staff for coordination of
benefits, or communications with providers for payment activities.
2.
Access to confidential information regarding recipients will be restricted to those
persons or agencies whose standards of confidentiality are comparable to those of
the DHCFP.
•
3.
December 15, 2010
Those standards of confidentiality will be outlined in appropriate
agreements which the DHCFP may require, including business associate
agreements and limited data set use agreements (as defined by HIPAA)
data sharing agreements, and other agreements deemed necessary by the
DHCFP.
In accordance with NRS 232.357, an individual’s health information may be
shared without an Authorization for Disclosure among the divisions of the DHHS
in the performance of official duties and with local governments that help the
Department carry out official duties as long as the disclosure is related to
treatment, payment, or health care operations.
MEDICAID PROGRAM
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MTL 48/10CL 27936
DRAFT
Section:
100
Subject:
d.
INTRODUCTION
4.
The DHCFP will make reasonable efforts to follow HIPAA’s “minimum
necessary” standard when releasing confidential information.
5.
Detailed policies and procedures are found in the DHCFP HIPAA Privacy and
Security Manuals, available for reference in hard copy form in the District Office
and on the DHCFP Intranet.
Penalties
Penalties for inappropriate use and disclosure of confidential information are:
e.
1.
The HITECH Act imposes civil and criminal penalties depending upon the nature
and scope of the violation, which range from $100 to $1.5 million dollars and up
to ten years in prison. This is enforced by the Office for Civil Rights. State
Attorneys General have the authority to bring civil actions on behalf of state
residents for violations of HIPAA Privacy and Security Rules.
2.
Penalties under Nevada state law are found at NRS 193.170.
Ownership
All recipient information contained in the DHCFP records is the property of the DHCFP,
and employees of the DHCFP shall protect and preserve such information from
dissemination except as provided within these rules.
December 15, 2010
MEDICAID PROGRAM
Section 100 Page 6
MTL 26/12CL 27936
DRAFT
Section:
Subject:
PROVIDER RULES AND
REQUIREMENTS
103.4A
103.5
103
d.
provide signed Certification Form, signed provider agreement, copies of written policy
and employee handbook, and documentation staff has been educated, within the required
timeframes;
e.
maintain documentation on the education of staff, and make it readily available for review
by state or federal officials; and
f.
provide requested re-certification within required timeframes to ensure ongoing
compliance.
COVERAGE AND LIMITATIONS
1.
The DHCFP has a program to identify providers that fit the criteria of being an entity, and
will identify additional or new providers fitting the criteria at the beginning of each federal
fiscal year.
2.
The DHCFP will issue a letter advising an entity of the regulations and require the entity
to:
a.
submit a certification stating they are in compliance with the requirements;
b.
sign a provider agreement, or Managed Care Contract Amendment incorporating
this requirement;
c.
provide copies of written policies developed for educating their staff on false
claims, fraud and abuse, and whistleblowers protections under law; and
d.
provide documentation of employees having received the information.
3.
Re-certification of existing entities will be done annually for ongoing compliance.
4.
The DHCFP is authorized to take administrative action for non-compliance through nonrenewal of provider or contract, or suspension or termination of provider status.
SAFEGUARDING INFORMATION ON APPLICANTS AND RECIPIENTS
Federal and state regulations including Health Insurance Portability and Accountability Act
(HIPAA) of 1996, and the Health Information Technology for Economic and Clinical Health
(HITECH) Act of 2009 and confidentiality standards within 42 CFR § 431.301 – 431.305 restrict
the use or disclosure of information concerning applicants and recipients. The information
providers must to be safeguarded includes, but is not limited to, recipient demographic and
eligibility information, social and economic conditions or circumstances, medical diagnosis and
December 12, 2012
MEDICAID PROGRAM
Section 103 Page 5
MTL 26/12CL 27936
DRAFT
Section:
103
Subject:
PROVIDER RULES AND
REQUIREMENTS
services provided, and information received in connection with the identification of legally liable
third party resources.
In accordance with HIPAA, protected health information may be disclosed for the purposes of
treatment, payment, or health care operations without a signed Authorization for Disclosure from
the participant or designated representative. However, mMost other disclosures require a signed
Authorization for Disclosure from the participant or designated representative authorization.
Additional dDetails about allowable uses and disclosures are available to participants in the
DHCFP Notice of Privacy Practices, which is provided to all new Medicaid enrollees.
The DHCFP has implemented detailed policies and procedures to ensure that privacy rules and
security safeguards are observed and practiced by its staff. The DHCFP HIPAA Privacy Manual
is available for reference in hard copy form in the District Office and on the DHCFP Intranet
website.
Additionally, in accordance with Nevada Revised Statute (NRS) 232.357, an individual’s health
information may be shared without an Authorization for Disclosure among the divisions of the
Department of Health and Human Services (DHHS) in the performance of official duties and with
local governments that help the Department carry out official duties as long as the disclosure is
related to treatment, payment, or health care options.
The NRS state the unauthorized disclosure of confidential information is a misdemeanor,
punishable by up to six months in jail and/or up to $1,000 fine. The HITECH Act allows for civil
and criminal penalties of up to $1.5 million, and allows states’ Attorney General to levy fines and
seek attorney’s fees from covered entities on behalf of victims.For penalties associated with
impermissible use and disclosure of recipient information, see Section 100.2(d).
103.5A
MEDICAL AND PSYCHOLOGICAL INFORMATION
1.
Any psychological information received about an applicant or recipient shall not be shared
with that person. This ruling applies even if there is a written release on file from his or
her physician. If the applicant/recipient wishes information regarding his or her
psychological condition, he or she must discuss it with his or her physician.
2.
Medical information, regardless of source, may be shared with the applicant or recipient
upon receipt of their written request. However, any other agency needing copies of
medical information must submit a Medicaid release stating what information is requested
and signed by the applicant or recipient in question or their authorized representative.
The exception to this policy is in the case of a fair hearing. Agency material presented at a
fair hearing constituting the basis of a decision will be open to examination by the
applicant/recipient and/or his or her representative.
December 12, 2012
MEDICAID PROGRAM
Section 103 Page 6
MTL 26/12CL 27936
DRAFT
Section:
Subject:
PROVIDER RULES AND
REQUIREMENTS
103.6
103
3.
Information may be released to the Federal DHHS for purposes directly related to the
furtherance of any of the Medicaid programs.
4.3.
The HIPAA of 1996 Privacy Rules permit the disclosure of a recipient’s health
information without their authorization in certain instances (e.g. for treatment, payment,
health care operations, or emergency treatment; to make appointments to the DHCFP
business associates; to recipient’s personal representatives; as required by law; for the
good of public health; etc.)
5.4.
The HIPAA Privacy Rules assure the recipient certain rights regarding their health
information (e.g. to access/copy, to correct or amend, restrict access, receive an
accounting of disclosures, and confidential communications).
6.5.
A provider may not disclose information concerning eligibility, care or services given to a
recipient except as specifically allowed by state and federal laws and regulations.
NON-DISCRIMINATION AND CIVIL RIGHTS COMPLIANCE
Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age
Discrimination Act of 1975 and the Americans with Disabilities Act (ADA) of 1990, prohibit
discrimination on the basis of race, color, national origin, religion, sex, age, disability (including
AIDS or related conditions) or any other class status protected by federal or state law or
regulation by programs receiving Federal Financial Participation (FFP). The DHCFP service
providers must comply with these laws as a condition of participation in the Nevada Medicaid
program in offering or providing services to the Division’s program beneficiaries or job
applicants and employees of the service providers.
All service providers are required to follow and abide by the DHCFP’s nondiscrimination
policies. In addition, hospitals, nursing facilities and Intermediate Care Facility for the Mentally
Retarded (ICF/MRs) will be reviewed by Medicaid periodically to assure they follow
requirements specific to them. Requirements for compliance:
a.
Hospitals, nursing facilities and ICF/MRs must designate an individual as having
responsibility for civil rights coordination, handling grievances and assuring compliance
with all civil rights regulations. This person will serve as coordinator of the facility’s
program to achieve nondiscrimination practices, as well as be the liaison with Medicaid
for Civil Rights compliance reviews.
b.
Notices/signs must be posted throughout a facility, as well as information contained in
patient and employee handouts, which notifies the public, patients and employees that the
facility does not discriminate with regards to race, color, national origin, religion, gender,
age, or disability (including AIDS and related conditions) in:
December 12, 2012
MEDICAID PROGRAM
Section 103 Page 7
TRANSMITTAL LETTER
June 12, 2014
TO:
FROM:
SUBJECT:
CHAPTER 600 – PHYSICIAN SERVICES
Revisions to MSM Chapter 600 are being proposed to clarify language pertaining to Rural
Health Clinics/ Federally Qualified Health Centers (RHCs/FQHCs) and their encounter payment
policy, as well as, an updated list of medical professionals who can provide services. Language
was added regarding the coverage guidelines for our Teaching Physician policy.
Throughout the chapter, grammar, punctuation, and capitalization changes were made,
duplications removed, acronyms used and standardized, and language reworded for clarity.
Renumbering and re-arranging of sections was necessary.
CL 27847
MATERIAL SUPERSEDED
MTL 25/10, 39/10, 32/11, 08/12, 05/13
Manual Section
Section Title
603.1A.3
Coverage and
Limitations
603.5
Annual Gynecologic
Exam
Updated Title to Annual Gynecologic Exam.
603.8.A.1
Physicians Services
Provided in
Outpatient Clinics
Clarified language pertaining to the
reimbursable encounter per day limitation.
Added verbiage so that the Division of Health Care
Financing and Policy (DHCFP) follows the
Medicare coverage guidelines for Teaching
Physicians, Interns, and Residents.
Updated list of medical professionals.
Page 1 of 2
one
Manual Section
Section Title
603.8.A.2.a.1
Physicians Services
Provided in
Outpatient Clinics
Added core visits to include medical and dental
offices.
603.8.A.2.c
Physicians Services
Provided in
Outpatient Clinics
Revised language to up to two times a calendar year
the RHC/FQHC may bill for additional
reimbursement along with the encounter rate.
603.8.A.3
Physicians Services
Provided in
Outpatient Clinics
Removed language that Medicare requires these
physicians to bill usual and customary fee.
Medicaid will apply the established core visit rate
as the billed charges on the remittance advice (RA)
received with any Medicaid payment.
Added language for billing instructions for RHCs/
FQHCs to Billing Manual for Provider Type 17.
603.8.B
Policy #6-09
Physicians Services
Provided in
Outpatient Clinics
Prior Authorization Is
Not Required
Removed section on Indian Health Programs (IHP).
Added reference to MSM Ch 3000 regarding IHP.
Removed language requiring prior authorization.
Page 2 of 2
MTL 05/13CL 27847
DRAFT
Section:
601
Subject:
601
AUTHORITY
AUTHORITY
A.
Medicaid is provided in accordance with the requirements of Title 42 Code of Federal
Regulation (CFR) Part 440, Subpart A – Definitions, Subpart B and sections 1929 (a),
1902 (e), 1905 (a), 1905 (p), 1915, 1920, and 1925 of the Act. Physician’s services are
mandated as a condition of participation in the Medicaid Program Nevada Revised Statute
(NRS) 630A.220.
B.
Regulations for services furnished by supervising physicians in teaching settings are found
in 42 CFR Part 415; Subpart D. Key portion is defined in [Reg. 415.172(a)].
C.
The State Legislature sets forth standards of practice for licensed professionals in the
Nevada Revised Statutes (NRS) for the following Specialists:
May 17, 2013
1.
NRS Chapter 634 - Chiropractic;
2.
NRS Chapter 629 - Healing Arts Generally;
3.
NRS Chapter 632 - Nursing;
4.
NRS Chapter 630 - Physicians and Physician Assistants and Practitioners of
Respiratory Care General Provisions;
5.
NRS Chapter 633 - Osteopathic Medicine; and
6.
NRS Chapter 635 - Podiatry.
PHYSICIAN SERVICES
Section 601 Page 1
MTL 05/13
Section:
603
Subject:
POLICY
603
PHYSICIANS AND LICENSED PROFESSIONAL POLICY
603.1
PHYSICIAN’S ROLE IN RENDERING SERVICES
603.1A
1.
2.
The Division of Health Care Financing and Policy (DHCFP) reimburses for covered
medical services that are reasonable and medically necessary, ordered or performed by a
physician or under the supervision of a physician, and that are within the scope of practice
of their prognosis as defined by state law. The physician must:
a.
Examine the recipient;
b.
Make a diagnosis;
c.
Establish a plan of care; and
d.
Document these tasks in the appropriate medical records for the recipient before
submitting claims for services rendered. Documentation is subject to review by a
state authority or contracted entity.
Services must be performed by the physician or by a licensed professional working under
the personal supervision of the physician.
a.
b.
May 17, 2013
The following are examples of services that are considered part of the billable visit
when it is provided under the direct and professional supervision of the physician:
1.
An injection of medication;
2.
Diagnostic test like an EKG;
3.
Blood pressure taken and recorded between MD visits;
4.
Dressing changes; and
5.
Topical application of fluoride.
Physicians or their designee may not bill Medicaid for services provided by, but
not limited to, the following:
1.
Another Provider;
2.
Psychologist;
PHYSICIAN SERVICES
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MTL 39/10CL 27847
DRAFT
Section:
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Subject:
3.
POLICY
3.
Medical Resident (unless teaching physician);
4.
Therapist: Physical Therapist (PT), Occupational Therapist (OT), Speech
Therapist (SP), Respiratory Therapist (RT);
5.
Counselor/Social Worker;
6.
Nurse Practitioner (other than diagnostic tests done in the office which
must be reviewed by the physician);
7.
Physician Assistants; and
8.
Certified Registered Nurse Anesthetist.
Teaching Physicians
Medicaid covers teaching physician services when they participate in the recipient’s care.
The teaching physician directs no more than four residents at any given time and is in such
proximity as to constitute immediate availability. The teaching physician’s documentation
must show that he or she either performed the service or was physically present while the
resident performed the key and critical portions of the service. Documentation must also
show participation of the teaching physician in the management of the recipient and
medical necessity for the service. When choosing the appropriate procedure code to bill,
consideration is based on the time and level of complexity of the teaching physician, not
the resident’s involvement or time.
The DHCFP follows Medicare coverage guidelines for Teaching Physicians, Interns, and
Residents.
4.
October 13, 2010
Out-of-State Physicians
a.
If a prior authorization is required for a specific outpatient or inpatient service instate, then a prior authorization is also required for an out-of-state outpatient or
inpatient service by the Nevada Medicaid Quality Improvement Organization
(QIO)-like vendor. The QIO-like vendor’s determination will consider the
availability of the services within the State. If the recipient is being referred out-ofstate by a Nevada physician, the Nevada physician is required to obtain the prior
authorization and complete the referral process. Emergency care will be
reimbursed without prior authorization.
b.
When medical care is unavailable for Nevada recipients residing near state borders
(catchments areas) the contiguous out-of-state physician/clinic is considered the
pPrimary cCare pPhysician (PCP). All in-state benefits and/or limitations apply.
PHYSICIAN SERVICES
Section 603 Page 2
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DRAFT
Section:
603
Subject:
c.
5.
POLICY
All service physicians must enroll in the Nevada Medicaid program prior to billing
for any services provided to Nevada Medicaid recipients. (See Medicaid Services
Manual (MSM) Chapter 100.)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program
The EPSDT program provides preventative health care to recipients (from birth through
age 20 years) eligible for medical assistance. The purpose of the EPSDT program is the
prevention of health problems through early detection, diagnosis, and treatment. The
required screening components for an EPSDT examination are to be completed according
to the time frames on a periodicity schedule that was adopted by the American Academy
of Pediatrics and the Division of Health Care Financing and Policy (DHCFP). See MSM
Chapter 1500 – Healthy Kids.
603.2
PHYSICIAN OFFICE SERVICES
Covered services are those medically necessary services when the physician either examines the
patient in person or is able to visualize some aspect of the recipient’s condition without the
interposition of a third person’s judgment. Direct visualization would be possible by means of Xrays, electrocardiogram and electroencephalogram tapes, tissue samples, etc.
Telehealth services are also covered services under the DHCFP. See MSM Chapter 3400 for the
complete coverage and limitations for Telehealth.
a.
Consultation Services
A consultation is a type of evaluation and management service provided by a physician
and requested by another physician or appropriate source, to either recommend care for a
specific condition or problem or determine whether to accept responsibility for ongoing
management of the patient’s entire care. A consultant may initiate diagnostic and/or
therapeutic services at the same or subsequent visit. The written or verbal request for
consult may be made by a physician or other appropriate source and documented in the
patient’s medical record by either the consulting or requesting physician or appropriate
source. The consultant’s opinion and any services that are ordered or performed must also
be documented in the patient’s medical record and communicated by written report to the
requesting physician or appropriate source. When a consultant follows up on a patient on a
regular basis, or assumes an aspect of care on an ongoing basis, the consultant becomes a
manager or co-manager of care and submits claims using the appropriate hospital or office
codes.
1.
May 17, 2013
When the same consultant sees the same patient during subsequent admissions, the
physician is expected to bill the lower level codes based on the medical records.
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b.
A confirmatory consultation initiated by a patient and/or their family without a
physician request is a covered benefit. Usually, requested second opinions
concerning the need for surgery or for major non-surgical diagnostic and
therapeutic procedures (e.g., invasive diagnostic techniques such as cardiac
catheterization and gastroscopy) third opinion will be covered if the first two
opinions disagree.
New and Established Patients
1.
May 17, 2013
POLICY
The following visits are used to report evaluation and management services
provided in the physician’s office or in an outpatient or other ambulatory facility:
a.
Minimal to low level visits - Most patients should not require more than
nine office or other outpatient visits at this level by the same physician or
by physicians of the same or similar specialties in a three month period. No
prior authorization is required.
b.
Moderate visits - Generally, most patients should not require more than 12
office or other outpatient visits at this level by the same physician or by
physicians of the same or similar specialties in a 12 month calendar year.
No prior authorization is required.
c.
High severity visits - Generally, most patients should not require more than
two office or other outpatient visits at this level by the same physician or
by physicians of the same or similar specialties in a 12 month period. Any
exception to the limit requires prior authorization.
2.
Documentation in the patient’s medical record must support the level of service
and/or the medical acuity which requires more frequent visits and the resultant
coding. Documentation must be submitted to Medicaid upon request. A review of
requested reports may result in payment denial and a further review by Medicaid’s
Surveillance and Utilization Review subsystem (SURS).
3.
Medicaid does not reimburse physicians for telephone calls between physicians
and patients (including those in which the physician gives advice or instructions to
or on behalf of a patient) except documented psychiatric treatment in crisis
intervention (e.g. threatened suicide).
4.
New patient procedure codes are not payable for services previously provided by
the same physician or another physician of the same group practice, within the past
three years.
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5.
