DAR File No. 41559

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-2A-7

Limitations

Notice of Proposed Rule

(Amendment)

DAR File No.: 41559
Filed: 05/01/2017 05:03:48 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update prior authorization policy for inpatient psychiatric services.

Summary of the rule or change:

This amendment removes from rule the prior authorization requirement in regard to inpatient psychiatric services and prepaid mental health plans. This requirement had previously been removed from policy.

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 expected impact to the state budget because this change only updates ongoing prior authorization policy. It neither affects current services nor provider reimbursement.

local governments:

There is no impact to local governments because they do not fund inpatient psychiatric services under the Medicaid program.

small businesses:

There is no expected impact to small businesses because this change only updates ongoing prior authorization policy. It neither affects current services nor provider reimbursement.

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

There is no expected impact to Medicaid members and to Medicaid providers because this change only updates ongoing prior authorization policy. It neither affects current services nor provider reimbursement.

Compliance costs for affected persons:

There is no expected impact to a single Medicaid member or to a Medicaid provider because this change only updates ongoing prior authorization policy. It neither affects current services nor provider reimbursement.

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

There is no fiscal impact on business because this amendment updates ongoing Medicaid policy and will not affect provision of Medicaid providers.

Joseph K. Miner, MD, Executive Director

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

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
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 cdevashrayee@utah.gov

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:

06/14/2017

This rule may become effective on:

07/01/2017

Authorized by:

Joseph Miner, Executive Director

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

R414-2A. Inpatient Hospital Services.

R414-2A-7. Limitations.

(1) Inpatient admissions for 24 hours or more solely for observation or diagnostic evaluation do not qualify for reimbursement under the DRG system.

(2) Detoxification for a substance use disorder in a hospital is limited to medical detoxification for acute symptoms of withdrawal when the patient is in danger of experiencing severe or life-threatening withdrawal. The Department does not cover any lesser level of detoxification in an inpatient hospital.

(3) Abortion procedures must first be reviewed and preauthorized by the Department as meeting the requirements of Section 26-18-4 and 42 CFR 441.203.

(4) Sterilization and hysterectomy procedures must first be reviewed and preauthorized by the Department as meeting the requirements of 42 CFR 441, Subpart F.

(5) Organ transplant services are governed by Rule R414-10A, Transplant Services Standards.

(6) Take home supplies, dressings, non-rental durable medical equipment, and drugs are reimbursed as part of payment under the DRG.

(7) Hyperbaric oxygen therapy is limited to service in a facility in which the hyperbaric unit is accredited by the Undersea and Hyperbaric Medical Society.

(8) Inpatient services solely for pain management do not qualify for reimbursement under the DRG system. Pain management is adjunct to other Medicaid services.

(9) Medicaid does not cover inpatient admissions for the treatment of eating disorders.

(10) Physician services provided by a physician who is paid by a hospital are inpatient services reimbursed as part of payment billed on a 1500 form. Payment for physician services provided by providers who are not paid by the hospital is governed by Rule R414-10.

(11) Inpatient rehabilitation services must first be reviewed and preauthorized.

[(12) Inpatient psychiatric services not covered by mental health contractual agreements must first be reviewed and preauthorized by the Department to assure that the admission meets the requirements of 42 CFR 412.27 and Part 441, Subpart D.]

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [October 11, 2013]2017

Notice of Continuation: October 10, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-18-3.5