File No. 34893
This rule was published in the June 15, 2011, issue (Vol. 2011, No. 12) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Notice of Proposed Rule
DAR File No.: 34893
Filed: 06/01/2011 12:32:10 PM
Purpose of the rule or reason for the change:
The purpose of this amendment is to update the rule in conjunction with reimbursement updates for outpatient hospital services, which will be changing to Medicare's Outpatient Prospective Payment System (OPPS) methodology.
Summary of the rule or change:
This amendment updates the rule in conjunction with reimbursement updates for outpatient hospital services, which will be changing to Medicare's OPPS methodology.
State statutory or constitutional authorization for this rule:
- Section 26-18-3
Anticipated cost or savings to:
the state budget:
The change to Medicare's OPPS reimbursement methodology is not anticipated to impact the state budget as Medicare's payment is the upper limit Utah could pay for these services.
It is not possible to determine the exact impact of this change on local governments as the outpatient hospital services provided can vary widely from year to year. Reimbursement using Medicare's methodology will ensure that providers are receiving the maximum allowed under 42 CFR 447.321, which governs upper payment limits for outpatient hospital services.
It is not possible to determine the exact impact of this change on small businesses as the outpatient hospital services provided can vary widely from year to year. Reimbursement using Medicare's methodology will ensure that providers are receiving the maximum allowed under 42 CFR 447.321, which governs upper payment limits for outpatient hospital services.
persons other than small businesses, businesses, or local governmental entities:
It is not possible to determine the exact impact of this change as the outpatient hospital services provided can vary widely from year to year. Reimbursement using Medicare's methodology will ensure that providers are receiving the maximum allowed under 42 CFR 447.321, which governs upper payment limits for outpatient hospital services.
Compliance costs for affected persons:
Compliance costs may be slightly reduced as affected persons will be able to bill Medicaid similar to how they currently bill Medicare.
Comments by the department head on the fiscal impact the rule may have on businesses:
Medicaid's billing system for outpatient hospital services will now be more similar to Medicare and should reduce the administrative burden on providers and have a positive 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 firstname.lastname@example.org
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:
This rule may become effective on:
David Patton, Executive Director
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-3A. Outpatient Hospital Services.
(1) Services appropriate in the outpatient hospital setting for adequate diagnosis and treatment of a client's illness are limited to less than 24 hours and encompass medically necessary diagnostic, therapeutic, rehabilitative, or palliative medical services and supplies ordered by a physician or other practitioner of the healing arts.
(2) Outpatient hospital services include:
(a) the service of nurses or other personnel necessary to complete the service and provide patient care during the provision of service;
(b) the use of hospital facilities, equipment, and supplies; and
(c) the technical portion of clinical laboratory and radiology services.
(3) Laboratory services are limited to tests identified by the Centers for Medicare and Medicaid Services (CMS) where the individual laboratory is CLIA certified to provide, bill and receive Medicaid payment.
(4) Cosmetic, reconstructive, or plastic surgery is limited to:
(a) correction of a congenital anomaly;
(b) restoration of body form following an injury; or
(c) revision of severe disfiguring and extensive scars resulting from neoplastic surgery.
(5) Abortion procedures are limited to procedures certified as medically necessary, cleared by review of the medical record, approved by division consultants, and determined to meet the requirements of Section 26-18-4 and 42 CFR 441.203.
(6) Sterilization procedures are limited to those that meet the requirements of 42 CFR 441, Subpart F.
(7) Nonphysician psychosocial counseling services are limited to evaluations and may be provided only through a prepaid mental health plan by a licensed clinical psychologist for:
(a) mentally retarded persons;
(b) cases identified through a CHEC/EPSDT screening; or
(c) victims of sexual abuse.
(8) Outpatient individualized observation of a mental health patient to prevent the patient from harming himself or others is not covered.
(9) Sleep studies are available only in a sleep disorder center accredited by the American Academy of Sleep Medicine.
(10) Hyperbaric Oxygen Therapy is limited to service in a facility in which the hyberbaric unit is accredited by the Undersea and Hyperbaric Medical Society.
(11) Lithotripsy is covered by an all-inclusive fixed fee.
This payment covers all hospital and ambulatory surgery-related
services for lithotripsy on the same kidney for 90 days, including
repeat treatments. Lithotripsy for treatment of the other kidney is
a separate service. (12) Reimbursement for services in the emergency
department is limited to codes and diagnoses that are medically
necessary emergency services as described in the provider
13]) Take home supplies and durable medical equipment are not
14]) Prescriptions are not a covered Medicaid service for a
client with the designation "Emergency Services Only
Program" printed on the Medicaid Identification Card.
Date of Enactment or Last Substantive Amendment: [
January 1, ]2011
Notice of Continuation: November 8, 2007
Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2011/b20110615.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact 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@example.com.