Some of the procedures or services listed in the Current Procedural Terminology
(CPT) code book are commonly carried out as an integral component of a total
service or procedure and have been identified by the inclusion of the term
“separate procedure”. Do not report a designated “separate procedure” in addition
to the code for the total procedure or service of which it is considered an integral
component. A designated “separate procedure” can be reported if it is carried out
independently or is considered to be unrelated or distinct from other
procedures/services provided at the same time.
6.
Physical therapy administered by a physical therapist on staff or under contract in
the physician’s office requires a prior authorization before rendering service.
If the physician bills for physical therapy, the physician, not the physical therapist,
must have provided the service.
A physician may bill an office visit in addition to physical therapy, on the same
day in the following circumstances:
a.
A new patient examination which results in physical therapy on the same
day;
b.
An established patient with a new problem or diagnosis; and/or
c.
An established patient with an unrelated problem or diagnosis.
Reference MSM Chapter 1700 for physical therapy coverage and limitations.
May 17, 2013
7.
Physician administered drugs are a covered benefit under Nevada Medicaid.
Reference MSM Chapter 1200 for coverage and limitations.
8.
Non-Covered Physician services
a.
Investigational or experimental procedures not approved by the Food and
Drug Administration (FDA).
b.
Reimbursement for clinical trials and investigational studies.
c.
Temporomandibular Joint (TMJ) related services (see MSM Chapter 1000Dental Services).
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Referrals
When a prior authorization is required for either in-state or out-of-state services, the
referring physicians are responsible for obtaining a prior authorization from the QIO-like
vendor. If out-of-state services are medically necessary, the recipient must go to the
nearest out-of-state provider for services not provided in-state. It is also the responsibility
of the referring physician to obtain the authorization for a recipient to be transferred from
one facility to another, either in-state or out-of-state.
d.
Hospice
Physicians are responsible for obtaining prior authorization for all services not related to
the morbidity that qualifies the recipient for Hospice. Physicians should contact Hospice
to verify qualifying diagnosis and treatment. Reference MSM Chapter 3200 for coverage
and limitations.
e.
Home Health Agency (HHA)
Home Health Agency services provide periodic nursing care along with skilled and nonskilled services under the direction of a qualified physician. The physician is responsible
for writing the orders and participating in the development of the plan of care. Reference
MSM Chapter 1400 for coverage and limitations.
f.
Laboratory
Reference MSM Chapter 800 for coverage and limitations for laboratory services.
g.
Diagnosic Testing
Reference MSM Chapter 300 for coverage and limitations for diagnostic services.
603.2A
AUTHORIZATION PROCESS
Certain physician services require prior authorization (PA). There is no PA prior authorization
requirement for allergy testing, allergy injections or for medically necessary minor office
procedures unless specifically noted in this chapter. Contact the QIO-like vendor for prior
authorization information.
603.3
FAMILY PLANNING SERVICES
State and federal regulations grant the right for eligible Medicaid recipients of either sex of childbearing age to receive family planning services provided by any participating clinics, physician,
physician’s assistant, nurse practitioner, certified nurse midwife, or pharmacy.
December 14, 2011
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POLICY
i.
Contraceptive dermal patch; and/or
j.
Contraceptive injection, other.
Vasectomy or tubal ligation (age 21 and over). In accordance with federal
regulations, the recipient must fill out a consent form at least 30 days prior to the
procedure. The physician is required to send the consent form to the fiscal agent
with the initial claim. (See Attachment-B for consent forms).
b.
Medicaid has removed all barriers to family planning counseling/education provided by
qualified physicians. (e.g., Physicians, Rural Health Clinics/Federally Qualified Clinics,
Indian Health Services/Tribal Clinics, and Home Health Agencies, etc.) The physician
must provide adequate counseling and information to each recipient when they are
choosing a birth control method. If appropriate, the counseling should include the
information that the recipient must pay for the removal of any implants when the removal
is performed after Medicaid eligibility ends.
c.
Family planning education is considered a form of counseling intended to encourage
children and youth to become comfortable discussing issues such as sexuality, birth
control and prevention of sexually transmitted disease. It is directed at early intervention
and prevention of teen pregnancy. Family planning services may be provided to any
eligible recipient of childbearing age (including minors who can be considered to be
sexually active).
d.
Family Planning Services are not covered for those recipients, regardless of eligibility,
whose age or physical condition precludes reproduction.
MATERNITY CARE
Maternity Care is a program benefit which includes antepartum care, delivery, and postpartum
care provided by a physician and/or a nurse midwife. For women who are eligible for pregnancyrelated services only, their eligibility begins with enrollment and extends up to sixty (60) days
postpartum including the month in which the 60th day falls. She is eligible for pregnancy related
services only which are prenatal care and postpartum services, including family planning
education and services. Recipients under age 21, and eligible for pregnancy only, are not entitled
to EPSDT services.
It is the responsibility of the treating physician to employ a care coordination mechanism to
facilitate the identification and treatment of high risk pregnancies. “High Risk” is defined as a
probability of an adverse outcome to the woman and/or her baby greater than the average
occurrence in the general population.
May 17, 2013
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For those females enrolled in a managed care program, the Managed Care Organization (MCO)
physicians are responsible for making referrals for early intervention and case management
activities on behalf of those women. Communication and coordination between the physicians,
service physicians, and MCO staff is critical to promoting optimal birth outcomes.
a.
Stages of Maternity Care
1.
Antepartum care includes the initial and subsequent history, physical
examinations, recording of weight, blood pressures, fetal heart tones, routine
chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to
36 weeks gestation, and weekly visits until delivery totaling approximately 13
routine visits. Any other visits or services within this time period for non-routine
maternity care should be coded separately. Antepartum care is not a covered
benefit for illegal non-U.S. citizens.
2.
Delivery services include admission to the hospital, the admission history and
physical examination, management of uncomplicated labor, vaginal delivery (with
or without an episiotomy/forceps), or cesarean delivery. Medical problems
complicating labor and delivery management may require additional resources and
should be identified by utilizing the codes in the (CPT) Medicine and Evaluation
and Management Services section in addition to codes for maternity care.
a.
In accordance with standard regulations, vaginal deliveries with a hospital
stay of three days or less and C-section deliveries with a hospital stay of
four days or less, do not require prior authorization. Reference MSM
Chapter 200 for inpatient coverage and limitations.
b.
Non-Medically Elective Deliveries
1.
Reimbursement for Avoidable C-Sections
To make certain that cesarean sections are being performed only in
cases of medical necessity, the DHCFP will reimburse physicians
for performing cesarean sections only in instances that are
medically necessary and not for the convenience of the provider or
patient. Elective or avoidable cesarean sections will be reviewed to
determine medical necessity. Those cesarean sections that do not
qualify for medical necessity will be reimbursed at the same rate as
a vaginal delivery.
May 17, 2013
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2.
Early Induction of Labor (EIOL)
The American Congress of Obstetricians and Gynecologists
(ACOG) issued a Revision of Labor Induction Guidelines in July
2009, citing, “The rate of labor induction in the US has more than
doubled since 1990. In 2006, more than 22% (roughly 1one out of
every 5 five) of all pregnant women had their labor induced.” The
revision further states, “… the ACOG recommendations say the
gestational age of the fetus should be determined to be at least 39
weeks or that fetal lung maturity must be established before
induction.”
Research shows that early elective induction (<39 weeks gestation)
has no medical benefit and may be associated with risks to both the
mother and infant. Based upon these recommendations, the
DHCFP will require prior authorization for hospital admissions for
EIOL prior to 39 weeks to determine medical necessity.
The DHCFP encourages providers to review the toolkit compiled
by The March of Dimes, The California Maternity Quality Care
Collaborative, and The California Department of Public Health,
Maternal, Child and Adolescent Health Division. The aim of the
toolkit is to offer guidance and support to OB/GYN providers,
clinical staff, hospitals and healthcare organizations in order to
develop quality improvement programs which will help to
eliminate elective deliveries <39 weeks gestation.
c.
June 1, 2012
Physician responsibilities for the initial newborn examination and
subsequent care until discharge includes the following:
1.
The initial physical examination done in the delivery room is a
rapid screening for life threatening anomalies that may require
immediate billable attention.
2.
Complete physical examination is done within 24 hours of delivery
but after the 6six hour transition period when the infant has
stabilized. This examination is billable.
3.
Brief examinations should be performed daily until discharge. On
day of discharge, physician may bill either the brief examination or
discharge day code, not both.
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b.
4.
Routine circumcision of a newborn male is not a Medicaid benefit.
Obtain authorization from the QIO-like vendor for covered
medically necessary (e.g., phimosis) circumcision prior to the
service.
5.
If a newborn is discharged less than 24 hours after delivery,
Medicaid will reimburse newborn follow-up visits in the
physician’s office up to 4four days post delivery.
6.
In accordance with Nevada Revised Statute (NRS) 442.540, all
newborns must receive hearing screenings. This testing and
interpretation is included in the facility’s per diem rate.
3.
Postpartum care includes hospital and office visits following vaginal or cesarean
section delivery. Women, who are eligible for Medicaid on the last day of their
pregnancy, remain eligible for all pregnancy related and postpartum medical
assistance including family planning education and services for 60 days
immediately following the last day of pregnancy. Pregnancy related only eligible
women are not covered for any Medicaid benefits not directly related to their
pregnancy.
4.
Reimbursement: If a physician provides all or part of the antepartum and/or
postpartum care, but does not perform delivery due to termination of the pregnancy
or referral to another physician, reimbursement is based upon the antepartum and
postpartum care CPT codes. A global payment will be paid to the delivering
obstetrician, when the pregnant woman has been seen seven (7) or more times by
the delivering obstetrician. If the obstetrician has seen the pregnant woman less
than seven (7) times with or without delivery, the obstetrician will be paid
according to the Fee-for-Service (FFS) visit schedule using the appropriate CPT
codes. For MCO exceptions to the global payment please refer to MSM Chapter
3600. Please refer to MSM Chapter 700 – Rates and Cost Containment for more
information.
Maternal Diagnostic Testing
1.
May 17, 2013
POLICY
Fetal Non-Stress testing (NST) is the primary means of fetal surveillance for most
conditions that place the fetus at high risk for placental insufficiency. The test is
classified as reactive if, during a 20- minute period, at least 2 two accelerations of
the fetal heart rate are present, each at least 15 beats above the baseline rate and
lasting at least 15 seconds. The test is non-reactive if fewer than 2two such
accelerations are present in a 45-minute period.
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POLICY
There is a difference in placing a patient on a monitor to see if she is contracting,
versus performing a complete NST. Therefore, when billing for an NST, the
following must be included in the final interpretation:
a.
patient name;
b.
date of service;
c.
gestational age;
d.
diagnosis;
e.
indication for test;
f.
interpretation;
g.
fetal heart rate baseline;
h.
periodic changes;
i.
recommended follow up; and
j.
provider signature
2.3.
Medicaid recognizes the following NST schedule (presuming fetal viability has
been reached):
DIAGNOSIS
Testing interval
Prior stillbirth
Weekly (starting at 32-35 weeks)
Maternal medical conditions:
Weekly at 32-35 weeks (earlier if indicated), then twice
Insulin-dependent diabetes
weekly
Hypertension
Weekly (starting at 32-35 weeks or when indicated)
Renal disease
Collagen vascular disease
Obstetric complications:
Premature rupture of membranes
At admission to hospital
Preeclampsia
Twice weekly if stable
Discordant twins
Twice weekly
Intrauterine growth retardation
Twice weekly
Postdates pregnancy
Twice weekly from 41.5 weeks
Fetal abnormalities:
Diminished movement
As needed
Decreased amniotic fluid volume
Twice weekly
Labor
As needed
July 14, 2010
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c.
POLICY
Home uterine activity monitoring service may be ordered for a recipient who has a
current diagnosis of pre-term labor and a history of pre-term labor/delivery with
previous pregnancies. Reference Nevada Medicaid’s Durable Medical Equipment
(DME) Coverage and Limitation Guidelines (MSM, Chapter 1300).
Maternal/Fetal Diagnostic Studies
Obstetrical ultrasound of a pregnant uterus is a covered benefit of Nevada Medicaid when
it is determined to be medically necessary. Ultrasound for the purpose of sex
determination is not a covered benefit. Per CPT guidelines, an obstetrical ultrasound
includes determination of the number of gestational sacs and fetuses, gestational sac/fetal
structure, qualitative assessment of amniotic fluid volume/gestational sac shape, and
examination of the maternal uterus and adnexa. The patient’s record must clearly identify
all high risk factors and ultrasound findings.
A first trimester ultrasound may be covered to confirm viability of the pregnancy, to rule
out multiple births and better define the Estimated Date of Confinement (EDC).
One second trimester ultrasound with detailed anatomic examination is considered
medically necessary per pregnancy to evaluate the fetus for known or suspected fetal
anatomic abnormalities.
It is policy to perform ultrasound with detailed fetal anatomic study only on those
pregnancies identified as being at risk for structural defects (e.g. advanced maternal age,
prior anomalous fetus, medication exposure, diabetes, etc.).
The use of a second ultrasound in the third trimester for screening purposes is not covered.
Subsequent ultrasounds, including biophysical profiles should clearly identify the findings
from the previous abnormal scan and explain the high-risk situation which makes repeated
scans medically necessary. The patient’s record must clearly identify all high risk factors
and ultrasound findings.
For a list of maternal/fetal diagnostic codes, please refer to the billing manual.
NOTE: The use of the diagnosis of “Supervision of High Risk Pregnancy” or
“Unspecified Complications of Pregnancy” without identifying the specific high
risk or complication will result in non-payment.
May 17, 2013
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hemoglobinopathies, cyanotic heart disease, systemic lupus erythematosus)
or substance abuse;
2.
603.4B
8.
Suspected macrosomia; or
9.
Intrauterine Growth Retardation-IUGR ( ≤ 15th percentile of the combined
biometrical parameters-biparietal diameter, head circumference, abdominal
circumference, head/abdominal circumference ration, length of femur and
length of humerus, and estimated fetal weight).
c.
Confirmation of the EDC when clinical history and exam are uncertain. In general,
a single ultrasound performed between 14 and 24 weeks is sufficient for this
purpose.
d.
Diagnosis of “decreased fetal movement” (accompanied by other clinical data, i.e.
abnormal kick counts).
e.
Follow up ultrasounds which may be considered medically necessary if the study
will be used to alter or confirm a treatment plan.
Noncoverage - Ultrasound is not covered when it fails to meet the medical necessity
criteria listed above or for the reasons listed below:
a.
When the initial screening ultrasound (regardless of trimester) is within normal
limits or without a significant second diagnosis.
b.
When used solely to determine the sex of the neonate, or to provide the mother
with a picture of the baby.
PROVIDER RESPONSIBILITY
1.
May 17, 2013
For repeat evaluations, documentation should include, at a minimum:
a.
Documentation of the indication for the study (abnormality or high risk factors).
b.
Crown-rump length (CRL).
c.
Biparietal diameter (BPD).
d.
Femur length (FL).
e.
Abdominal circumference (AC).
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f.
Re-evaluation of organ system.
g.
Placental location.
h.
Number of fetuses (embryos).
i.
Amniotic fluid volume assessment (qualitative or quantitative).
j.
1.
Oligohydramnios.
2.
Polyhydramnios.
Intrauterine growth restriction (IUGR).
The following table offers a guideline for biophysical profile.
BPP SCORE
10/10 or 8/10 with normal AFV*
ASSESSMENT
Low risk
8/10 with abnormal AFV*
6/10 with normal AFV*
6/10 with abnormal AFV*
0/10, 2/10, 4/10
High Risk
Equivocal Result
High Risk
High Risk
MANAGEMENT
 for high risk pregnancies
 may repeat in 1 week
re-eval for AVF* within 24 hours**
may repeat in 24 hours**
may repeat in 24 hours**
intervention or delivery
*AFV – Amniotic Fluid Volume
**The repeat biophysical profile must clearly indicate the previous abnormal result and reason for repeating this
exam.
Abortion/Termination of pregnancy
May 17, 2013
a.
Reimbursement is available for an induced abortion to save the life of the mother,
only when a physician has attached a signed certification to the claim that on the
basis of his/her professional judgment, and supported by adequate documentation,
the life of the mother would be endangered if the fetus were carried to term. (See
Attachment G or substitute any form that includes the required information.)
b.
Reimbursement is available for induced abortion services resulting from a sexual
assault (rape) or incest. A copy of the appropriate certification statement must be
attached to the claim (See Attachment H or substitute any form that includes the
required information). The Nevada mandatory reporting laws related to child abuse
and neglect must be followed for all recipients under the age of 18 and physicians
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are still required to report the incident to Child Protective Services (CPS) through
the Division of Child and Family Services (DCFS) or, in some localities, through
County Child Welfare Services.
c.
Reimbursement is available for the treatment of incomplete, missed, or septic
abortions under the criteria of medical necessity. The claim should support the
procedure with sufficient medical information and by diagnosis. No certification or
prior authorization is required.
NOTE:
3.
Any abortion that involves inpatient hospitalization requires a prior
authorization from the QIO-like vendor. See MSM Chapter 200 for
further information.
Hysterectomy
According to federal regulations, a hysterectomy is not a family planning (sterilization)
procedure. Hysterectomies performed solely for the purpose of rendering a female
incapable of reproducing are not covered by Medicaid. All hysterectomy certifications
must have an original signature of the physician certifying the forms. A stamp or initial by
billing staff is not acceptable. Payment is available for hysterectomies as follows:
July 14, 2010
a.
Medically Necessary – A medically necessary hysterectomy may be covered only
when the physician securing the authorization to perform the hysterectomy has
informed the recipient or her representative, if applicable, orally and in writing
before the surgery is performed that the hysterectomy will render the recipient
permanently incapable of reproducing, and the recipient or her representative has
signed a written Acknowledgment of Receipt of Hysterectomy Information Form
(See Attachment E, at the end of this chapter for a sample of the form).
b.
When a hysterectomy is performed as a consequence of abdominal exploratory
surgery or biopsy, the Acknowledgment of Receipt of Hysterectomy Information
Form is also required. Therefore, it is advisable to inform the recipient or her
authorized representative prior to the exploratory surgery or biopsy.
c.
Emergency – The physician who performs the hysterectomy certifies in writing
that the hysterectomy was performed under a life-threatening emergency situation
in which the physician determined prior acknowledgment was not possible. The
completed Physician Statement must be attached to each claim form related to the
hysterectomy (e.g., surgeon, hospital, and anesthesiologist). The physician must
include a description of the nature of the emergency and this certification must be
dated after the emergency. The recipient does not have to sign this form. An
example of this situation would be when the recipient is admitted to the hospital
through the emergency room for immediate medical care and the recipient is
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unable to understand and respond to information pertaining to the acknowledgment
of receipt of hysterectomy information due to the emergency nature of the
admission.
603.5
d.
Sterility – The physician who performs the hysterectomy certifies in writing that
the recipient was already sterile at the time of the hysterectomy and needs to
include a statement regarding the cause of the sterility. The completed Physician
Statement must be attached to each claim form related to the hysterectomy. The
recipient does not have to sign the form. (For example, this form would be used
when the sterility was postmenopausal or the result of a previous surgical
procedure.)
e.
