Utah Administrative Code
The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).
NOTE: For a list of rules that have been made effective since January 1, 2020, please see the codification segue page.
NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
Rule R414-3A. Outpatient Hospital Services.
As in effect on January 1, 2020
Table of Contents
- R414-3A-1. Introduction and Authority.
- R414-3A-2. Definitions.
- R414-3A-3. Member Eligibility Requirements.
- R414-3A-4. Program Access Requirements.
- R414-3A-5. Services.
- R414-3A-6. Prior Authorization.
- R414-3A-7. Cost Sharing.
- R414-3A-8. Reimbursement for Services.
- Date of Enactment or Last Substantive Amendment
- Notice of Continuation
- Authorizing, Implemented, or Interpreted Law
This rule defines the scope of outpatient hospital services available to Medicaid 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.
(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.
Outpatient hospital services are available to categorically and medically needy individuals.
(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) Services appropriate in the outpatient hospital setting encompass medically necessary diagnostic, therapeutic, rehabilitative, or palliative medical services and supplies.
(2) Outpatient hospital services include:
(a) the service of nurses or other personnel necessary to complete the service and provide 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) Cosmetic or reconstructive procedures are set forth in Section R414-1-29.
(4) Coverage of sleep studies requires sleep center accreditation through one of the following nationally recognized accreditation organizations:
(a) American Academy of Sleep Medicine (AASM);
(b) Accreditation Commission for Health Care (ACHC); or
(c) The Joint Commission (TJC).
(5) Hyperbaric oxygen therapy is limited to service in a facility in which the hyperbaric 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.
Prior authorization is required on certain medical and surgical procedures in accordance with Section R414-1-14.
Each Medicaid member is responsible for a copayment as established in the Utah Medicaid State Plan and incorporated by reference in Rule R414-1.
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.
May 8, 2018
September 15, 2017
26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4
For questions regarding the content or application of rules under Title R414, please contact the promulgating agency (Health, Health Care Financing, Coverage and Reimbursement Policy). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.