DAR File No. 42180

This rule was published in the October 15, 2017, issue (Vol. 2017, No. 20) of the Utah State Bulletin.

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-3A

Outpatient Hospital Services

Notice of Proposed Rule


DAR File No.: 42180
Filed: 10/02/2017 05:13:27 PM


Purpose of the rule or reason for the change:

The purpose of this change is to update and clarify Medicaid policy on coverage for outpatient hospital services.

Summary of the rule or change:

This amendment updates and removes definitions in the text to be consistent with current policy. It also clarifies requirements for member eligibility and program access, and clarifies coverage for Prepaid Mental Health Plan (PMHP) members. This change further clarifies policy for services and prior authorization and makes other technical changes.

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 this change only clarifies Medicaid policy. It neither affects service coverage to Medicaid members nor reimbursement to Medicaid providers.

local governments:

There is no budget impact to local governments because they do not fund outpatient hospital services for Medicaid members.

small businesses:

There is no impact to small businesses because this change only clarifies Medicaid policy. It neither affects service coverage to Medicaid members nor reimbursement to Medicaid providers.

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

There is no impact to Medicaid providers nor to Medicaid members because this change only clarifies Medicaid policy. It neither affects service coverage nor provider reimbursement.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because this change only clarifies Medicaid policy. It neither affects service coverage nor provider reimbursement.

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

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

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 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 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:


This rule may become effective on:


Authorized by:

Joseph Miner, Executive Director


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

R414-3A. Outpatient Hospital Services.

R414-3A-1. Introduction and Authority.

This rule defines the scope of outpatient hospital services available to Medicaid [clients]members for the treatment of disorders other than mental disease. This rule is authorized under Section 26-18-3 and governs the services allowed under 42 CFR 440.20.


R414-3A-2. Definitions.

[(1) "Allowed charges" mean actual charges submitted by the provider less any charges for non-covered services.

(2) "CHEC" means Child Health Evaluation and Care and is the Utah specific term for the federally mandated program of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for children under the age of 21.

(3) "Clinical Laboratory Improvements Act" (CLIA) is the Centers for Medicare and Medicaid Services (CMS) program that limits reimbursement for laboratory services based on the equipment and capability of the physician or laboratory to provide an appropriate, competent level of laboratory service.

(4) "Hyperbaric Oxygen Therapy" is therapy that places the patient in an enclosed pressure chamber for medical treatment.

(5) "Other Practitioner of the Healing Arts" means a doctor of dental surgery or a podiatrist.

]([6]1) "Outpatient" is defined in 42 CFR 440.20.

(2) "Outpatient hospital" is a facility that:

(a) is in, or physically connected to, a hospital licensed by the Department as a general hospital, as defined by Subsection 26-21-2(11), and meets the standards set forth in Rule R432-100 and 42 CFR Part 482;

(b) meets participation requirements in the Medicare program; and

(c) has a Medicaid provider agreement with the Department.

([7]3) "Prepaid Mental Health Plan" (PMHP) means the [prepaid, capitated program through which the Department pays contracted community mental health centers to provide all needed inpatient and outpatient mental health services to residents of the community mental health center's catchment area who are enrolled in the plan]Medicaid mental and substance use disorder managed care plan that covers inpatient and outpatient mental health services, and outpatient substance use disorder services for PMHP-enrolled Medicaid members.


R414-3A-3. [Client]Member Eligibility Requirements.

Outpatient hospital services are available to categorically and medically needy individuals .[who are under the care of a physician or other practitioner of the healing arts.]


R414-3A-4. Program Access Requirements.

(1) An outpatient hospital must:

(a) Be licensed or formally-approved as a hospital by an officially designated authority for state-standard setting;

(b) Meet participation requirements in Medicare as a hospital;

(c) Be a hospital that accepts a Medicaid member for treatment and accepts responsibility to make sure the member receives all medically necessary services from Medicaid providers; and

(d) Accept financial responsibility for any services a member receives from a non-Medicaid provider.[(1) The Department reimburses for outpatient hospital services and supplies only if they are:

(a) furnished in a hospital;

(b) provided by hospital personnel by or under the direction of a physician or dentist;

(c) provided as evaluation and management of illness or injury under hospital medical staff supervision and according to the written orders of a physician or dentist.

(2) All outpatient hospital services are subject to review by the Department.]


R414-3A-5. Prepaid Mental Health Plan.

A Medicaid member who resides in a county covered by the PMHP may only obtain outpatient mental health and substance use disorder services from an approved PMHP unless:

(1) The Medicaid member is eligible under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program and is in the care or custody of the State of Utah;

(2) Services are provided during a period of presumptive eligibility. When a member is presumptively eligible, all services are billed directly to the State on a fee-for-service basis.[A Medicaid client residing in a county for which a prepaid mental health contractor provides mental health services must obtain authorization for outpatient psychiatric services from the prepaid mental health contractor for the client's county of residence.]


R414-3A-6. 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]member 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]3) Cosmetic or reconstructive procedures are set forth in Section R414-1-29.

[(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]4) Sleep studies are available only in a sleep disorder center accredited by the American Academy of Sleep Medicine.

([10]5) Hyperbaric [O]oxygen [T]therapy is limited to service in a facility in which the hy[b]perbaric unit is accredited by the Undersea and Hyperbaric Medical Society. Hyperbaric oxygen therapy is therapy that places the member in an enclosed pressure chamber for medical treatment.[

(11) Take home supplies and durable medical equipment are not reimbursable.

(12) Prescriptions are not a covered Medicaid service for a client who is eligible to receive emergency services only.]


R414-3A-7. Prior Authorization.

Prior authorization [must be obtained]is required on certain medical and surgical procedures in accordance with Section R414-1-14.


R414-3A-8. [Copayment Policy]Cost Sharing.

Each Medicaid [client]member is responsible for a copayment as established in the Utah Medicaid State Plan and incorporated by reference in Rule R414-1.


R414-3A-9. Reimbursement for Services.

Reimbursement for outpatient hospital services is in accordance with Attachment 4.19-B of the Utah Medicaid State Plan, which is incorporated by reference in Rule R414-1.


KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 1], 2017

Notice of Continuation: October 10, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4

Additional Information

More information about a Notice of Proposed Rule is available online.

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/2017/b20171015.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.

Text to be deleted is struck through and surrounded by brackets ([example]). Text to be added is underlined (example).  Older browsers may not depict some or any of these attributes on the screen or when the document is printed.

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 cdevashrayee@utah.gov.  For questions about the rulemaking process, please contact the Office of Administrative Rules.