Hysterectomies Performed During a Period of Retroactive Eligibility –
Reimbursement is available for hysterectomies performed during periods of
retroactive eligibility. In order for payment to be made in these cases, the physician
must submit a written statement certifying one of the following conditions was
met:
1.
He or she informed the woman before the operation the procedure would
make her sterile. In this case, the recipient and the physician must sign the
written statement; or,
2.
The woman met one of the exceptions provided in the physician’s
statement. In this case, no recipient signature is required. Claims submitted
for hysterectomies require the authorization number for the inpatient
admission. The authorization process will ensure the above requirements
were met. Payment is not available for any hysterectomy performed for the
purpose of sterilization or which is not medically necessary.
ANNUAL GYNECOLOGIC EXAM
Nevada Medicaid reimburses providers for annual preventative gynecological examinations,
along with the collection of a Pap smear, for women who are or have been sexually active or are
age 18 or older. The examinations include breast exam, pelvic exam and tissue collection (also
known as Pap smear).
603.6
CHIROPRACTIC SERVICES POLICY
Medicaid will pay for a chiropractic manual manipulation of the spine to correct a subluxation if
the subluxation has resulted in a neuro-musculoskeletal condition for which manipulation is the
appropriate treatment.
July 14, 2010
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Services are limited to Medicaid eligible children under 21 years of age and Qualified Medicare
Beneficiaries (QMB’s).
a.
b.
Prior authorization is not required for:
1.
Four or less chiropractic office visits (emergent or non-emergent) for children
under 21 years of age in a rolling 365 days. The visits must be as a direct result of
an EPSDT screening examination, diagnosing acute spinal subluxation.
2.
Chiropractic services provided to a QMB recipient.
Prior authorization is required for:
Chiropractic visits for children under 21 years of age whose treatment exceeds the four
visits. The physician must contact the Nevada Medicaid QIO-like vendor for prior
authorization.
603.7
PODIATRY
Podiatry services are those services provided by health professionals trained to diagnose and treat
diseases and other disorders of the feet. A podiatrist performs surgical procedures and prescribes
corrective devices, medications and physical therapy. For Nevada Medicaid recipient’s podiatric
services are limited to Qualified Medicare Beneficiary recipients and Medicaid eligible children
referred as the result of a Healthy Kids (EPSDT) screening examination.
a.
May 17, 2013
Prior Authorization
1.
Prior authorization is not required for podiatric office visits provided for children
as a direct result of a Healthy Kids (EPSDT) screening examination).
2.
Policy limitations regarding diagnostic testing (not including x-rays), therapy
treatments and surgical procedures which require prior authorization, remain in
effect. Orthotics ordered as a result of a podiatric examination or a surgical
procedure must be billed using the appropriate Centers for Medicare and Medicaid
Services (CMS) Healthcare Common Procedural Coding System (HCPCS) code.
Medicaid will pay for the orthotic in addition to the office visit.
3.
Prior authorization is not required for Podiatry services provided to a QMB or
QMB/MED recipient. Medicaid automatically pays the co-insurance and
deductible up to Medicaid’s maximum reimbursement after Medicare pays. If
Medicare denies the claim, Medicaid will also deny payment.
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Non Covered Services
Preventive care including the cleaning and soaking of feet, the application of creams to
insure skin tone, and routine foot care are not covered benefits. Routine foot care includes
the trimming of nails, cutting or removal of corns and calluses in the absence of infection
or inflammation.
603.8
PHYSICIAN SERVICES PROVIDED IN OUTPATIENT CLINICS
A.
Rural Health Clinic/Federally Qualified Health CenterClinic (RHC/FQHC)
1.
Medicaid covered Ooutpatient services provided in RHC’s and/or FQHC’s are
reimbursed at an all inclusive per recipient per encounter rate. Regardless of the
number or types of providers seen, only one encounter is reimbursable per day.
This all-inclusive rate includes any one or more of the following services and
medical professionals:
May 17, 2013
a.
Physician (MD/DO)
b.
Dentist
c.
Advance Practice Registered Nurse
d.
Physician Assistant
e.
Certified Registered Nurse Anesthetist
f.
Certified Registered Nurse Midwife
g.
Psychologist
h.
Licensed Clinical Social Worker
i.
Registered Dental Hygienist
j.
Podiatrist
k.
Radiology
l.
Optometrist
m.
Optician (including dispensing of eyeglasses)
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Clinical Laboratory
Physician/(MD/DO)
Nurse Anesthetist
Radiology
2.
Podiatrist
Nurse Mid-Wife
Clinical Laboratory
Dentist
Optometrist
Advanced
Practitioner of
Nursing
Psychologist
Physician Assistant
Opticians – Including
eyeglasses dispensed
Encounter codes are used for primary care services provided by the FQHCs and
RHCs in the following areas:
a.
Core visits include the following:
1.
Medical and dental Ooffice visits, patient hospital visits, injections
and oral contraceptives;
2.
Women’s
annual
examinations; and
3.
Colorectal screenings.
b.
Home visit.
c.
Family planning education
preventative
preventive
gynecological
Up to two times a calendar year the RHC/FQHC receives an additional
may bill for additional reimbursement along with the encounter rate. For
billing instructions for RHC/FQHCs, please refer to the billing manual for
Provider Type 20.
B.
3.
Medicare requires these physicians to bill usual and customary fee. Medicaid will
apply the established core visit rate as the billed charges on the remittance advice
(RA) received with any Medicaid payment.
4.3.
For billing instructions for RHC/FQHCs, please refer to Billing Manual for
Provider Type 17.
Indian Health Programs (IHP)
Please refer to MSM Chapter 3000.
1.
May 17, 2013
Outpatient services provided in IHP are reimbursed at an all inclusive per recipient
per encounter rate. The encounter rate is developed by the most recent Federal
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Register. Reimbursement and services for IHPs are the same for both tribal and
non-tribal recipients. For billing guidelines, please refer to the billing manual for
Provider Type 20.
This all inclusive rate includes any one or more of the following services and
medical professionals:
Physician/(MD/DO)
Nurse Anesthetist
Radiology
Podiatrist
Nurse Mid-Wife
Clinical Laboratory
Dentist
Optometrist
Pharmacy
Psychologist
Physician Assistant
Opticians – Including
eyeglasses dispensed
Certified Nurse Practitioner
603.9
ANESTHESIA
Medicaid payments for anesthesiology services provided by physicians and Certified Registered
Nurse Anesthetists (CRNA) are based on the Centers for Medicare and Medicaid Services (CMS)
base units.
a.
Each service is assigned a base unit which reflects the complexity of the service and
includes work provided before and after reportable anesthesia time. The base units also
cover usual preoperative and post operative visits, administering fluids and blood that are
part of the anesthesia care, and monitoring procedures.
b.
Time for anesthesia procedures begins when the anesthesiologist begins to prepare the
recipient for the induction of anesthesia and ends when the anesthesiologist/CRNA is no
longer in personal attendance, and the recipient is placed under postoperative supervision.
c.
All anesthesia services are reported by use of the anesthesia five digit procedure codes.
Nevada Medicaid does not reimburse separately for physical status modifiers or qualifying
circumstances.
d.
Using the CPT/ASA codes, providers must indicate on the claim the following:
May 17, 2013
1.
Type of surgery;
2.
Length of time;
3.
Diagnosis;
4.
Report general anesthesia and continuous epidural analgesia for obstetrical
deliveries using the appropriate CPT codes; and
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Unusual forms of monitoring and/or special circumstances rendered by the
anesthesiologist/CRNA are billed separately using the appropriate CPT code.
Special circumstances include but are not limited to nasotracheal/bronchial
catheter aspiration, intra-arterial, central venous and Swan-Ganz lines,
transesophageal echocardiography, and ventilation assistance.
PHYSICIAN SERVICES IN OUTPATIENT SETTING
A.
Outpatient (OP) hospital based clinic services include non-emergency care provided in the
emergency room, OPoutpatient therapy department/burn center, observation area, and any
established OPoutpatient clinic sites. Visits should be coded using the appropriate
Evaluation/Management (E/M) CPT code (e.g. office visit/observation/etc.) on a CMS1500 billing form. Do not use emergency visit codes.
Services requiring prior authorization include the following:
B.
1.
Hyperbaric Oxygen Therapy for chronic conditions (reference Appendix for
Coverage and Criteria);
2.
Bariatric surgery for Morbid Obesity;
3.
Cochlear implants (See MSM Chapter 2000 – Audiology Services);
4.
Diabetes training exceeding 10 hours;
5.
Vagus nerve stimulation; and
6.
Services requiring authorization per Ambulatory Surgical Center (ASC) list.
Emergency Room Policy
The DHCFP uses the prudent layperson standard as defined in the Balanced Budget Act of
1997 (BBA). Accordingly, emergency services are defined as “a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe pain) such
that a prudent lay person, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in placing
the health of the recipient (or, with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious
function of any bodily organ or part.” The threat to life or health of the recipient
necessitates the use of the most accessible hospital or facility available that is equipped to
furnish the services. The requirement of non-scheduled medical treatment for the
stabilization of an injury or condition will support an emergency.
December 14, 2011
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1.
Prior authorization will not be required for admission to a hospital as a result of a
direct, same day admission from a physician’s office and/or the emergency
department. The requirement to meet acute care criteria is dependent upon the
QIO-like vendor’s determination. The QIO-like vendor will continue to review and
perform the retrospective authorization for these admissions based upon approved
criteria. Prior authorization is still required for all other inpatient admissions.
2.
Direct physical attendance by a physician is required in emergency situations. The
visit will not be considered an emergency unless the physician’s entries into the
record include his or her signature, the diagnosis, and documentation that he or she
examined the recipient. Attendance of a physician’s assistant does not substitute
for the attendance of a physician in an emergency situation.
3.
Physician’s telephone or standing orders, or both, without direct physical
attendance does not support emergency treatment.
4.
Reimbursement for physician directed emergency care and/or advanced life
support rendered by a physician located in a hospital emergency or critical care
department, engaged in two-way voice communication with the ambulance or
rescue personnel outside the hospital is not covered by Medicaid.
5.
Services deemed non-emergency and not reimbursable at the emergency room
level of payment are:
a.
Non-compliance with previously ordered medications or treatments
resulting in continued symptoms of the same condition;
b.
Refusal to comply with currently ordered procedures or treatments;
c.
The recipient had previously been treated for the same condition without
worsening signs or symptoms of the condition;
d.
Scheduled visit to the emergency room for procedures, examinations, or
medication administration. Examples include, but are not limited to, cast
changes, suture removal, dressing changes, follow-up examinations, and
consultations for a second opinion;
e.
Visits made to receive a “tetanus” injection in the absence of other
emergency conditions;
f.
The conditions or symptoms relating to the visit have been experienced
longer than 48 hours or are of a chronic nature, and no emergency medical
treatment
was
provided
to
stabilize
the
condition;
and
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g.
Medical clearance/screenings for psychological or temporary detention
ordered admissions.
h.
Diagnostic x-ray, diagnostic laboratory, and other diagnostic tests provided
as a hospital outpatient service are limited to physician ordered tests
considered to be reasonable and necessary for the diagnosis and treatment
of a specific illness, symptom, complaint, or injury or to improve the
functioning of a malformed body member. For coverage and limitations,
reference MSM Chapter 300 for Radiology and Diagnostic Services and
MSM Chapter 800 for Laboratory Services.
Therapy Services (OT, PT, RT, ST)
Occupational, Physical, Respiratory and Speech Therapy services provided in the hospital
outpatient setting are subject to the same prior authorization and therapy limitations found
in the MSM, Chapter 1700 – Therapy.
D.
Observation Services Provided By The Physician
1.
Observation services are provided by the hospital and supervising physician to
recipients held but not admitted into an acute hospital bed for observation.
Consistent with federal Medicare regulations, the DHCFP reimburses hospital
“observation status” for a period up to, but no more than 48 hours.
2.
Observation services are conducted by the hospital to evaluate a recipient’s
condition or to assess the need for inpatient admission. It is not necessary that the
recipient be located in a designated observation area such as a separate unit in the
hospital, or in the emergency room in order for the physician to bill using the
observation care CPT codes, but the recipient’s observation status must be clear.
3.
If observation status reaches 48 hours, the physician must make a decision to:
4.
December 14, 2011
a.
Send the recipient home;
b.
Obtain authorization from the QIO-like vendor to admit into the acute
hospital; or
c.
Keep the recipient on observation status with the understanding neither the
physician nor the hospital will be reimbursed for any services beyond the
48 hours.
The physician must write an order for observation status, and/or an observation
stay that will rollover to an inpatient admission status.
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See MSM Chapter 200 in the MSM for policy specific to the facility’s
responsibility for a recipient in “observation status.”
E.
F.
End Stage Renal Disease (ESRD) Outpatient Hospital/Free-Standing Facilities. The term
“end-stage renal disease” means the stage of kidney impairment that appears irreversible
and permanent and requires a regular course of dialysis or kidney transplantation to
maintain life.
1.
Treatment of ESRD in a physician-based (i.e. hospital outpatient) or independently
operated ESRD facility certified by Medicare is a Medicaid covered benefit.
Medicaid is secondary coverage to Medicare for ESRD treatment except in rare
cases when the recipient is not eligible for Medicare benefits. In those cases,
private insurance and/or Medicaid is the primary coverage
2.
ESRD Services, including hemodialysis, peritoneal dialysis, and other
miscellaneous dialysis procedures are Medicaid covered benefits without prior
authorization.
3.
If an established recipient in Nevada needs to travel out of state, the physician or
the facility must initiate contact and make financial arrangements with the out of
state facility before submitting a prior authorization request to the QIO-like
vendor. The request must include dates of service and the negotiated rate. (This
rate cannot exceed Medicare’s reimbursement for that facility).
4.
Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Nutrition (IPN) are
covered services for hemodialysis and cContinuous aAmbulatory pPeritoneal
dDialysis (CAPD) recipients who meet all of the requirements for Parenteral and
Enteral Nutrition coverage. The recipient must have a permanently inoperative
internal body organ or function. Documentation must indicate that the impairment
will be of long and indefinite duration.
5.
Reference Attachment A, Policy #6-09 for ESRD Coverage.
Ambulatory Centers (ASC) Facility And Non-Facility Based
Surgical procedures provided in an ambulatory surgical facility refers to freestanding or
hospital-based licensed ambulatory surgical units that can administer general anesthesia,
monitor the recipient, provide postoperative care and provide resuscitation as necessary.
These recipients receive care in a facility operated primarily for performing surgical
procedures on recipients who do not generally require extended lengths of stay or
extensive recovery or convalescent time.
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Outpatient surgical procedures designated as acceptable to be performed in a physician’s
office/outpatient clinic, ambulatory surgery center or outpatient hospital facility are listed
on the QIO-like vendors website. For questions regarding authorization, the physician
should contact the QIO-like vendor.
1.
2.
3.
May 17, 2013
Prior authorization is not required when:
a.
Procedures listed are to be done in the suggested setting or a setting which
is a lower level than suggested;
b.
Procedures are part of the emergency/clinic visit; and
c.
If the recipient is a QMB the procedure is covered first by Medicare, and
Medicaid reimburses the co-insurance and deductible, up to the Medicaid
allowable.
Prior authorization is required from the QIO-like vendor when:
a.
Procedures are performed in a higher level facility than it is listed in the
ASC surgical list; (e.g., done in an ASC but listed for the office)
b.
Procedures on the list are designated for prior authorization;
c.
Designated podiatry procedures; and
d.
The service is an out-of-state service, and requires a PAprior authorization
if that same service was performed in-state.
Surgical procedures deemed experimental, not well established or not approved by
Medicare or Medicaid are not covered and will not be reimbursed for payment.
Below is a list of definitive non-covered services.
a.
Cosmetic Surgery: The cosmetic surgery exclusion precludes payment for
any surgical procedure directed at improving appearance. The condition
giving rise to the recipient’s preoperative appearance is generally not a
consideration. The only exception to the exclusion is surgery for the
prompt repair of an accidental injury or the improvement of a malformed
body member, to restore or improve function, which coincidentally services
some cosmetic purpose. Examples of procedures which do not meet the
exception to the exclusion are facelift/wrinkle removal (rhytidectomy),
nose hump correction, moon-face, routine circumcision, etc;
b.
Fabric wrapping of abdominal aneurysm;
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c.
Intestinal bypass surgery for treatment of obesity;
d.
Transvenous (catheter) pulmonary embolectomy;
e.
Extracranial-Intracranial (EC-IC) Arterial bypass when it is performed as a
treatment for ischemic cerebrovascular disease of the carotid or middle
cerebral arteries;
f.
Breast reconstruction for cosmetic reasons, however breast reconstruction
following removal of a breast for any medical reason may be covered;
g.
Stereotactic cingulotomy as a means of psychosurgery to modify or alter
disturbances of behavior, thought content, or mood that are not responsive
to other conventional modes of therapy, or for which no organic
pathological cause can be demonstrated by established methods;
h.
Radial keratotomy and keratoplasty to treat refractive defects. Keratoplasty
that treats specific lesions of the cornea is not considered cosmetic and may
be covered;
i.
Implants not approved by the Food and Drug Administration (FDA);
Partial ventriculectomy, also known as ventricular reduction, ventricular
remodeling, or heart volume reduction surgery;
j.
Gastric balloon for the treatment of obesity;
k.
Transsexual surgery, also known as sex reassignment surgery or intersex
surgery and all ancillary services including the use of pharmaceuticals;
l.
Cochleostomy with neurovascular transplant for Meniere’s Disease;
m.
Surgical procedures to control obesity other than bariatric for morbid
obesity with significant comorbidities. See Appendix A for policy
limitations; and
n.
Organ transplantation and associated fees are a limited benefit for Nevada
Medicaid recipients.
The following organ transplants, when deemed the principal form of treatment are
covered:
a.
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POLICY
Bone Marrow/Stem Cell – allogeneic and autologous;
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1.
a.
Allogeneic stem cell transplantation is not covered as
treatment for multiple myeloma;
b.
Autologous stem cell transplantation is not covered as
treatment for acute leukemia not in remission, chronic
granulocytic leukemia, solid tumors (other than
neuroblastoma) and tandem transplantation for recipients
with multiple myeloma;
b.
Corneal – allograft/homograft;
c.
Kidney – allotransplantation/autotransplantation; and
d.
Liver – transplantation for children (under age 21) with extrahepatic biliary
atresia or for children or adults with any other form of end-stage liver
disease. Coverage is not provided with a malignancy extending beyond the
margins of the liver or those with persistent viremia.
5.
Prior authorization is required for bone marrow, kidney, and liver transplants from
Medicaid’s contracted QIO-like vendor.
6.
A transplant procedure shall only be approved upon a determination that it is a
medically necessary treatment by showing that:
d.
July 14, 2010
Noncovered conditions for bone marrow/stem cell:
a.
