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
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.
There is no budget impact to local governments because they do not fund outpatient hospital services for Medicaid members.
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
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 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:
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] 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.
(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] "Outpatient" is defined in 42 CFR 440.20.
7]) "Prepaid Mental Health Plan"
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].
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) 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 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
(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
(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 or reconstructive procedures are set forth in
(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 [ O]xygen [ T]herapy is limited to service in a facility in which the hy[ b]erbaric unit is accredited by the Undersea and Hyperbaric
[ (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
R414-3A-7. Prior Authorization.
Prior authorization [
must be obtained] on certain medical and surgical procedures in
accordance with Section R414-1-14.
Each Medicaid [
client] is responsible for a copayment as established in the
Utah Medicaid State Plan and incorporated by reference in Rule
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.
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
More information about a Notice of Proposed Rule is available online.
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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. For questions about the rulemaking process, please contact the Office of Administrative Rules.