The following guidelines are found in the Nebraska Administrative Code
The Nebraska Medical Assistance Program (NMAP) uses the following definition of medical necessity:
Health care services and supplies which are medically appropriate and:
The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid. Services and supplies which do not meet the definition of medical necessity set out above are not covered.Approval by the federal Food and Drug Administration (FDA) or similar approval does not guarantee coverage by NMAP. Licensure/certification of a particular provider type does not guarantee NMAP coverage.
Certain medical services, while being medically necessary, may exceed the NMAP coverage guidelines which have been established by the Department. Under these circumstances, the determination of medical necessity for payment purposes is based upon the professional judgment of the Department's consultants and other appropriate staff.
NMAP covers medically necessary and reasonable ambulance services required to transport a client to obtain or after receiving Medicaid-coverable medical care.
4-002.01 Medical necessity of the service: To be covered by NMAP, ambulance services must be medically necessary and reasonable. Medical necessity is established when the client's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the client's health, whether or not such other transportation is actually available, NMAP shall not make payment for ambulance service. Claims for ambulance services must include adequate documentation for determination of medical necessary.
NMAP does not cover all American Dental Association (ADA) procedure codes. Covered codes are listed in the Nebraska Medicaid Dental Fee Schedule in 471-000-506.
6-005.01 Services for individuals age 21 and older: Dental coverage is limited to $1000 per fiscal year. The $1000 limit is calculated at the Medicaid dental fee schedule rate for the treatment provided or on the all inclusive encounter rate paid to Indian Health Service (IHS) or Federally Qualified Health Centers (FQHC) facilities.
6-005.01A Providers responsibility and client responsibility regarding the yearly dental limit: Providers must inform a client before treatment is provided of the client's obligation to pay for a service if the client's annual limit has already been reached or if the amount of treatment proposed will cause the client's annual limit to be exceeded.
A client must inform a provider in advance of receiving treatment if a portion of his/her annual dental benefit amount has already been expended.
The provider shall obtain written documentation from the prescribing physician which justifies the medical necessity for durable medical equipment, medical supplies, orthotics and prosthetics and related services provided. The original documentation of medical necessity must be kept on file by the provider. The documentation must:
Use of the following Medicaid Certification of Medical Necessity (CMN) forms is required. Form examples and completion instructions are included in the Medicaid provider handbook - Form MS-78, "Augmentative Communication Device Selection Report" Form MS-79, "Wheelchair and Wheelchair Seating System Selection Report" Form MS-80, "Air Fluidized and Low Air Loss Bed Certification of Medical Necessity."
Use of Medicare CMN forms, when a specific Medicaid CMN form does not exist, is strongly encouraged. When using Medicare CNM forms, Medicare completion instructions apply. Use of the following Medicare CMN form is required.
Criteria for NMAP coverage of durable medical equipment, medical supplies, orthotics and prosthetics is outlined in this chapter's coverage index (see 471 NAC 7-013). Items not specifically listed may not be covered by NMAP. In order to be covered by NMAP, the client's condition must meet the coverage criteria for the specific item. Documentation which substantiates that the client's condition meets the coverage criteria must be on file with the provider (see 471 NAC 7-007 for documentation of medical necessity requirements).
NMAP requires that the following information be submitted when requesting prior authorization for a hearing aid or assistive listening device.
Form DM-5H "Physician's Report on Hearing Loss," (see 471-000-3) must be used when submitting a request for prior authorization. The examining physician must complete the front portion of Form DM-5H. The back portion of Form DM-5H must be completed by either the examiner or the hearing aid dispenser.The provider must submit requests for prior authorization using the standard electronic Health Care Services Review – Request for Review and Response transaction (ASC X12N 278) (see standard electronic transaction instructions at 471-000-50) or by completing and submitting Form MC-9S, "Prior Authorization Document for Hearing Aids" (see 471-000-205 for completion instructions).Prior authorization is obtained from the Medicaid division.
All home health services must be:
Therapies must be recertified every 30 days by the licensed physician.
NMAP defines medical necessity as follows:
Medical Necessity: Health care services and supplies which are medically appropriate and -
The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid. Services and supplies that do not meet the definition of medical necessity set out above are not covered.
All skilled nursing services must be:
NMAP covers transplants including donor services that are medically necessary and defined as non-experimental by Medicare. If no Medicare policy exists for a specific type of transplant, the medical director of the Division of Medicaid and Long-Term Care shall determine whether the transplant is medically necessary or non-experimental.
Notwithstanding any Medicare policy on liver or heart transplants, the Nebraska Medical Assistance program covers liver or heart transplantation when the written opinions of two physicians specializing in the specific transplantation state that a transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the patient's life in a meaningful, qualitative way and at a reasonable level of functioning.
NMAP is the payor of last resort.
NMAP requires prior authorization of all transplant services before the services are provided (see 471 NAC 18-004.40D). An exception may be made for emergency situations, in which case verbal approval is obtained and the notification of authorization is sent.
NMAP covers home infant apnea monitoring services for infants who meet one of the following criteria. NMAP defines infancy as birth through completion of one year of age.
NMAP recognizes the Nebraska chapter of the American Academy of Pediatrics' Standard of Care for home phototherapy. Home phototherapy services will be covered when the following conditions are met:
Medical Guidelines for the Placement of Ambulatory Uterine Monitors: Ambulatory uterine monitors will be covered when the following conditions are met:
Others at high risk for preterm labor and delivery may be covered for this service upon approval by the Department's medical director through written communication from the client's physician (preferably in consultation with a perinatologist).
For additional guidance, please refer to the Medicaid member's Heritage Health plan and the Medicaid Provider Bulletins.