The procedure is not experimental and/or investigational based on Title 42,
Code of Federal Regulations (CFR), Chapter IV (Health Care Financing
Administration) and Title 21, Code of Federal RegulationsCFR, Chapter I
(Food and Drug AdministrationFDA;
b.
The procedure meets appropriate Medicare criteria; or
c.
The procedure is generally accepted by the professional medical
community as an effective and proven treatment for the condition for which
it is proposed, or there is authoritative evidence that attests to the proposed
procedures safety and effectiveness.
If the authorization request is for chemotherapy to be used as a preparatory therapy
for transplants, an approval does not guarantee authorization for any harvesting or
transplant that may be part of the treatment regimen. A separate authorization is
required for inpatient/outpatient harvesting or transplants, both in-state and out of
state.
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SERVICES IN THE ACUTE HOSPITAL SETTING
A.
Admissions to acute care hospitals both in and out of state are limited to those authorized
by Medicaid’s QIO-like vendor as medically necessary and meeting Medicaid benefit
criteria.
B.
Physicians may admit without prior approval only in the following situations:
1.
An emergency (defined in MSM Chapter 100);
2.
Obstetrical labor and delivery; or
3.
Direct Admission from doctor’s office.
C.
All other hospital admissions both in-state and out-of-state must be prior authorized by the
QIO-like vendor. Payment will not be made to the facility or to the admitting physician,
attending physician, consulting physician, anesthesiologist, or assisting surgeons denied
by the QIO-like vendor admissions.
D.
Attending physicians are responsible for ordering and obtaining prior authorization for all
transfers from the acute hospital to all other facilities.
E.
Physicians may admit recipients to psychiatric and/or substance abuse units of general
hospitals (regardless of age), or freestanding psychiatric and substance abuse hospitals for
recipients 65 and older or those under the age of 21. All admissions must be prior
authorized by the QIO-like vendor with the exception of a psychiatric emergency. Refer to
MSM Chapter 400 for coverage and limitations.
F.
Inpatient Hospital Care
May 17, 2013
1.
Routine Inpatient Hospital Care is limited to reimbursement for one visit per day
(same physician or physicians in the same group practice) except when extra care
is documented as necessary for an emergency situation (e.g., a sudden serious
deterioration of the recipient’s condition).
2.
The global surgical package includes the following when provided by the
physician who performs the surgery, whether in the office setting, out-patient or
in-patient:
a.
Preoperative visits up to two days before the surgery;
b.
Intraoperative services that are normally a usual and necessary part of a
surgical procedure;
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c.
Services provided by the surgeon within the Medicare recommended
global period of the surgery that do not require a return trip to the
operating room; and follow-up visits related to the recovery from the
surgery which are provided during this time by the surgeon; and
d.
Post surgical pain management.
3.
The surgeon’s initial evaluation or consultation is considered a separate service
from the surgery and is paid as a separate service, even if the decision, based on
the evaluation, is not to perform the surgery. If the decision to perform a major
surgery (surgical procedures with a 90-day global period) is made on the day of or
the day prior to the surgery, separate payment is allowed for the visit on which the
decision is made, however supporting documentation may be requested. If post
payment audits indicate documentation is insufficient to support the claim,
payment will be adjusted accordingly.
4.
If a recipient develops complications following surgery that requires the recipient
to be returned to the operating room for any reason for care determined to be
medically necessary, these services are paid separately from the global surgery
amount. Complications that require additional medical or surgical services but do
not require a return trip to the operating room are included in the global surgery
amount.
5.
Payment may be made for services by the surgeons that are unrelated to the
diagnosis for which the surgery was performed during the post operative period.
Supportive documentation may be requested. Services provided by the surgeon for
treating the underlying condition and for a subsequent course of treatment that is
not part of the normal recovery from the surgery are also paid separately. Full
payment for the procedure is allowed for situations when distinctly separate but
related procedures are performed during the global period of another surgery in
which the recipient is admitted to the hospital for treatment, discharged, and then
readmitted for further treatment.
6.
Payment for physician services related to patient-controlled analgesia is included
in the surgeon’s global payment. The global surgical payment will be reduced if
post-payment audits indicate that a surgeon’s recipients routinely receive pain
management services from an anesthesiologist. (For a list of covered codes, please
refer to the billing manual).
7.
For information on payment for assistant surgeons, please refer to the billing
manual.
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8.
There is no post-operative period for endoscopies performed through an existing
body orifice. Endoscopic surgical procedures that require an incision for insertion
of a scope will be covered under the appropriate major or minor surgical policy
which will include a post-operative period according to the Medicare
recommended global period.
9.
For some dermatology services, the CPT descriptors contain language, such as
“additional lesion”, to indicate that multiple surgical procedures have been
performed. The multiple procedure rules do not apply because the RVU’s for these
codes have been adjusted to reflect the multiple nature of the procedure. These
services are paid according to the unit. If dermatologic procedures are billed with
other procedures, the multiple surgery rules apply. For further information, please
refer to the billing manual.
10.
Critical Care
Critical Care, the direct delivery of medical care by a physician or physicians for a
critically ill or critically injured recipient to treat a single or multiple vital organ
system failure and/or to prevent further life threatening deterioration of the
recipient’s conditions, is reimbursed by Medicaid. Reimbursement without
documentation is limited to a critical illness or injury which acutely impairs one or
more vital organ systems such that there is a high probability of imminent or life
threatening deterioration in the recipient’s condition. Critical care involves high
complexity decision making to assess, manipulate, and support vital system
functions. Examples of vital organ system failure include, but are not limited to:
central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic,
and/or respiratory failure. Although critical care typically requires interpretation of
multiple physiologic parameters and/or application of advanced technology,
critical care may be provided in life threatening situations when these elements are
not present.
May 17, 2013
a.
Critical care may be provided on multiple days, even if no changes are
made in the treatment rendered to the recipient, provided that the
recipient’s condition continues to require the level of physician attention
described above. Providing medical care to a critically ill, injured, or postoperative recipient qualifies as a critical care service only if both the illness
or injury and the treatment being provided meet the above requirements.
b.
Critical care is usually, but not always, given in a critical care area, such as
the coronary care unit, intensive care unit, pediatric intensive care unit,
respiratory care unit, or the emergency care facility.
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c.
Services for a recipient who is not critically ill but happen to be in a critical
care unit, are reported using other appropriate evaluation/management
(E/M) codes.
d.
According to CPT, the following services are included in reporting critical
care when performed during the critical period by the physicians providing
critical care: the interpretation of cardiac output measurements, chest xrays, pulse oximetry, blood gases, and information data stored in computers
(e.g., ECGs, blood pressures, hematologic data) gastric intubation,
temporary transcutaneous pacing, ventilatory management and vascular
access procedures. Any services performed which are not listed above
should be reported separately.
e.
Time spent in activities that occur outside of the unit or off the floor (e.g.,
telephone calls, whether taken at home, in the office, or elsewhere in the
hospital) may not be reported as critical care since the physician is not
immediately available to the patient.
Neonatal and Pediatric Critical Care
a.
Neonatal and Pediatric Critical Care CPT codes are used to report services
provided by a single physician directing the care of a critically ill
neonate/infant. The same definitions for critical care services apply for the
adult, child and neonate. The neonatal and pediatric critical care codes are
global 24-hour codes (billed once per day) and are not reported as hourly
services consistent with CPT coding instructions.
b.
Neonatal critical care codes are used for neonates (28 days of age or less)
and pediatric critical care codes are used for the critically ill infant or
young child age 29 days through 71 months of age, admitted to an intensive
or critical care unit. These codes will be applicable as long as the child
qualifies for critical care services during the hospital stay.
c.
If the physician is present for the delivery and newborn resuscitation is
required, the appropriate E&M code can be used in addition to the critical
care codes.
d.
Care rendered under the pediatric critical care codes includes management,
monitoring, and treatment of the recipient including respiratory, enteral and
parenteral nutritional maintenance, metabolic and hematologic
maintenance, pharmacologic control of the circulatory system,
parent/family counseling, case management services, and personal direct
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supervision of the health care team in the performance of cognitive and
procedural activities.
e.
July 14, 2010
In addition to critical services for adults, the pediatric and neonatal critical
care codes also include the following procedures:
1.
peripheral vessel catheterization;
2.
other arterial catheters;
3.
umbilical venous catheters;
4.
central vessel catheters;
5.
vascular access procedures;
6.
vascular punctures;
7.
umbilical arterial catheters;
8.
endotracheal intubation;
9.
ventilator management;
10.
bedside pulmonary function testing;
11.
surfactant administration;
12.
continuous positive airway pressure (CPAP);
13.
monitoring or interpretation of blood gases or oxygen saturation;
14.
transfusion of blood components;
15.
oral or nasogastric tube placement;
16.
suprapubic bladder aspiration;
17.
bladder catheterization; and
18.
lumbar puncture.
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Any services performed which are not listed above, may be reported
separately.
f.
603.12
603.13
Initial and Continuing Intensive Care Services are reported for the child
who is not critically ill, but requires intensive observation, frequent
interventions and other intensive care services, or for services provided by
a physician directing the continuing intensive care of the lLow bBirth
wWeight (LBW) (1500-2500 grams) present body weight infant, or normal
(2501-5000 grams) present body weight newborn who does not meet the
definition of critically ill, but continues to require intensive observation,
frequent interventions, and other intensive care services.
PHYSICIAN’S SERVICES IN NURSING FACILITIES
A.
Physician services provided in a Nursing Facility (NF) are a covered benefit when the
service is medically necessary. Physician visits must be conducted in accordance with
federal requirements for licensed facilities. Reference MSM Chapter 500 for coverage and
limitations.
B.
When the recipient is admitted to the nursing facility NF in the course of an encounter in
another site of service (e.g., hospital ER, physician’s office), all E/M services provided by
that physician in conjunction with that admission are considered part of the initial nursing
facility care when performed on the same date as the admission or readmission.
Admission documentation and the admitting orders/plan of care should include the
services related to the admission he/she provided in the other service sites.
C.
Hospital discharge or observation discharge services performed on the same date of
nursing facilityNF admission or readmission may be reported separately. For a recipient
discharged from inpatient status on the same date of nursing facility admission or
readmission, the hospital discharge services should be reported as appropriate. For a
recipient discharged from observation status on the same date of nursing facilityNF
admission or readmission, the observation care discharge services should be reported with
the appropriate CPT code.
PHYSICIAN’S SERVICES IN OTHER MEDICAL FACILITIES
A.
Intermediate Care Facility/Mentally Retarded (ICF/MR)
A physician must certify the need for ICF/MR care prior to or on the day of admission (or
if the applicant becomes eligible for Medicaid while in the ICF/MR, before the Nevada
Medicaid Office authorizes payment.) The certification must refer to the need for the
ICF/MR level of care, be signed and dated by the physician and be incorporated into the
resident’s record as the first order in the physician’s orders.
May 17, 2013
PHYSICIAN SERVICES
Section 603 Page 35
MTL 05/13CL 27847
DRAFT
Section:
603
Subject:
POLICY
Recertification by a physician or a nurse practitioner of the continuing need for ICF/MR
care is required within 365 days of the last certification. In no instance is recertification
acceptable after the expiration of the previous certification. For further information
regarding ICF/MR refer to MSM Chapter 1600.
B.
Residential Treatment Center (RTC)
Physician services, except psychiatrist are not included in the all inclusive facility rate for
RTCs. Please reference MSM Chapter 400.
May 17, 2013
PHYSICIAN SERVICES
Section 603 Page 36
MTL 25/10CL 27847
DRAFT
Section:
604
Subject:
604
HEARINGS
HEARINGS
Please reference Nevada Medicaid Services Manual (MSM), 3100 for hearings procedures.
July 14, 2010
PHYSICIAN SERVICES
Section 604 Page 1
POLICY #6-09
END STAGE RENAL DISEASE SERVICES
EFFECTIVE DOS 9/1/03
Superseded Policy News N199-10
and New ESRD Policy
DESCRIPTION
Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Nutrition (IPN) are a covered service for
hemodialysis and continuous ambulatory peritoneal dialysis (CAPD) recipients who meet all of the
requirements for Parenteral and Enteral Nutrition coverage. The recipient must have a permanently
inoperative internal body organ or function. Documentation must indicate that the impairment will be of
long and indefinite duration.
PRIOR AUTHORIZATION IS NOT REQUIRED
Prior authorization is required if an established patient in Nevada needs to travel out of state. The
physician or the facility must initiate contact and make financial arrangements with the out of state
facility before submitting a payment authorization request to the QIO-like vendor. The request must
include dates of service and the negotiated amount. (Amount can not exceed Medicare’s reimbursement
for that facility.)
A physician’s service furnished to dialysis recipients who are treated as outpatients, are divided into two
major categories: direct recipient care and administrative.
Physician’s evaluation and management-type services, “unrelated” to the dialysis procedure (not
provided during a dialysis treatment) may be billed in addition to the dialysis procedure.
Physicians providing evaluation and management-type services “related” to the dialysis procedure same
day dialysis is performed, or during a dialysis treatment) are billed as included in the dialysis procedure.
Service units equal number of treatments. (Fee schedule paid to physician.)
Criteria for instituting IDPN/IPN:

Three month average predialysis serum albumin level of <3.4 mg/dl.

Three month average predialysis serum creatine of <8.0 mg/dl.

Three month average predialysis serum pre-albumin level of <25 mg/dl.

Weight loss of 7.5% of usual body weight over 3 months.

A clinical exam consistent with moderate to severe malnutrition.

A dietary history of reduced food intake (protein <0.8 g/kg/day; calories <25 cal/kg/day).

Failed attempts at dietary and oral supplementation.

Eternal tube feeding contraindicated.
July 14, 2010
PHYSICIAN SERVICES
Attachment A Page 12
TRANSMITTAL LETTER
June 12, 2014
TO:
FROM:
SUBJECT:
CHAPTER 1200 – PRESCRIBED DRUGS
Revisions to MSM Chapter 1200 are being proposed to reflect approved actions by the Drug Use
Review (DUR) Board at the July 25, 2013 meeting.
The DUR Board is a requirement of the Social Security Act to identify and reduce fraud, abuse,
overuse, and medically unnecessary care. The DUR Board also works to minimize drug
interactions, drug-induced illness, and undesirable drug reactions in recipients.
Prior authorization criteria was approved by the DUR Board on July 25, 2013 for the following
drugs. Prior authorization criteria will be added or criteria will be revised to MSM Chapter 1200
for Eliquis® (apixaban); Pradaxa® (dabigatran etexilate); Xarelto® (rivaroxaban); Ampyra®
(dalfampridine); Cymbalta® (duloxetine); Suboxone® (buprenorphine/naloxone); Subutex®
(buprenorphine); Genotropin® (somatropin); Humatrope® (somatropin); Norditropin®
(somatropin) Nutropin® (somatropin); Omnitrope® (somatropin); Saizen® (somatropin); TevTropin® (somatropin); Serostim® (somatropin); Zorbtive® (somatropin); Cinryze® (C1
esterase inhibitor); Berinert® (C1 esterase inhibitor); Kalbitor® (ecallantide); Firazyr®
(icatibant); Leukine® (sargramostim); Neulasta® (pegfilgrastim); Neupogen® (filgrastim);
Subsys® (fentanyl sublingual spray); Onsolis® (fentanyl citrate buccal film); Fentora® (fentanyl
citrate buccal tablet); Lazanda® (fentanyl citrate nasal spray); Abstral® (fentanyl citrate
sublingual tablet); Cesamet® (nabilone); Marinol® (dronabinol); and Actiq® (fentanyl citrate
transmucosal lozenge).
The length of prioritization approval for Omontys® (peginesatide) will be changed from one
year to one month.
Clarifying language was added under Injectable Immunomodulators, Crohn’s Disease.
Bone pain was removed under Cox-2 Inhibitors.
Page 1 of 4
MTL N/A
MSM CHAPTER 1200 – PRESCRIBED
DRUGS
MATERIAL SUPERSEDED
CL 27787
MSM CHAPTER 1200 – PRESCRIBED
DRUGS
Manual Section
Section Title
Appendix A
Table of Contents
Added the drugs with new criteria listed to the
Table of Contents.
Appendix A
B - Cox-2
Inhibitors
Bone pain was removed, as this currently is not a
FDA approved indication.
Appendix A
D - Growth
Hormone
For children up to age 21, criteria was revised to
remove idiopathic short stature as a qualifying
diagnosis for growth hormone. All recipients must
fail two growth hormone stimulation tests. The
previous criteria required one failure. Criteria for
Serostim® (somatropin) was added for recipients
with weight loss associated with HIV. Criteria for
Zorbtive® (somatropin) was added for recipients
with weight loss from short bowel syndrome.
Appendix A
G - Immediate
Release Fentanyl
Products
Incorporated the previous criteria for Fentora®, and
Actiq® into a new drug category called Immediate
Release Fentanyl Products. The criteria now
includes Subsys® (fentanyl sublingual spray);
Onsolis® (fentanyl citrate buccal film); Fentora®
(fentanyl citrate buccal tablet); Lazanda® (fentanyl
citrate nasal spray); Abstral® (fentanyl citrate
sublingual tablet); and Actiq® (fentanyl citrate
transmucosal lozenge). The only revision to the
original criteria was the removal of Non-Covered
Indications.
Appendix A
H - Hematopoietic /
Hematinic Agents
Under Coverage and Limitations,
parenthesis after Epogen®.
Appendix A
L - Injectable
Immunomodulator
Drugs
Under Coverage and Limitations, Section (f.) added
Cimzia®, Humira® to clarify the drugs included for
the treatment of Crohn’s disease.
Appendix A
V - Sedative
Hypnotics
added
Deleted Quantity Limitations as they
documented in the Pharmacy Billing Manual.
Page 2 of 4
a
are
Manual Section
Section Title
Appendix A
X - Antiemetics –
Serotonin Receptor
Antagonists (also
known as 5-HT3
Antiemetics)
Appendix A
Z - Cymbalta®
(duloxetine)
Added language that Cymbalta® is subject to prior
authorization and quantity limits as well as a
reference to the Pharmacy Manual for specific
quantity limit information. Added Chronic
Musculoskeletal Pain, Generalized Anxiety
Disorder, and Major Depressive Disorder to the list
of qualifying diagnoses. Each diagnosis requires an
inadequate response to other specified drugs before
Cymbalta® will be approved. Also added language
indicating that certain documentation must be
included on the claim form as a qualifying criteria
for payment.
Appendix A
BB - Suboxone®
(buprenorphone/
naloxone) and
Subutex®
(buprenorphone)
Revision to original criteria where now formal
substance counseling is encouraged rather than
required and deleted language regarding parameters
of previously required counseling. Added new
criteria for Subutex® (buprenorphone) that all
recipients must either be pregnant or breastfeeding
an infant dependent on methadone or morphine.
