Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-4A

Outpatient Hospital Services: Payment of Triage Fee

Notice of Proposed Rule

(Repeal)

DAR File No.: 34894
Filed: 06/01/2011 12:38:35 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule states authority and purpose, outlines triage policies, and defines terms in the rule text. It also specifies service coverage, standards of care, prior authorization requirements, and reimbursement for services. The Department needs to repeal this rule based on internal review that shows that the Department no longer uses the policies spelled out in the text.

Summary of the rule or change:

This rule is repealed in its entirety.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because the Department no longer uses the policies set forth in this rule.

local governments:

There is no impact to local governments because they do not fund or provide outpatient hospital services under the Medicaid program.

small businesses:

There is no impact to small businesses because the Department no longer uses the policies set forth in this rule.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid clients and to Medicaid providers because the Department no longer uses the policies set forth in this rule.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid client or to a Medicaid provider because the Department no longer uses the policies set forth in this rule.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule specifies an obsolete practice. Repeal should have no fiscal impact.

W. David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/15/2011

This rule may become effective on:

07/22/2011

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

[R414-4A. Outpatient Hospital Services: Payment of Triage Fee.

R414-4A-1. Policy Statement.

(1) Primary medical care is best delivered by a primary care physician who, through the physician-patient therapeutic relationship, can deliver or arrange the appropriate mix of medical and other services that the patient needs. Primary care physicians are skilled at early detection of disease and delivering prompt treatment, and in promoting health and preventing illnesses.

(2) Hospital emergency rooms are not the appropriate place for patients to receive primary or routine medical care.

 

R414-4A-2. Authority and Purpose.

(1) The Utah Department of Health is the Single State Agency. The Division of Health Care Financing has the authority to define the scope of outpatient hospital services to be delivered under the Utah State Plan for Medicaid.

(2) The purpose of paying a triage fee is to reimburse the hospitals for the emergency room physician's service of assessing the medical status of a patient. If a patient's medical needs are determined by the emergency room physicians to be routine, that is, not of an emergency or urgent nature, the patient will be referred to his primary care physician for the treatment of his routine care needs and will not be treated in the emergency room.

(3) It is cost-effective for clients to seek primary and routine medical care through their primary medical provider rather than seeking these services through hospital emergency rooms.

 

R414-4A-3. Definitions.

(1) "Emergency" means a condition for which a delay in treatment may result in death or permanent impairment of health.

(2) "Primary care physician" means a practitioner whose practice is the field of general practice, family practice, pediatrics, internal medicine, obstetrics/gynecology, osteopathy, or nurse midwifery.

(3) "Primary medical care" means services to diagnose and treat illness and injury as well as preventive health care services. Primary and preventive health care services promote early identification and treatment of health problems, which can help to reduce unnecessary complications of illness or injury and maintain or improve overall health status.

(4) "Triage" means the sorting and classification of patients, to determine priority of need for treatment and proper place of treatment.

(5) "Urgent" means a condition not likely to cause death or lasting harm, but for which treatment should not wait for a normally scheduled appointment (e.g., suturing minor cuts, setting simple broken bones, and treating conditions characterized by abnormally high temperatures).

 

R414-4A-4. Service Coverage.

(1) Triage service includes services such as: assessment and diagnosis of a patient's condition and determination of a proper place for treatment.

(2) Triage service may only be performed by a licensed physician.

 

R414-4A-5. Standards of Care.

It is a decision of the emergency room physician whether medical care is classified as routine, urgent, or is an emergency.

 

R414-4A-6. Prior Authorization.

None required.

 

R414-4A-7. Reimbursement for Services.

(1) Payment for triage services is made on a revenue code basis.

(2) When a triage service is billed, no other medical care services will be paid by Medicaid for that date of service, to the same provider for the same triage encounter.

(3) Rates are based on an encounter unit of service.

(4) The Division of Health Care Financing will not pay a claim for triage services for which another payer is liable, nor for services for which no payment liability is incurred.

 

KEY: medicaid

Date of Enactment or Last Substantive Amendment: 1993

Notice of Continuation: January 26, 2007

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3]