Appendix A
CC - Ampyra®
(delfampridine)
Remove ™ from Ampyra and add ®. The original
criteria requiring a timed 25 foot walk and the
criteria for renewal of the prior authorization has
been removed. Clarifying language was added
under Prior Authorization Guidelines.
Appendix A
FF - Pradaxa®
(dabigatran
etexilate); Eliquis®
(apixaban);
Xarelto®
(rivaroxaban)
Added Eliquis® (apixaban) and Xarelto®
(rivaroxaban) to the Pradaxa® (dabigatran
etexilate) criteria. Added the disclaimer related to
prior authorization and quantity limits as well as a
reference to the Pharmacy Manual. Revised the
criteria to allow for the submittal of a specified
ICD-9 code on the prescription to bypass the
requirement of a prior authorization. Revised the
original criteria to focus on nonvalvular atrial
fibrillation, pulmonary embolism and infarction,
acute venous embolism and thrombosis of the deep
vessels of the lower extremity. Added verbiage
stating recipients must not have an active
Corrected typo
Antiemetics.
Page 3 of 4
under
Therapeutic
Class:
Manual Section
Section Title
pathological bleed.
Appendix A
KK - Xarelto®
(rivaroxaban)
Deleted the criteria as this information has been
incorporated into Appendix A, Section FF.
Appendix A
KK - Hereditary
Angiodema Agents
New criteria for Cinryze® (C1 esterase inhibitor),
Beromert® (C1 esterase inhibitor), Kalbitor®
ecallantide) and Firazyr® (icatibant). In addition to
the addition of the quantity limit disclaimer, new
criteria requires recipients have a diagnosis of
hereditary angioedema. Drugs must be prescribed
by or in consultation with an immunologist or
allergist. The recipient must have experienced an
inadequate response to attenuated androgen agents.
Prior Authorization Guidelines document an initial
approval of six months with continuation of therapy
for one year.
Appendix A
RR - Cesamet®
(nabilone)
Marinol®
(dronabinol)
Added “all” to Coverage and Limitations regarding
approval if all of the following criteria are met and
documented.
Under Cesamet® (nabilone) added “and” after
criteria #1 and #2 for clarity.
Under Marinol® (dronabinol) renumbered and
added sub-criteria. Added “and” after criteria #1,
(a.), (b.) and after criteria #2; added “or” after
criteria #1(c.) for clarity.
Appendix A
SS - Omontys®
(peginesatide)
Revised Prior Authorization (PA) Guidelines to
indicate that PA approvals are for one month rather
than one year.
Appendix A
TT - Colony
Stimulating Factors
(Point of Sale
Claims Only)
New criteria for Leukine® (sargramostim),
Neulasta® (pegfilgrastim) and Neupogen®
(filgrastim). In addition to the addition of the
quantity limit disclaimer, new criteria requires
recipients to have a qualifying diagnosis such as
non-myeloid malignancy, or must be undergoing
bone marrow transplantation, or is at high risk for
neutropenia, or has experienced a prior episode of
febrile neutropenia. PA Guidelines document
approval for one month.
Page 4 of 4
APPENDIX A – Coverage and Limitations
DRUGS REQUIRING PRIOR AUTHORIZATION AND/OR QUANTITY LIMITATIONS............................. 34
A
ABSTRAL® (Fentanyl Citrate Sublingual Tablet)...............................................................................................21
ACTIQ® (Fentanyl Citrate Transmucosal Lozenge)............................................................................................21
AGENTS USED FOR THE TREATMENT OF ATTENTION DEFICIT DISORDER (ADD)/ATTENTION
DEFICIT HYPERACTIVITY DISORDER (ADHD) ............................................................................................ 78
AMPYRA™ ® (Dalfampridine) ........................................................................................................................ 4754
ANDROGEL®, ANDRODERM®, TESTIM® (testosterone gel and transdermal system) ............................. 4956
ANTIEMETICS – SEROTONIN RECEPTOR ANTAGONIST ....................................................................... 4146
ANTI-FUNGAL ONCYCHOMYCOSIS (Lamisil®, Sporanox®, Penlac®) .................................................... 2025
ANTI-MIGRAINE MEDICATIONS (Triptans) ................................................................................................ 3540
ANTIRETROVIRALS ....................................................................................................................................... 6885
B
BERINERT® (C1 Esterase Inhibitor)...................................................................................................................67
BLOOD GLUCOSE TESTING .......................................................................................................................... 6986
BRILINTA® (Ticagrelor) .................................................................................................................................. 6271
Buprenorphine (SUBUTEX®).............................................................................................................................52
Buprenorphine/Naloxone (SUBOXONE®).........................................................................................................52
BYDUREON® (Exenatide Extended-Release).....................................................................................................68
BYETTA® (Exenatide), Bydureon (Exenatide extended-release), VICTOZA (liraglutide) ............................ 5968
C
CESAMET® (Nabilone) .................................................................................................................................... 6675
CINRYZE® (C1 Esterase Inhibitor)....................................................................................................................67
COLCHICINE (Colcrys®) ................................................................................................................................. 5057
COLONY STIMULATING FACTORS...............................................................................................................78
COX-2 INHIBITORS ............................................................................................................................................. 56
CYMBALTA® (Duloxetine).............................................................................................................................. 4449
D
DALIRESP® (Roflumilast) ............................................................................................................................... 5765
DURAGESIC® (fentanyl transdermal) PATCHES ........................................................................................... 1520
E
ELIQUIS® (Apixaban)..........................................................................................................................................58
F
FENTANYL CITRATE BUCCAL TABLET AND LOZENGE (Fentora® and Actiq®) .................................... 16
FENTORA® (Fentanyl Citrate Buccal Tablet)....................................................................................................21
FIRAZYR® (Icatibant).........................................................................................................................................67
FORTEO® (Teriparatide) ................................................................................................................................... 6574
G
GENOTROPIN® (Somatropin)...........................................................................................................................15
GROWTH HORMONE ...................................................................................................................................... 1011
H
HEMATOPOIETIC/HEMATINIC AGENTS .................................................................................................... 1823
HEREDITARY ANGIOEDEMA AGENTS.........................................................................................................66
HORMONES ..................................................................................................................................................... 6582
November 1, 2013
PRESCRIBED DRUGS
Appendix A Page 1
HUMATROPE® (Somatropin).............................................................................................................................15
I
IMMEDIATE-RELEASE FENTANYL PRODUCTS........................................................................................21
INCIVEK® (Telaprevir) ..................................................................................................................................... 5664
INJECTABLE IMMUNOMODULATOR DRUGS .......................................................................................... 2328
INHALED ANTICHOLINERGIC AGENTS .................................................................................................... 4045
K
KALBITOR® (Ecallantide)..................................................................................................................................67
KALYDECO® (Ivacaftor) ................................................................................................................................ 6069
L
LAZANDA® (Fentanyl Citrate Nasal Spray).......................................................................................................21
LEUKINE® (Sargramostim).................................................................................................................................78
LIDODERM 5% PATCHES® ........................................................................................................................... 3136
LONG ACTING NARCOTICS .......................................................................................................................... 3338
M
MAKENA™ ....................................................................................................................................................... 5361
MARINOL® (Dronabinol) ................................................................................................................................. 6675
MEDICATIONS FOR THE TREATMENT OF ACNE .................................................................................... 6784
MEDICATIONS WITH GENDER/AGE EDITS ............................................................................................... 6380
N
NATROBA® (Spinosad) ................................................................................................................................... 6170
NEULASTA® (Pegfilgrastim).............................................................................................................................78
NEUPOGEN® (Filgrastim)..................................................................................................................................79
NORDITROPIN® (Somatropin)..........................................................................................................................15
NUTROPIN® (Somatropin).................................................................................................................................15
O
OMALIZUMAB (Xolair®) ................................................................................................................................ 3237
OMNITROPE® (Somatropin).............................................................................................................................15
OMONTYS® (Peginesatide) .............................................................................................................................. 6877
ONSOLIS® (Fentanyl Citrate Buccal Film).......................................................................................................21
ORAL/TOPICAL CONTRACEPTIVES ........................................................................................................... 6481
OVER-THE-COUNTER MEDICATIONS ........................................................................................................ 1419
P
PRADAXA® (Dabigatran Etexilate) ................................................................................................................. 5158
PRAMLINITIDE INJECTION (Symlin®) ........................................................................................................ 2126
PRENATAL VITAMINS ................................................................................................................................... 6380
PROLIA® (Denosumab) .................................................................................................................................... 6372
PROTON PUMP INHIBITORS (PPI’s) ................................................................................................................. 34
PSYCHOTROPIC MEDICATIONS FOR CHILDREN AND ADOLESCENTS ............................................. 2833
R
REGRANEX® ................................................................................................................................................. 2227
S
SAIZEN® (Somatropin).......................................................................................................................................15
SAVELLA® (Milnacipran) ............................................................................................................................... 4551
November 1, 2013
PRESCRIBED DRUGS
Appendix A Page 2
SEDATIVE HYPNOTICS ................................................................................................................................. 3944
SEROSTIM® (Somatropin)................................................................................................................................17
SUBOXONE® (Buprenorphine/Naloxone) and SUBUTEX® (Buprenorphine) .................................................. 46
SUBSYS® (Fentanyl Sublingual Spray).............................................................................................................21
SYNAGIS® (palivizumaub) ............................................................................................................................... 4247
T
TEV-TROPIN® (Somatropin).............................................................................................................................15
TOBACCO CESSATION PRODUCTS ........................................................................................................... 3742
TOPICAL IMMUNOMODULATORS .............................................................................................................. 2732
TORADOL® (Ketorolac Tromethamine) TABLETS ........................................................................................ 3439
V
VICTOZA® (Liraglutide).....................................................................................................................................68
VICTRELIS® (Boceprevir)................................................................................................................................ 5462
VITAMINS WITH FLOURIDE ......................................................................................................................... 6683
X
XARELTO® (Rivaroxaban) .................................................................................................................................. 58
XOPENEX® (Levalbuterol) ............................................................................................................................... 3843
Z
ZORBTIVE® (Somatropin)..................................................................................................................................18
All drugs in Appendix A may be subject Quantity Limitations.
Check the Nevada Medicaid and Nevada Check Up Pharmacy Manual for a listing of the
exact Quantity Limitation.
November 1, 2013
PRESCRIBED DRUGS
Appendix A Page 3
B.
Cox-2 Inhibitors
Therapeutic Class: NSAIDs (nonsteriodal anti-inflammatory drugs)
Last Reviewed by the DUR Board: April 28, 2011
Cox-2 Inhibitors are subject to prior authorizations and quantity limitations based on the
Application of Standards in Section 1927 of the Social Security Act and/or approved by the DUR
Board. Refer for the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity
limits.
1.
Coverage and Limitations
Indications:
A diagnosis of osteoarthritis, rheumatoid arthritis, alkylosing spondylitis, juvenile
rheumatoid arthritis, primary dysmenorrheal, bone pain or acute pain in adults.
Upon documentation of a listed indication, authorization will be given if the patient meets
one of the following criteria:
a.
May 17, 2013
Patient is at high risk of NSAID induced adverse GI events as evidenced by any
of the following:
1.
Patient has a documented history or presence of peptic ulcer disease.
2.
Patient has a history or presence of NSAID-related ulcer.
3.
Patient has a history or presence of clinically significant GI bleeding.
b.
Patient is greater than 65 years of age.
c.
Patient is at risk for GI complications due to the presence of any of the following
concomitant drug therapies:
1.
Anticoagulants (e.g. warfarin, heparin or Low Molecular Weight (LMW)
heparin).
2.
Chronic use of oral corticosteroids.
d.
Patient has a documented history of inability to tolerate therapy with at least two
non-selective (traditional) NSAIDs.
e.
The patient is not being treated daily with aspirin for cardioprophylaxis unless
concurrent use of a proton pump inhibitor is documented.
PRESCRIBED DRUGS
Appendix A Page 6
D.
Growth Hormone
Therapeutic Class: Growth Hormone
Last Reviewed by the DUR Board: January 24, 2008 July 25, 2013
Growth Hormone (GH) therapy is subject to prior authorization. A Food and Drug
Administration (FDA)-approved indication for the diagnosis being treated is required.
1.
a.
Children (up to age 21)
The following apply to all requests for children:
1.
An evaluation by a pediatric endocrinologist or pediatric nephrologist with
a recommendation for therapy.
2.
All other causes for short stature are ruled out.
3.
Patient is receiving adequate replacement therapy for any other pituitary
hormone deficiencies, such as thyroid, glucocorticoids or gonatropic
hormones.
Therapy will be approved for any one of the following:
May 17, 2013
4.
Diagnosis of Turner’s Syndrome.
5.
Diagnosis of Prader-Willi Syndrome.
6.
Patient has chronic renal insufficiency (defined as Creatinine Clearance
between five and 75/ml/min/1.73m2).
7.
If the patient has evidence of hypothalamic-pituitary disease or structure
lesions/trauma to the pituitary including pituitary tumor, pituitary surgical
damage, trauma, or cranial irradiation and meeting any one of the
following:
a.
Has failed at least one GH stimulation test (peak GH level <10
nanograms (ng/ml).
b.
Had at least one documented low IGF-1 level (below normal range
for patients age – refer to range on submitted lab document).
c.
Has deficiencies in three or more pituitary axes (i.e. TSH, LH,
FSH, ACTH, ADH).
PRESCRIBED DRUGS
Appendix A Page 11
b.
8.
If the patient is a newborn infant and has evidence of hypoglycemia and
either a low GH level (<20ng/ml) or a low for age IGF-1 or IGF Binding
Protein #3 level (IGFPB#3) (no stimulation test required for infants).
9.
Children with a history of intrauterine growth restriction (small for
gestational age (SGA)) who at age two years have a height at least two
Standard Deviations (SD) below the mean for the patient’s age and
gender.
10.
For Idiopathic Short Stature all the following criteria must be met:
a.
Bone age>2 SD below the mean for age, Epiphysis open. Height
>2.25 SD below the mean for age or >2 SD below the midparenteral height percentile or growth velocity <25th percentile for
bone age.
b.
At least one provocative stimuli test to show failure to raise the
grow hormone level above 10 ng/ml.
c.
Exception to the requirement for stimuli testing: Patients meeting
(10)(a) and (10)(b) above in addition to a documented low serum
insulin-like growth factor 1 (IGF-1) and/or insulin-like growth
factor binding protein #3 (IGFPB#3) will not be required to have
stimuli testing.
Criteria for the continuation of growth hormone therapy for children includes all
of the following:
Bone age >2 SD below the mean for age. Epiphysis open.
c.
May 17, 2013
1.
Growth rate with treatment is at least two centimeters greater than the
untreated rate. Copy of the growth chart must accompany forms.
2.
Child has not reached the 25th percentile of normal height for gender.
3.
No diagnosis of an expanding lesion or tumor formation.
4.
Patient has not undergone renal transplant.
Reasons for Non-Coverage/Denial include, but are not limited to, the following:
1.
Indications other than those specified in this policy;
2.
Any condition(s) which is contraindicated and/or considered to be
experimental;
PRESCRIBED DRUGS
Appendix A Page 12
3.
Patients with expanding lesions or tumor formation;
4.
Patients who have received renal transplantation; or
5.
Patients who do not meet criteria as set by this policy.
6.
Also, growth rate that is less than 2.0 cm/yr of untreated rate; growth that
has reached the 25% of normal height for gender; bone age that is over
recommended age for gender; or if epiphysis is closed.
An evaluation by a pediatric endocrinologist or a pediatric nephrologist is
mandatory for initiation of growth hormone therapy and close monitoring either
by a pediatric endocrinologist, pediatric nephrologist or the recipient’s primary
care physician is required throughout therapy.
Prior authorization will be given for a six month time period for initiation of
therapy, and six-12 months for continuation of therapy, dependent upon the
response of growth by the recipient.
d.
Adults (age 21 and older)
Indications for growth hormone therapy in adults are:
Adults who were growth hormone deficient as children or adolescents.
All of the following criteria must be met:
e.
May 17, 2013
1.
The patient is evaluated by an endocrinologist.
2.
Patient has a growth hormone deficiency either alone or with multiple
hormone deficiencies (hypopituitarism), as a result of either disease of the
pituitary or hypothalamus, or injury to either the pituitary or hypothalamus
from surgery radiation therapy or trauma.
3.
Patient is receiving adequate replacement therapy for any other pituitary
hormone deficiencies, such as thyroid, glucocorticoids or gonadotropic
hormone. Patient has failed to respond to standard growth stimulation
tests. Exception: Complete hypopituitarism.
4.
Patient has failed a growth hormone stimulation test. Failure generally
defined as a maximum peak of <5ng/ml.
Human Immune Deficiency Virus/Acquired Immune Deficiency Syndrome
(HIV/AIDS) Wasting or Cachexia.
PRESCRIBED DRUGS
Appendix A Page 13
Agents selected for treatment must have an FDA approved indication for the
diagnosis being treated as stated in the package insert.
The following criteria must be met for the treatment of HIV/AIDS wasting or
cachexia:
1.
Patient must be stable on antiretroviral therapy and compliant with
therapy.
2.
Documented involuntary weight loss greater than 10% pre-illness baseline
or a body mass index of <20KG/M2 (weight and diagnosis must be
confirmed by faxed chart notes).
3.
a.
Patient has failed to adequately respond to dietary measures.
b.
Patient has failed to respond or is intolerant to appetite-stimulating
drugs, (e.g. Megace) and anabolic steroids.
c.
Absence of a concurrent illness or medical condition other than
HIV infection that would explain these findings.
No active malignancy other than Kaposi’s Sarcoma.
Prior authorization will be given for 12 weeks.
If patient maintains or gains weight, is experiencing no adverse events, and is
being monitored on a regular basis by the prescriber, approve the prior
authorization for 12 additional weeks. Subsequent prior authorization approvals
based on this criteria may be granted in 12 week increments.
f.
Requests involving the following should be denied:
1.
Indications other than those specified above.
2.
Any condition that is considered contraindicated and/or considered to be
experimental.
3.
Patients who do not meet the criteria.
Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
Growth Hormones are subject to prior authorization and quantity limitations based on the
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity
limits.
May 17, 2013
PRESCRIBED DRUGS
Appendix A Page 14
1.
Coverage and Limitations:
Approval will be given if the following criteria are met and documented.
a.
Genotropin®
(somatropin);
Humatrope®
(somatropin);
Norditropin®
(somatropin); Nutropin® (somatropin); Omnitrope® (somatropin); Saizen®
(somatropin); Tev-Tropin® (somatropin):
1.
Children, (up to age 21, with open epiphyses and with remaining growth
potential) must meet all of the following:
a.
The recipient has had an evaluation by a pediatric endocrinologist
or pediatric nephrologist with a recommendation for growth
hormone therapy; and
b.
The recipient has had an evaluation ruling out all other causes for
short stature; and
c.
The recipient is receiving adequate replacement therapy for any
other pituitary hormone deficiencies, such as thyroid,
glucocorticoids or gonadotropic hormones.
The recipient must then meet one of the following:
May 17, 2013
1.
The recipient has a diagnosis of Noonan Syndrome, PraderWilli Syndrome or Turner Syndrome and their height is as
least two standard deviations below the mean or below the
third percentile for the patient’s age and gender; or
2.
The recipient has a diagnosis of chronic renal insufficiency
(<75 mL/minute, and their height is at least two standard
deviations below the mean or below the third percentile for
the recipient’s age and gender; or
3.
The recipient has a diagnosis of being small for gestational
age, the recipient is two years of age or older, and their
height is at least two standard deviations below the mean or
below the third percentile for the recipient’s age and
gender; or
4.
The recipient is a newborn infant with evidence of
hypoglycemia, and has low growth hormone level (<20
ng/mL), low for age insulin like growth factor (IGF)-1 or
IGF binding protein (BP) 3 (no stimulation test required for
infants); or
PRESCRIBED DRUGS
Appendix A Page 15
5.
The recipient has a diagnosis of growth hormone deficiency
or hypothalamic pituitary disease (e.g., hypopituitarism due
to structure lesions/trauma to the pituitary including
pituitary tumor, pituitary surgical damage, trauma or
cranial irradiation), and their height is at least two standard
deviations below the mean or below the third percentile for
the patient’s age and gender.
And recipient must meet one of the following:
2.
a.
The recipient has failed two growth hormone
stimulation tests (<10 ng/mL); or
b.
The recipient has failed one growth hormone
stimulation test (<10 ng/mL) and one IGF-1 or
IGFBP-3 test; or
c.
The recipient has failed one growth hormone
stimulation test (<10 ng/mL) or IGF-1 or IGFBP-3
test and they have deficiencies in three or more
pituitary axes (e.g., thyroid stimulating hormone
(TSH), luteinizing hormone (LH), follicle
stimulating hormone (FSH), adrenocorticotropic
hormone (ACTH) or antidiuretic hormone (ADH).
Adults, (age 21 years and older, with closed epiphyses, and no remaining
growth potential) must meet all of the following:
a.
The recipient is being evaluated by an endocrinologist; and
b.
The recipient is receiving adequate replacement therapy for any
other pituitary hormone deficiencies, such as thyroid,
glucocorticoids or gonadotropic hormones; and
c.
The recipient has a diagnosis of growth hormone deficiency or
hypothalamic pituitary disease (e.g., hypopituitarism due to
structure lesions/trauma to the pituitary including pituitary tumor,
pituitary surgical damage, trauma, or cranial irradiation) and
The recipient must then meet one of the following:
May 17, 2013
1.
The recipient has failed two growth hormone stimulation
tests (<5 ng/mL); or
2.
The recipient has failed one growth hormone stimulation
test (<5 ng/mL) and one IGF-1 or IGFBP-3 test; or
PRESCRIBED DRUGS
Appendix A Page 16
3.
3.
4.
b.
The recipient has failed one growth hormone stimulation
test (<5 ng/mL) or IGFBP-3 test and has deficiencies in
three or more pituitary axes (i.e., TSH, LH, FSH, ACTH,
ADH), and has severe clinical manifestations of growth
hormone deficiency as evident by alterations in body
composition (e.g., decreased lean body mass, increased
body fat), cardiovascular function (e.g., reduced cardiac
output, lipid abnormalities) or bone mineral density.
Continued authorization will be given for recipients (up to age 21, with
remaining growth potential) who meet all of the following:
a.
The recipient has a diagnosis of chronic renal insufficiency, growth
hormone deficiency, hypothalamic pituitary disease, newborn
infant with evidence of hypoglycemia, Noonan Syndrome, PraderWilli Syndrome, small for gestational age or Turner Syndrome;
and
b.
The recipient’s epiphyses are open; and
c.
The recipient’s growth rate on treatment is at least 2.5 cm/year;
and
d.
The recipient does not have evidence of an expanding lesion or
tumor formation; and
e.
The recipient has not undergone a renal transplant.
Continued authorization will be given for recipients (age 21 years and
older, with closed epiphyses and no remaining growth potential) who
meet all of the following:
a.
The recipient has a diagnosis of growth hormone deficiency or
hypothalamic pituitary disease; and
b.
There is documentation of improvement in clinical manifestations
associated with growth hormone deficiency.
Serostim® (somatropin)
Recipients must meet all of the following:
1.
May 17, 2013
The recipient has a diagnosis of Human Immune Deficiency Virus (HIV)
with wasting or cachexia; and
PRESCRIBED DRUGS
Appendix A Page 17
c.
2.
The medication is indicated to increase lean body mass, body weight and
physical endurance; and
3.
The recipient is receiving and is compliant with antiretroviral therapy; and
4.
The recipient has experienced an involuntary weight loss of >10% preillness baseline or they have a body mass index of <20 kg/m²; and
5.
The recipient has experienced an adverse event, allergy or inadequate
response to megestrol acetate, or the recipient has a contraindication to
treatment with this agent; and
6.
The recipient has experienced an adverse event, allergy or inadequate
response to an anabolic steroid (e.g., testosterone, oxandrolone,
nandrolone), or the recipient has a contraindication to treatment with these
agents.
Zorbtive® (somatropin)
Recipients must meet all of the following:
2.
May 17, 2013
1.
The recipient has a diagnosis of short bowel syndrome; and
2.
The recipient is age 18 years or older; and
3.
The medication is being prescribed by or following a consultation with a
gastroenterologist; and
4.
The recipient is receiving specialized nutritional support (e.g., high
carbohydrate, low-fat diets via enteral or parenteral nutrition).
Prior Authorization Guidelines:
a.
Prior Authorization approval will be 12 weeks for Serostim® (somatropin).
b.
Prior Authorization approval will be six months for initial authorization (for all
somatropin products except for Serostim®).
c.
Prior Authorization approval will be one year for continuing treatment (for all
somatropin products except Serostim®).
d.
PRESCRIBED DRUGS
Appendix A Page 18
G.
Fentora® and Actiq® (Fentanyl Citrate Buccal Tablet and Lozenge)Immediate-Release Fentanyl
Products
Therapeutic Class: Analgesics, Narcotic
Last Reviewed by the DUR Board: July 30, 2009 25, 2013
1.
Fentanyl Citrate and Buccal Tablets and Lozenges Immediate-Release Fentanyl Products are
subject to prior authorization and quantity limitations based on the Application of Standards in
Section 1927 of the Social Security Act and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1.
Approval will be given if the following criteria are met and documented:
2.
May 17, 2013
a.
Recipient must be age 18 years or older to receive fentanyl citrate buccal tablets;
b.
Recipient must be age 16 years or older to receive fentanyl citrate lozenges; and
c.
Recipient must have pain due to a malignancy; and
d.
Recipient is already receiving and is tolerant to opioid therapy; and
e.
Recipient is intolerant of two other immediate-release opioids including
morphine, hydrocodone, oxycodone, or hydromorphone.
Non-Covered Indications
a.
Recipient with non-malignant pain including but not limited to fibromyalgia,
migraines, headaches, peripheral neuropathy, chronic pain syndrome.
b.
Recipient is not opioid tolerant.
c.
Recipient diagnosis is for acute pain or chronic pain due to surgery or injury.
d.
Recipient diagnosis is for migraine/headache pain relief or prevention.
e.
a.
Recipients not taking chronic opiates.
Subsys® (fentanyl sublingual spray), Onsolis® (fentanyl citrate buccal film),
Fentora® (fentanyl citrate buccal tablet), Lazanda® (fentanyl citrate nasal spray),
Abstral® (fentanyl citrate sublingual tablet) and Actiq® (fentanyl citrate
transmucosal lozenge):
PRESCRIBED DRUGS
Appendix A Page 21
The recipient must meet all of the following:
32.
1.
The recipient is ≥ 18 years of age or ≥ 16 years of age if requesting
fentanyl citrate transmucosal lozenge (Actiq®); and
2.
The recipient has pain resulting from a malignancy; and
3.
The recipient is already receiving and is tolerant to opioid therapy; and
4.
The recipient is intolerant of at least two of the following immediaterelease opioids: hydrocodone, hydromorphone, morphine or oxycodone.
Prior Authorization Guidelines
a.
Initial pPrior aAuthorization approval will be for six months.
Continued coverage will require documentation of continued pain from the malignancy
and the recipient is unable to use other oral dosage forms.
b.
May 17, 2013
PRESCRIBED DRUGS
Appendix A Page 22
H.
Hematopoietic/Hematinic Agents
Therapeutic Class: Erythropoiesis Stimulating Agents (ESAs)
Last Reviewed by the DUR Board: January 24, 2008
This policy applies in all settings with the exception of inpatient facilities. Hematopoietics and
Hematinics are subject to prior authorizations and quantity limitations based on the Application
of Standards in Section 1927 of the Social Security Act and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1.
Recipients must meet one of the following criteria for coverage:
a.
b.
2.
May 17, 2013
Achieve and maintain hemoglobin levels within the range of 10 to 12 gm/dl in
one of the following conditions:
1.
Treatment of
chemotherapy.
anemia
secondary to
myelosuppressive
anticancer
2.
Treatment of anemia related to zidovudine therapy in HIV-infected
patients.
3.
Treatment of anemia secondary to End Stage Renal Disease (ESRD).
Epoetin alfa (Epogen®) is indicated to reduce the need for allogenic transfusions
in surgery patients when a significant blood loss is anticipated. It may be used to
achieve and maintain hemoglobin levels within the range of 10 to 13 gm/dl.
Darbepoetin Alfa (Aranesp®) does not have this indication.
Non-Covered Indications
a.
Any anemia in cancer or cancer treatment patients due to folate deficiency, B-12
deficiency, iron deficiency, hemolysis, bleeding, or bone marrow fibrosis.
b.
Anemia associated with the treatment of acute and chronic myelogenous
leukemias (CML, AML), or erythroid cancers.
c.
Anemia of cancer not related to cancer treatment.
d.
Any anemia associated only with radiotherapy.
e.
Prophylactic use to prevent chemotherapy-induced anemia.
f.
Prophylactic use to reduce tumor hypoxia.
PRESCRIBED DRUGS
Appendix A Page 23
L.
Injectable Immunomodulator Drugs
Therapeutic Class: Immunomodulators, Injectable
Last Reviewed by the DUR Board: June 3, 2010
Actemra® (tocilizumab)
Amevive® (alefacept)
Enbrel® (etanercept)
Humira® (adalimumab)
Simponi™ (golimumab)
Cimzia® (certolizumab pegol)
Kineret® (ankinra)
Orencia® (abatacept)
Remicade® (infliximab)
Stelara™ (ustekinumab)
Injectable immunomodulator drugs are subject to prior authorization.
1.
a.
Rheumatoid Arthritis (Enbrel®, Humira®, Remicade®, Orencia®, Kineret®,
Cimzia®, Simponi™, Actemra®):
1.
Diagnosis of rheumatoid arthritis; and
2.
Rheumatology consult with date of visit; and
3.
Negative tuberculin test (Remicade®, Humira®, Orencia®, Cimzia®,
Enbrel®, Simponi™, Actemra®) or if positive, therapy with isoniazid was
initiated at least one month prior to request;
4.
Patient does not have an active infection or a history of recurring
infections;
5.
Patient has had RA for ≤ six months (early RA) and has high disease
activity;
Patient has had RA for ≥ six months (intermediate or long-term disease
duration) and has moderate disease activity and has an inadequate
response to a Disease Modifying Antirheumatic Drug (DMARD)
(methotrexate, hydroxychloroquine, leflunomide, minocycline or
sulfasalazine); or
6.
b.
Psoriatic Arthritis (Enbrel®, Humira®, Remicade®, Simponi™):
1.
May 17, 2013
Patient has had RA for ≥ six months (intermediate or long-term disease
duration) and has high disease activity.
Diagnosis of moderate or severe psoriatic arthritis; and
PRESCRIBED DRUGS
Appendix A Page 28
c.
d.
May 17, 2013
2.
Rheumatology consult with date of visit or Dermatology consult with date
of visit;
3.
Inadequate response to any one NSAID or contraindication to treatment
with an NSAID or to any one of the following DMARD (methotrexate,
leflunomide, cyclosporine or sulfasalazine) as documented by a physician;
4.
Negative tuberculin test (Enbrel®, Humira®, Remicade®, Simponi™) or
if positive, therapy with isoniazid was initiated at least one month prior to
request; and
5.
Patient does not have active infection or a history of recurring infections.
Ankylosing Spondylitis (Enbrel®, Remicade®, Humira®, Simponi™):
1.
Diagnosis of ankylosing spondylitis; and
2.
Inadequate response to NSAIDs and to any one of the DMARDs
(methotrexate,
hydroxychloroquine,
sulfasalzine,
leflunomide,
minocycline);
3.
Negative tuberculin test (Enbrel®, Humira®, Remicade®, Simponi™) or
if positive, isoniazid was initiated at least one month prior to request; and
4.
infections.
Juvenile Rheumatoid Arthritis/Juvenile Idiopathic Arthritis (Enbrel®, Humira®,
Orencia®, Actemra®):
1.
Diagnosis of moderately or severely active juvenile rheumatoid arthritis;
and
2.
Patient is at least two years of age; and
3.
At least five swollen joints; and
4.
Three or more joints with limitation of motion and pain, tenderness or
both; and
5.
Inadequate response to one DMARD;
6.
Negative tuberculin test (Enbrel®, Humira®, Orencia®), or if positive,
isoniazid was initiated at least one month prior to request; and
PRESCRIBED DRUGS
Appendix A Page 29
7.
e.
f.
g.
May 17, 2013
infections.
Plaque Psoriasis (Amevive®, Enbrel®, Humira®, Remicade®, Stelara™):
1.
Diagnosis of chronic, moderate to severe plaque psoriasis; and
2.
Prescribed by a dermatologist; and
3.
Failed to adequately respond to a topical agent; and
4.
Failed to adequately respond to at least one oral treatment;
5.
Negative tuberculin test (Amevive®, Humira®, Enbrel®, Remicade®,
Stelara™) or if positive, therapy with isoniazid was initiated at least one
month prior to request; and
6.
infections.
Crohn’s Disease (Cimzia®, Humira®, Remicade®):
1.
Diagnosis of moderate to severe Crohn’s Disease; and
2.
Failed to adequately respond to conventional therapy (e.g. sulfasalzine,
mesalamine, antibiotics, corticosteroids, azathioprine, 6-mercaptopurine,
parenteral methotrexate) or those with fistulizing Crohn’s disease, and;
3.
Negative tuberculin test, or if positive, isoniazid therapy was initiated at
least one month prior to request (Cimzia®, Humira®, Remicade®); and
4.
infections.
Ulcerative Colitis (Remicade®):
1.
Diagnosis of moderate to severe ulcerative colitis; and
2.
Failed to adequately respond to one or more of the following standard
therapies:
a.
Corticosteroids;
b.
5-aminosalicylic acid agents;
c.
Immunosuppresants; and/or
PRESCRIBED DRUGS
Appendix A Page 30
V.
Sedative Hypnotics
Therapeutic Class:
Last Reviewed by the DUR Board:
Sedatives Hypnotics are subject to prior authorization and quantity limitations based on the
limits.
1.
Quantity limit of 30 tablets per month of only one strength.
May 17, 2013
PRESCRIBED DRUGS
Appendix A Page 44
X.
Antiemetics – Serotonin Receptor Antagonists (also known as 5-HT3 Antiemetics)
Therapeutic Class: Antiemetics, Antivertigo Agents
Last Reviewed by the DUR Board: October 28, 2010
1.
5-HT3 Antiemetics are subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the Social Security Act and/or approved
by the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for
specific quantity limits.
An approved prior authorization is required for any prescription exceeding the quantity
limits. Approval for additional medication beyond these limits will be considered only
under the following circumstances:
2.
a.
The recipient has failed on chemotherapy-related antiemetic therapy at lower
doses; or
b.
The recipient is receiving chemotherapy treatments more often than once a week;
or
c.
The recipient has a diagnosis of AIDS associated nausea and vomiting; or
d.
The recipient has a diagnosis of hyperemesis gravidarum and has failed at least
one other antiemetic therapy or all other available therapies are medically
contraindicated.
A prior authorization to override the quantity limits to allow for a 30 day fill for these
drugs may be effective for up to six months.
May 17, 2013
PRESCRIBED DRUGS
Appendix A Page 46
Z.
Cymbalta® (duloxetine)
Therapeutic Class: Sertonin-Norepinephrine Reuptake Inhibitor (SNRI)
Last Reviewed by the DUR Board: Not AvailableJuly 25, 2013
Cymbalta® (duloxetine) is subject to prior authorization and quantity limitations based on the
limits.
1.
Approval will be given if the following criteria are met and documented. Recipients
must meet at least one diagnosis listed below:
1.a.
b.
c.
Diabetic Peripheral Neuropathy (DPN):
a.1.
If an ICD-9 code of 250.6 Diabetes with Neurological Manifestations is
documented on the prescription and transmitted on the claim; or
b.2.
Completion of a prior authorization documenting a diagnosis of Diabetes
with Neurological Manifestations.
2.
Fibromyalgia:
1.
a.
If an ICD-9 code 729.1 Myalgia and Myositis unspecified is
documented on the prescription and transmitted on the claim; or
2.
b.
Completion of a prior authorization documenting a diagnosis of
Fibromyalgia and/or Myalgia and Myositis, unspecified.
Chronic Musculoskeletal Pain:
The recipient must meet one of the following:
d.
1.
The recipient has experienced an inadequate response or adverse event to
at least two oral or topical non-steroidal anti-inflammatory drug
(NSAIDS); or
2.
The recipient has an allergy or contraindication to two NSAIDS.
Generalized Anxiety Disorder:
The recipient must meet the following:
May 17, 2013
PRESCRIBED DRUGS
Appendix A Page 49
1.
e.
The recipient has experienced an inadequate response or adverse event to
at least two antidepressants from any of the following classes: selective
serotonin reuptake inhibitors, tricyclic antidepressants, serotonin and
norepinephrine reuptake inhibitors or buspirone.
Major Depressive Disorder:
The recipient must meet the following:
1.
2.
May 17, 2013
The recipient has experienced an inadequate response, and/or adverse
event and/or an allergy and/or contraindication to at least two
antidepressants.
a.
Prior Authorization approval will be for one year.
b.
PRESCRIBED DRUGS
Appendix A Page 50
BB.
Buprenorphine/Naloxone (Suboxone®)
(Subutex®) (buprenorphine)
(buprenorphine/naloxone)
and
Buprenorphine
Therapeutic Class: Narcotic Withdrawal Therapy Agents
Last Reviewed by the DUR Board: June 3, 2010 July 25, 2013
Buprenorphine/Naloxone (Brand Suboxone®) and Buprenorphine (Brand Subutex®) is are
subject to prior authorization and quantity limitations based on the Application of Standards in
Section 1927 of the Social Security Act and/or approved by the DUR Board. Refer to the Nevada
1.
Nevada Medicaid encourages recipients to participate in formal substance abuse
counseling and treatment.
AuthorizationApproval will be given if all of the following criteria are met and
documented:
May 17, 2013
a.
Diagnosis of Opioid Dependence;
b.
Patient is 16 years of age or older;
c.
Medication is prescribed by a physician with a Drug Addiction Treatment Act
(DATA) of 2000 waiver:
1.
Authorizes a physician to treat narcotic-dependent patients using Schedule
III-V substances without obtaining a separate Drug Enforcement Agency
(DEA) registration as a narcotic treatment program.
2.
A Unique Identification Number (UIN), in addition to the DEA number, is
required on the prescription, and is the same as the DEA number except an
“X” replaces the first alpha character of the DEA number.
d.
Formal substance abuse counseling/treatment must be in place or, if the prescriber
is a psychiatrist or certified addiction specialist, they may confirm that they
personally render the counseling;
e.
Document the name of the specific substance abuse program or the name of the
psychiatrist or certified addiction specialist that will provide the counseling
services. The program license number and/or the treating psychiatrist’s or
certified addiction specialist’s license number may be requested and documented;
and
f.
Confirm that the patient has honored all of their office visits and counseling
sessions in a compliant manner.
PRESCRIBED DRUGS
Appendix A Page 52
a.
Buprenorphine/Naloxone (Suboxone®)
b.
1.
The recipient has a diagnosis of opioid dependence; and
2.
The recipient is 16 years of age or older; and
3.
There is documentation that the recipient has honored all of their office
visits; and
4.
The medication is being prescribed by a physician with a Drug Addiction
Treatment Act (DATA) of 2000 waiver who has a unique “X” DEA
number.
Buprenorphine (Subutex®) (for female recipients):
2.
May 17, 2013
1.
There is documentation that the recipient is pregnant or there is
documentation the recipient is breastfeeding an infant who is dependent on
methadone or morphine; and
2.
The recipient has a diagnosis of opioid dependence; and
3.
The recipient is 16 years of age or older; and
4.
There is documentation that the recipient has honored all of their office
visits; and
5.
The medication is being prescribed by a physician with a Drug Addiction
Treatment Act (DATA) of 2000 waiver who has a unique “X” DEA
number.
a.
b.
PRESCRIBED DRUGS
Appendix A Page 53
CC.
Ampyra™® (dalfampridine)
Therapeutic Class: Agents for the treatment of Neuromuscular Transmission Disorder
Last Reviewed by the DUR Board: July 22, 2010 July 25, 2013
Ampyra™® (dalfampridine) is subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the Social Security Act and/or approved by the
DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1.
Approval for Ampyra™® (dalfampridine) will be given if all of the following criteria are
met and documented:
a.
Prescriber is a neurologist;
b.
The patient has a diagnosis of Multiple Sclerosis (ICD-9 code of 340);
c.
The use is for the FDA Approved Indication: to improve walking;
d.
The patient is ambulatory and has an EDSS score between 2.5 and 6.5;
e.
The patient has undergone a timed 25 foot walk to establish baseline walking
speed and baseline walking speed is documented to be between eight and 45
seconds;
f.
The patient does not have moderate to severe renal dysfunction (CrCL >
50ml/min);
g.
The patient does not have a history of seizures; and
h.
a.
The patient is not pregnant.
Ampyra® (dalfampridine)
May 17, 2013
1.
The recipient must have a diagnosis of Multiple Sclerosis (ICD-9 code of
340); and
2.
The medication is being used to improve the recipient’s walking speed;
and
3.
The medication is being prescribed by or in consultation with a
neurologist; and
PRESCRIBED DRUGS
Appendix A Page 54
2.
4.
The recipient is ambulatory and has an EDSS score between 2.5 and 6.5;
and
5.
The recipient does not have moderate to severe renal dysfunction (CrCL
>50 ml/min); and
6.
The recipient does not have a history of seizures; and
7.
The recipient is not currently pregnant or attempting to conceive.
The prior authorization initial approval duration is 12 weeks. At 12 weeks of treatment,
the prescriber may request continuation of the prior authorization.
a.
Initial Prior Authorization approval will be for three months.
3.
b.
Requests for continuation of therapy will be approved for one year.
c.
Criteria for renewal of the prior authorization
Approval for continuation of Ampyra™ (dalfampridine) will be given if all of the
following criteria are met and documented:
4.
a.
Patient still meets all initial criteria;
b.
Patient has demonstrated an improvement in timed walking speed of at least 20%
on Ampyra™; and
c.
The patient is not pregnant.
Renewal Prior Authorization Guidelines
The duration of renewal of the prior authorization is one year.
May 17, 2013
PRESCRIBED DRUGS
Appendix A Page 55
FF.
Pradaxa® (dabigatran etexilate); Eliquis® (apixaban); Xarelto® (rivaroxaban)
Therapeutic Class: Thrombin Inhibitors
Last Reviewed by the DUR Board: Not Available July 25, 2013
Pradaxa® (dabigatran etexilate), Eliquis® (apixaban) and Xarelto® (rivaroxaban) is are subject
to prior authorization and quantity limitations based on the Application of Standards in Section
1927 of the Social Security Act and/or approved by the DUR Board. Refer to the Nevada
1.
a.
b.
May 17, 2013
Recipient has a diagnosis of non-valvular (no prosthetic valve) atrial fibrillation;
andPradaxa® (dabigatran etexilate)
1.
An ICD-9 code of 427.31 (Atrial Fibrillation) documented on the
prescription and transmitted on the claim; or
2.
An approved Prior Authorization documenting the recipient having all of
the following and:
a.
The recipient has a diagnosis of nonvalvular Atrial Fibrillation;
and
b.
The recipient does not have an active pathological bleed; and
c.
The recipient does not have a mechanical prosthetic heart valve.
Recipient has at least one of the following documented risk factors for stroke:
1.
History of stroke, TIA, or systemic embolism; or
2.
Age ≥75 years; or
3.
Diabetes Mellitus; or
4.
History of left ventricular dysfunction or heart failure; or
5.
Age ≥65 years with the presence of one of the following:
1.
Diabetes mellitus; or
2.
Coronary artery disease (CAD); or
PRESCRIBED DRUGS
Appendix A Page 58
c.
3.
Hypertension; and
Recipient has failed warfarin therapy or has a contraindication to warfarin
therapy. Failure consists of an adequate trial of at least three months where the
goal INR (2.0-3.0) has not been achieved (most recent two INR values outside of
the therapeutic range). If recipient is being transitioned from warfarin to
dabigatran etexilate, current INR is <2.0; and
d.
Recipient is >18 years of age; and
e.
Recipient does not have a history of any of the following:
1.
Gastrointestinal bleeding.
2.
3.
Pathological bleeding.
Rheumatic heart disease.
4.
Mechanical valve prosthesis.
5.
Mitral valve disease.
6.
Severe renal impairment (estimated creatitine clearance <15 mL/minute)
or on dialysis.
7.
Inability to take capsules whole (capsules must not be broken, chewed or
opened).
Recipient is not receiving traditional (non-selective) nonsteroidal anti8.
inflammatory drugs (NSAIDs).
2.
Length of approval: up to one year.
b.
Eliquis® (apixaban)
c.
1.
An ICD-9 code of 427.31 (Atrial Fibrillation) documented on the
prescription and transmitted on the claim; or
2.
An approved Prior Authorization documenting the recipient having all of
the following:
The recipient has a diagnosis of nonvalvular Atrial Fibrilation; and
b.
The recipient does not have an active pathological bleed.
Xarelto® (rivaroxaban)
1.
May 17, 2013
a.
An ICD-9 code of 427.31 (Atrial Fibrillation) or an ICD-9 code beginning
with 415.1 (Pulmonary Embolism and Infarction) or an ICD-9 code
PRESCRIBED DRUGS
Appendix A Page 59
beginning with 453.4 (Acute Venous Embolism and Thrombosis of Deep
Vessels of Lower Extremity) documented on the prescription and
transmitted on the claim; or
2.
2.
May 17, 2013
An approved Prior Authorization documenting the recipient meeting all of
the following:
a.
The recipient has a diagnosis of nonvalvular Atrial Fibrillation, or
Deep Vein Thrombosis (DVT), or Pulmonary Embolism (PE), or
treatment is needed for the reduction in the risk of recurrence of
the DVT or PE; and
b.
The recipient does not have an active pathological bleed.
a.
Prior Authorization approval will be for up to one year.
b.
PRESCRIBED DRUGS
Appendix A Page 60
KK.
Xarelto® (rivaroxaban)Hereditary Angioedema Agents
Therapeutic Class: Direct Factor XO Inhibitors
Last Reviewed by the DUR Board: July 26, 2012
Xarelto® (rivaroxaban) is subject to prior authorization and quantity limitations based on the
limits.
1.
Authorization will be given if the following criteria are met and documented:
2.
a.
The recipient has a diagnosis of nonvalvular atrial fibrillation;
b.
The recipient does not have an active pathological bleed; and
c.
The recipient has failed to consistently achieve and maintain an INR of 2.0 to 3.0
on warfarin therapy despite an adequate trial that included patient education and
dose titration; or
d.
The recipient experienced an adverse event with warfarin therapy; or
e.
The recipient has an allergy or contraindication to warfarin therapy; or
f.
The recipient has a barrier of access to care.
Prior Authorization Guidelines:
a.
Prior authorization will be for one year.
b.
c.
Xarelto® 10 mg tablets are available without prior authorization and are indicated
for the prophylaxis of deep vein thrombosis in patients undergoing knee or hip
replacement surgery.
Therapeutic Class: Hereditary Angioedema Agents
Last Reviewed By DUR Board: July 25, 2013
Hereditary angioedema agents are subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the Social Security Act and/or approved by the
DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity
limits.
May 17, 2013
PRESCRIBED DRUGS
Appendix A Page 66
1.
Approval will be given if all the following criteria are met and documented:
a.
Cinryze® (C1 esterase inhibitor)
b.
1.
The recipient has a diagnosis of hereditary angioedema; and
2.
The medication is being prescribed by or in consultation with an allergist
or immunologist; and
3.
The medication is being used as prophylaxis for hereditary angioedema
attacks; and
4.
The recipient has experienced an inadequate response or adverse event
with an attenuated androgen (e.g. danazol, stanozolol) or antifibrinolytic
(e.g. tranexamic acid, aminocaproic acid) agent or has a contraindication
to all agents in these classes; and
5.
The recipient routinely experiences more than one hereditary angioedema
attack per month, or the recipient has a history of laryngeal attacks.
Berinert® (C1 esterase inhibitor), Kalbitor® (ecallantide) and Firazyr®
(icatibant)
2.
May 17, 2013
1.
The recipient has a diagnosis of hereditary angioedema; and
2.
The medication is being prescribed by or in consultation with an allergist
or immunologist; and
3.
The medication is being used to treat acute hereditary angioedema attacks.
a.
Initial Prior Authorization approval will be for six months.
b.
Prior Authorization requests for continuation therapy will be approved for one
year.
c.
PRESCRIBED DRUGS
Appendix A Page 67
RR.
Cesamet® (Nabilone) and Marinol® (Dronabinol)
Therapeutic Class: Antiemetic
Last Reviewed by DUR Board: October 25, 2012
Cesamet® (Nabilone) and Marinol® (Dronabinol) are subject to prior authorization and quantity
limitations based on the Application of Standards in Section 1927 of the Social Security Act
and/or approved by the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy
Manual for specific quantity limits.
1.
Approval will be given if all the following criteria are met and documented:
a.
b.
Cesamet® (Nabilone)
1.
The recipient has a diagnosis of chemotherapy-induced nausea and/or
vomiting; and
2.
The recipient has experienced an inadequate response, adverse event, or has
a contraindication to at least one serotonin receptor antagonist; and
3.
The recipient has experienced an inadequate response, adverse event or has
a contraindication to at least one other antiemetic agent; and
4.
The prescriber is aware of the potential for mental status changes
associated with the use of this agent and will closely monitor the recipient.
Marinol® (Dronabinol)
1.
November 1, 2013
The recipient has a diagnosis of chemotherapy-induced nausea and/or
vomiting; and
a.
2.
The recipient has experienced an inadequate response,
adverse event or has a contraindication to at least one serotonin
receptor antagonist; and
b.
3.
adverse event or has a contraindication to at least one other
antiemetic agent; and
c.
4.
The prescriber is aware of the potential for mental status
changes associated with the use of this agent and will closely
monitor the recipient; or
PRESCRIBED DRUGS
Appendix A Page 75
52.
2.
November 1, 2013
The recipient has been diagnosed with Acquired Immune Deficiency
Syndrome (AIDS) and has anorexia associated with weight loss; and
a.
6.
adverse event or has a contraindication to megestrol (Megace®);
and
b.
7.
The prescriber is aware of the potential for mental status
changes associated with the use of this agent and will closely
monitor the recipient.
a.
b.
PRESCRIBED DRUGS
Appendix A Page 76
SS.
Omontys® (Peginesatide)
Therapeutic Class: Erythropoiesis Stimulating Agent (ESA)
Last Reviewed by DUR Board: October 25, 2012
Omontys® (Peginesatide) is subject to prior authorization based on the Application of Standards
in Section 1927 of the Social Security Act and/or approved by the DUR Board.
1.
2.
November 1, 2013
a.
The recipient has a diagnosis of anemia secondary to chronic kidney disease, and
b.
The recipient must be over 18 years of age;
c.
The recipient is receiving dialysis;
d.
Other causes for anemia have been evaluated and ruled out (e.g., iron, vitamin B12
or folate deficiencies);
e.
The recipient’s hemoglobin level is <10 g/dL, (laboratory values from the previous
14 days must accompany the request); and
f.
The target hemoglobin level will not exceed 11 g/dL.
a.
Prior Authorization approval will be for one yearmonth.
b.
PRESCRIBED DRUGS
Appendix A Page 77
TT.
Colony Stimulating Factors (Point of Sale Claims Only)
Therapeutic Class: Colony Stimulating Factors
Last Reviewed by the DUR Board: July 25, 2013
Colony Stimulating Factors are subject to prior authorization and quantity limitations based on the
limits.
1.
a.
Leukine® (sargramostim)
The recipient must meet one of the following:
b.
1.
The requested medication is being used for mobilization of hematopoietic
progenitor cells into the peripheral blood for collection by leukapheresis;
or
2.
The recipient has a diagnosis of acute myeloid leukemia, and has received
induction chemotherapy; or
3.
The recipient has a diagnosis of non-Hodgkin’s lymphoma, acute
lymphoblastic leukemia or Hodgkin’s disease and is undergoing
autologous bone marrow transplantation; or
4.
The recipient is undergoing allogeneic bone marrow transplantation from
human leukocyte antigen-matched related donors; or
5.
The recipient has undergone allogeneic or autologous bone marrow
transplantation and is experiencing engraftment failure or delay.
Neulasta® (pegfilgrastim)
The recipient must meet the following criteria:
1.
November 1, 2013
The recipient has a diagnosis of nonmyeloid malignancy and
a.
The recipient is receiving myelosuppressive anticancer drugs that
are associated with a febrile neutropenia risk of ≥ 20%; or
b.
The recipient is at high risk for complications from neutropenia
(e.g., sepsis syndrome, current infection, age >65, absolute
PRESCRIBED DRUGS
Appendix A Page 78
neutrophil count (ANC) <100 cells/µL, or the expected duration of
neutropenia is > 10 days); or
c.
c.
The recipient has experienced a prior episode of febrile
neutropenia and the requested drug will be used as secondary
prophylaxis.
Neupogen® (filgrastim)
The recipient must meet one of the following (1 to 5):
1.
2.
November 1, 2013
The recipient has a diagnosis of nonmyeloid malignancy; and
a.
The recipient is receiving myelosuppressive anticancer drugs that
are associated with a febrile neutropenia risk of ≥20%; or
b.
The recipient is at high risk for complications from neutropenia
(e.g., sepsis syndrome, current infection, age >65, ANC <100
cells/µL or the expected duration of neutropenia is >10 days); or
c.
The recipient has experienced a prior episode of febrile
neutropenia and the requested drug will be used as a secondary
prophylaxis; or
2.
The recipient has a diagnosis of acute myeloid leukemia and has received
induction or consolidation chemotherapy; or
3.
The recipient has a diagnosis of nonmyeloid malignancy and is
undergoing myeloablative chemotherapy followed by marrow
transplantation; or
4.
The recipient has a diagnosis of symptomatic congenital neutropenia,
cyclic neutropenia or idiopathic neutropenia; or
5.
The requested medication is being used for mobilization of hematopoietic
progenitor cells into the peripheral blood for collection by leukapheresis.
a.
Prior Authorization approval will be for one month.
b.
PRESCRIBED DRUGS
Appendix A Page 79
TRANSMITTAL LETTER
June 12, 2014
TO:
FROM:
SUBJECT:
CHAPTER 2800 – SCHOOL BASED CHILD HEALTH SERVICES
Revisions to MSM Chapter 2800 are being proposed to reflect the requirement in 34 Code of
Federal Regulation (CFR) 300.154(d)(2)(iv) that parental consent be on file and to add a parental
notification requirement as mandated by 34 CFR 300.154(d)(2)(v).
CL 27631
CHAPTER 2800 – SCHOOL BASED
CHILD HEALTH SERVICES
MATERIAL SUPERSEDED
MTL 45/10
CHAPTER 2800 – SCHOOL BASED CHILD
HEALTH SERVICES
Background and Explanation of Policy
Changes, Clarifications and Updates
Manual Section
Section Title
2803.1A.4.p
Policy – Coverage and
Limitations – NonCovered SBCHS
Added language “without parental consent and
notification documented services are not
covered.”
2803.1B.9
Policy – Provider
Responsibility –
Eligibility Verification
Removed link to the Quality Improvement
Organization (QIO)-like vendor.
2803.1B.13
Policy – Provider
Responsibility –
Parental Notification
and Consent
Added the words “Notification And” in the title
for parent notification and consent.
2803.1D.1
Added language that includes parental
notification in accordance with the new federal
regulation and to meet the documentation
required to bill for Medicaid.
Policy – Authorization
Process
Removed link to the QIO-like vendor.
Page 1 of 1
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Section:
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Subject:
POLICY
2803
POLICY
2803.1
POLICY OVERVIEW
It is the policy of the Division of Health Care Financing and Policy (DHCFP) to support the
unique health needs to Medicaid eligible students with a disability in the special education setting.
Medicaid covers school based services when they are primarily medical and not educational in
nature. This chapter establishes a Medicaid provision for medically necessary health care services
a school district may provide to students with special health care needs.
For a school district to receive reimbursement for services through the Medicaid School Based
Service program, each Medicaid eligible student must receive an Individualized Education
Program (IEP) that specifies the services required to treat his or her identified medical
condition(s) (through correction and amelioration of any physical and mental disability).
2803.1A
1.
PROGRAM ELIGIBILITY CRITERIA
Only those services listed in the State Plan Amendment referring specifically to SBCHS
are covered benefits.
October 21, 2010
a.
School Based Child Health Services (SBCHS) are available for eligible Medicaid
and Nevada Check Up children between 3 years of age and under the age of 21, in
both Fee-For-Service (FFS) and Managed Care. SBCHS for children who are
enrolled in Medicaid Managed Care are covered and reimbursed under the FFS
Medicaid. The student must be Medicaid eligible when services are provided;
b.
DHCFP does not reimburse for any services considered educational or recreational
in nature;
c.
Any Medicaid eligible child requiring SBCHS services may receive these services
from the local school district provided:
1.
All SBCHS relate to a medical diagnosis and are medically necessary;
2.
The service performed is within the scope of the profession of the
healthcare practitioner performing the service;
3.
All services including the scope, amount and duration of service are
documented as part of the child’s school record, including the name(s) of
the health practitioner(s) actually providing the service(s);
SCHOOL BASED CHILD HEALTH SERVICES
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Subject:
2.
POLICY
4.
The treatment services are a part of the recipient’s written IEP on file with
the local school district. The plan may be subject to review by authorized
DHCFP personnel, and must include the signature by the school-based or
family designated physician, Advanced Practitioner of Nursing (APN) or
Physician’s Assistant substantiating that the treatment services are
medically necessary services.
5.
All applicable federal and state Medicaid regulations should be followed,
including those for provider qualifications, comparability of services and
the amount, duration and scope of provisions;
LIMITATIONS
The Nevada Medicaid Program pays for SBCHS services conforming to accepted methods
of diagnosis and treatment directly related to the recipient’s diagnosis, symptoms or
medical history. Limitations are:
3.
a.
Only qualified health care providers will be reimbursed for their participation in
the IEP development for medical related services concerning each specific
discipline. Nevada Medicaid reimbursement for the participation time in the IEP
development meeting is only allowed for medical related services not educational
process and goals.
b.
Services are limited to medical and related services described throughout the
Chapter and procedure codes listed on the DHCFP website Provider Type 60
SBCHS Fee Schedule at http://dhcfp.nv.gov/RatesUnit.htm.
c.
Services can only be reimbursed when the results of the provided services correct
or ameliorate any current or discovered deficits and/or conditions through the
evaluation and diagnostic process as identified in the IEP.
d.
Services may not be provided to students under the age of three years old or over
the age of 20.
COVERED SERVICES
SBCHS are medically necessary diagnostic, evaluative and direct medical services to
correct or ameliorate any physical or mental disability that meet the medical needs of
disabled children and youth. The services are provided as part of a local public school
district special education program to meet the health needs of a child and directed at
reducing physical or mental impairment and restoration of the child to his/her best
October 21, 2010
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Section:
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Subject:
POLICY
possible functioning level. The evaluative and diagnostic services which establish the need
for treatment are determined through the IEP process.
SBCHS Covered Services include:
4.
October 21, 2010
a.
Psychological counseling service when provided by a Nevada licensed
psychologist to perform diagnostic and treatment services for student’s to fully
benefit from an educational program. Refer to Section 2803.4 of this Chapter.
b.
Physical therapy service when provided by a Nevada licensed physical therapist to
restore, maintain or improve muscle tone, joint mobility or physical function.
Refer to Section 2803.6 of this Chapter.
c.
Nursing services when provided by a Nevada licensed nurse to perform
assessment, planning, delivery and evaluation of health services for students whose
health impairments require skilled nursing intervention to maintain or improve the
student’s health status. Refer to Section 2803.5 of this Chapter.
d.
Occupational therapy services when provided by a Nevada licensed occupational
therapist to improve or restore function. Refer to Section 2803.7 of this Chapter.
e.
Speech therapy services when provided by a Nevada certified or licensed speech
pathologist or audiologist for the treatment of speech, learning and language
disorders. Refer to Section 2803.8 of this Chapter.
f.
Assistive communication devices, audiological supplies and disposable medical
supplies provided to serve a medical purpose, intervention to maintain or improve
the student’s health status. Refer to Section 2803.9 of this Chapter.
NON-COVERED SBCHS
a.
Medical care not related or identified in the IEP e.g. illness, injury care, health
education classes and first aid classes;
b.
Evaluation and/or direct medical service performed by providers who do not meet
Medicaid provider qualifications;
c.
Information furnished by the provider to the recipient over the telephone;
d.
Services which are educational, vocational or career oriented;
e.
Speech services involving non-diagnostic, non-therapeutic, routine, repetitive, and
reinforced procedures or services for the child’s general good and welfare; e.g., the
practicing of word drills. Such services do not constitute speech pathology services
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for Medicaid purposes and are not to be covered since they do not require
performance by a licensed qualified health care provider;
October 21, 2010
f.
When maximum benefits from any treatment program are reached, the service is
no longer covered. There is no payment for services providing maintenance at
maximum functional levels;
g.
Dental or related services (these services are available through the Medicaid
Dental program);
h.
Treatment of obesity;
i.
Any immunizations, biological products and other products available free of
charge from the State Health Division;
j.
Any examinations and laboratory tests for preventable diseases which are
furnished free of charge by the State Division of Health;
k.
Any services recreational in nature, including those services provided by an
adaptive specialist or assistant; and
l.
Textbooks or other such items that are educational in nature and do not constitute
medical necessity.
m.
Transportation of school aged children to and from school, including specialized
transportation for Medicaid eligible children on days when they receive Medicaid
covered services at school.
n.
Covered medical service(s) listed in an IEP for those dates of service when the IEP
has expired.
o.
Covered medical or treatment service(s) which do not have a referral/prescription
or certified as medically necessary by a Nevada licensed physician (school based
or family designated), an APN or a Physician’s Assistant operating within their
scope of practice pursuant to Nevada State law.
p.
Covered medical services listed in an IEP when parental notification and consent
are not documented.
Section 2803 Page 4
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Section:
2803
Subject:
2803.1B
POLICY
PROVIDER RESPONSIBILITY
1.
GENERAL INFORMATION
The provider shall furnish psychological counseling, nursing services and other
therapeutic services such as, physical therapy, occupational therapy, speech therapy, etc.
as identified in the IEP.
As a condition of participation in the Nevada Medicaid program, all service providers
must abide by the policies of DHCFP and state and federal laws and regulations, including
but not limited to, the United States Code of Federal Regulations governing the Medicaid
Program, and all state laws and rules governing the Department of Education and the
DHCFP. All providers must meet the requirements established for being a Medicaid
provider. This includes the Local Education Agency’s subcontractors who must be
enrolled as Medicaid providers. Department of Education Certification is not sufficient
under federal regulations to meet Medicaid provider requirements.
All staff providing services to recipients under the SBCHS program must be licensed or
certified by the appropriate state entity or national organization and provide services
within their scope of practice.
2.
ENROLLMENT PROCEDURES AND REQUIREMENTS
To be enrolled in the Nevada Medicaid Program, a school district must enter into an InterLocal Agreement, signed by the school district and the DHCFP. Participating providers
must comply with Medicaid regulations, procedures and terms of the contract.
The provider must allow, upon request of proper representatives of the DHCFP, access to
all records which pertain to Medicaid recipients for regular review, audit or utilization
review. Refer to the Medicaid Services Manual (MSM) Chapter 100 for medical and fiscal
record retention timeframes.
3.
MEDICAL OR TREATMENT SERVICES
A medical referral/prescription is a Medicaid requirement for reimbursement. A
referral/prescription is any document that indicates that the student is in need of one or
more health related service(s). A referral/prescription is required for each school based
Medicaid covered service and must be recommended and certified as medically necessary
by a licensed physician (school based or family designated), an APN or a Physician’s
Assistant providing services within the scope of medicine as defined by state law and
provided through an IEP.
October 21, 2010
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Section:
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Subject:
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The referral/prescription services must be renewed at least annually and/or when the
scope, amount and frequency or duration of service(s) has changed. An IEP that includes
the required components of a referral/prescription for a service that has been reviewed and
signed by a Medicaid qualified provider operating within their scope of practice pursuant
to State law may serve as the referral/prescription for service(s).
Treatment services are provided by or under the direction of:
a.
a school-based licensed physician;
b.
a licensed physician or psychiatrist in a community-based or hospital clinic;
c.
a licensed private practice physician or psychiatrist; or
d.
an APN or Physician’s Assistant acting within their scope of practice.
Treatment services may also be provided by a community-based private practitioner
performing within the scope of his/her practice as defined by state law. In providing
SBCHS at a location other than the school campus, the school districts may contract with
community-based licensed health professionals and clinics.
4.
BY OR UNDER THE DIRECTION OF
“By or under the direction of” means that the Medicaid qualified staff providing direction
is a licensed practitioner of the healing arts qualified under State law and federal
regulations to diagnose and treat individuals with the disability or functional limitations at
issue and is operating within their scope of practice defined in State law and is supervising
each individual’s care.
The supervision must include, at a minimum, face to face contact with the individual
initially and periodically as needed, prescribing the services provided and reviewing the
need for continued services throughout the course of treatment. The Medicaid qualified
supervisor must also assume professional responsibility for the services provided and
ensure that the services are medically necessary. The Medicaid qualified supervisor must
spend as much time as necessary directly supervising the services to ensure the
recipient(s) are receiving services in a safe and efficient manner and in accordance with
accepted standards of practice. Documentation must be kept supporting the supervision of
services and ongoing involvement in the treatment.
5.
October 21, 2010
RESERVED FOR FUTURE USE
Section 2803 Page 6
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Section:
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Subject:
6.
POLICY
INDIVIDUALIZED EDUCATIONAL PROGRAM (IEP)
The IEP can be used as the initial plan of care when certified by the school-based or
family-designated physician, an APN or Physician’s Assistant.
Each service is to be documented in the specific service area. The IEP serves as a
summary of progress documentation. Treatment is authorized during the period covered
by the written IEP only.
7.
INDIVIDUALIZED EDUCATION PROGRAM (IEP) ASSESSMENT/EVALUATION
An IEP evaluation/assessment is completed by an interdisciplinary team consisting of a
minimum of a psychologist, registered nurse and special education teacher to determine a
student's need for further testing. Other professional staff such as physical therapists,
occupational therapists and speech therapists may provide input, as well as audiology,
vision, health, education and the student’s parents. As a result of this process, an IEP will
be established outlining treatment modalities.
8.
ASSESSMENT
EPSDT screening services should be encouraged for all students. Assessment is an
evaluation by a primary diagnostician to determine a student's need for a single service.
This assessment should review the following service areas:
a.
Vision Screening;
b.
Hearing Screening;
c.
Audiological Evaluation;
d.
Speech and Language Screening;
e.
Physical Therapy;
f.
Psychological Evaluation;
g.
Occupational Therapy; and
h.
Nursing Services.
The assessment should validate the need for medical services identified on the IEP.
October 21, 2010
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Subject:
9.
POLICY
ELIGIBILITY VERIFICATION
Medicaid recipient eligibility is determined on a monthly basis. Therefore, it is important
to verify the child’s eligibility on a monthly basis. Payments can only be made for covered
services rendered to eligible students. If the student was not eligible on the date the service
was rendered, payment will be denied.
Eligibility may be verified by accessing the Automated Response System (ARS) or the
Electronic Verification System (EVS) or using Health Insurance Portability
Accountability Act (HIPAA) compliant electronic transaction. Refer to our QIO-like
vender’s website for additional information: https://nevada.fhsc.com/.
10.
RECORDS
The evaluative and diagnostic services which determine the need for treatment and the IEP
which defines the treatment needs must be documented as part of the child's school record,
including the name(s) of the health practitioner(s) actually providing the service(s). The
written IEP must be on file with the participating local school district.
All medical and financial records which reflect services provided must be maintained by
the school district and furnished on request to the Department or its authorized
representative. A school, as a provider, must keep organized and confidential records that
detail all recipient specific information regarding all specific services provided for each
individual recipient of services and retain those records for review.
SBCHS providers must maintain appropriate records to document the recipient's progress
in meeting the goals of the therapy. Nevada Medicaid reserves the right to review the
recipient's records to assure the therapy is restorative and rehabilitative.
11.
NON-DISCRIMINATION
School Districts must be in accordance with federal rules and regulations, the Nevada
State DHCFP and providers of Medicaid services may not discriminate against recipients
on the basis of race, color, national origin, sex, religion, age, disability or handicap.
12.
THIRD PARTY LIABILITY (TPL)/FREE CARE PRINCIPAL
In 1988, as a result of the Medicare Catastrophic Coverage Act, Medicaid was authorized
by Congress to reimburse for Individuals with Disabilities Education Act (IDEA) related
medically necessary services for eligible children before IDEA funds are used. Medicaid
reimbursement is available for those services under Social Security Act, Section 1903(c)
to be the primary payer to the other resources as an exception. Federal legislation requires
Medicaid to be the primary payer for Medicaid services provided to eligible recipients
October 21, 2010
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under IDEA, Children with Special Health Care Needs, Women’s Infants and Children
(WIC) program, Title V programs, Indian Health Services (IHS), or Victims of Crimes
Act 1984.
Although Medicaid must pay for services before (or primary to) the U.S. Department of
Education (School Districts), it pays secondary to all other sources of payment. As such,
Medicaid is referred to as the “payer of last resort”.
Medicaid statutory provisions for TPL preclude Medicaid from paying for services
provided to Medicaid recipients if another payer (e.g. health insurer or other state or
Federal programs) is legally liable and responsible for providing and paying for services.
The Medicaid program is generally the payer of last resort; exceptions to this principle are
IEP and related services, Title V, and WIC, as mentioned previously.
Medicaid is required to take all reasonable measures to ascertain the legal liability of third
parties to pay for care and services available under the state Medicaid plan. If a state has
determined that probable liability exists at the time a claim for reimbursement is filed, it
generally must reject the claim and return it to the provider for a determination of the
amount of third-party liability (referred to as “cost avoidance”). If probable liability has
not been established or the third party is not available to pay the individual’s medical
expenses, the state must pay the claim and then attempt to recover the amount paid
(referred to as “pay and chase”). Nevada Medicaid has elected to pay and chase for
SBCHS found to have TPL.
Services provided through the Americans with Disability Act, Section 504 plans may not
be billed to Medicaid. Medicaid is the “payer of last resort”. Medicaid will not reimburse
for services that are provided free of charge to other students (the “free care” principal).
An exception to this principle is for Medicaid eligible children receiving services under
IDEA. Medicaid can be the primary payer for covered medical services under a child’s
IEP. Refer to Section 1902(a) (30) (A) of the Social Security Act.
13.
PARENTAL NOTIFICATION AND CONSENT
Nevada Medicaid and Nevada Check Up may cover medically necessary services that are
identified on the IEP. Reimbursement for services under the SBCHS does not interfere
with the IDEA program.
In order to assure parents of transparency in the use of Medicaid benefits for their child,
documentation demonstrating parental notification and parental consent to bill Medicaid is
required in accordance with Federal Regulation. This information is required to be kept on
file for review/audit purposes. The intent of parental consent notification is to inform the
parent that Nevada Medicaid may be billed for specific services that are identified through
October 21, 2010
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the IEP process. ThisParental consent allows the parent the opportunity to decline or
accept services rendered to be billed to Nevada Medicaid.
In order for children to remain eligible under the Katie Beckett eligibility category,
Medicaid must assure Centers for Medicare and Medicaid Services (CMS) that the per
capita expenditures under this program will not exceed the per capita expenditures for the
institutional level of care under the state plan. Parents with children eligible under the
Katie Beckett program may not want the SBCHS to be billed to Nevada Medicaid as this
may impact the child’s eligibility or may result in a cost to the parent for services outside
of the school arena. Parents with a child eligible under this benefit program are
encouraged to work closely with their Medicaid District Office (DO) case manager to
assure services do not impact their eligibility status.
Parental notification and Cconsent must be obtained prior to billing for services that have
been identified through the IEP process. The annual IEP meeting provides the schools
with an opportunity to review services and request consent to bill services to Nevada
Medicaid. Refer to Section 2803.1C of this Chapter. Parents have the right to refuse
consent to have their Nevada Medicaid insurance billed at any time.
14.
NOTIFICATION OF SUSPECTED ABUSE/NEGLECT
The Division expects that all Medicaid providers will be in compliance with all laws
relating to incident of abuse, neglect, or exploitation as it relates to students.
2803.1C
RECIPIENT RESPONSIBILITIES
The recipient or authorized representative shall:
1.
Provide the school district with a valid Medicaid card at the district’s request.
2.
Provide the school district with accurate and current medical information, including
diagnosis, attending physician, medication, etc.
3.
Notify the school district of all insurance information, including the name of other third
party insurance coverage.
4.
Participate in the IEP development meeting(s).
5.
Every student, their Legally Responsible Adult (LRA) or legal guardian is entitled to
receive a statement of students or parent/guardian rights from their school district. The
recipient, their LRA, or legal guardian should review and sign this document.
October 21, 2010
Section 2803 Page 10
MTL 45/10CL 27631
DRAFT
Section:
2803
Subject:
2803.1D
POLICY
AUTHORIZATION PROCESS
1.
Prior authorizations are not required for any School Based Health Services that may be
reimbursed for a Medicaid-eligible child. Refer to Section 2803.1A in this chapter
outlining service coverage and limitations. Services must be deemed medically necessary
and appropriate as defined in this chapter. The treatment services must be documented
through the IEP and substantiated that the services are medically necessary by a signature
by the school based or family designated physician, APN or Physician’s Assistant. A
referral and signature do not constitute medical necessity. Refer to MSM Chapter 100 for
the definition of medical necessity.
A referral for services must be from a physician or other licensed practitioner of the
healing arts operating within their scope of practice under State law to make a
determination. Proper documentation is required to show the referral/recommendation for
services. CMS recognizes an IEP as a referral for such services once reviewed and signed
by a physician.
As a method of protecting the integrity of the SBCHS program, Medicaid will perform
retro-review activities on claims data to evaluate medical necessity and billing procedures.
Services that have been reimbursed but are shown not to have been documented in the IEP
and progress notes of the recipient, as outlined in this chapter, may be subject to
recoupment.
Refer to the DHCFP website for billable codes http://dhcfp.nv.gov/RatesUnit.htm. The
School Based billing manual provider type 60 can be found at our QIO-like vendor’s
website https://nevada.fhsc.com.
2.
2803.2
MISCELLANEOUS PROVISIONS
a.
All payments for SBCHS are made to the school district. Separate payment will
not be made to those individual practitioners who actually provide the services.
b.
The school district can submit claims for reimbursement on a monthly basis
maintaining adherence to Medicaid’s timely filing requirements. Refer to MSM
Chapter 100, Eligibility, coverage and limitations.
PROVIDER QUALIFICATIONS
In order to be reimbursed by Nevada Medicaid, all school based services must be provided by a
licensed health care provider working within their scope of practice under state and federal
regulations.
October 21, 2010
Section 2803 Page 11

MEDICAID SERVICES MANUAL TRANSMITTAL LETTER June 12, 2014

Transcription

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