Medicaid Services Manual Complete
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TDOGGIEMedicaid Services Manual Complete
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TDOGGIEMEDICAID SERVICES MANUAL (MSM)
TRANSMITTAL LETTER
August 27, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: TAMMY MOFFITT, CHIEF OF OPERATIONS
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 100 - MEDICAID PROGRAM
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 100 , Section104.3 - Medicaid Program
are being proposed to move the MSM to the State's new Medicaid Operations Manual (MOM)
Chapter900 - Cost Avoidance Programs.
The content of the Health Insurance Premium Payments (HIPP) program has been removed to
better align with in-house operations.
Entities Financially Affected: No impact to Medicaid providers.
Financial Impact on Local Government: No financial impact to local Government.
These changes are effective: August 28, 2019 .
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL15/19 MTL04/19
MSM Chapter100 - Medicaid Program MSM Chapter100 - Medicaid Program
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
104.3 Health Insurance Removed sentence outlining HIPP program.
Premium Payment
(HIPP) Removed Nevada Check Up reference statement.
Added statement for HIPP reference to MOM900 for
program outline.
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DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
MEDICAID PROGRAM
100 INTRODUCTION ...........................................................................................................................1
100.1 AUTHORITY……………… ..........................................................................................................2
100.2 CONFIDENTIAL INFORMATION ...............................................................................................4
101 OVERVIEW OF PROGRAMS .......................................................................................................1
101.1 OUT OF STATE SERVICES ..........................................................................................................2
101.2 NEVADA MEDICAID AND NCU CARD ....................................................................................3
101.2A EIGIBILITY VERIFICATION AND CARD USE .........................................................................3
101.2B CHILD WELFARE RECIPIENTS ..................................................................................................4
101.2C RESTRICTIONS .............................................................................................................................4
102 PROVIDER ENROLLMENT .........................................................................................................1
102.1 REQUEST FOR ENROLLMENT, RE-ENROLLMENT AND REVALIDATION ......................3
102.2 CONDITIONS OF PARTICIPATION – ALL PROVIDERS AND APPLICANTS ......................4
102.3 ENHANCED PROVIDER SCREENING .......................................................................................9
102.4 PROVISIONAL ENROLLMENT .................................................................................................11
102.5 OUT OF STATE PROVIDER PARTICIPATION .......................................................................13
102.6 EMERGENCY SERVICES OUTSIDE THE STATE OF NEVADA ..........................................14
102.7 FACILITY DISCLOSURE............................................................................................................14
102.8 PROVIDER DISCLOSURE ..........................................................................................................15
102.9 DISPOSITION OF CONTRACT FOR PROVIDERS ..................................................................16
102.10 CERTIFICATION STATEMENT ................................................................................................16
102.11 CONTRACT APPROVAL ............................................................................................................17
102.12 CONTRACT DENIAL ..................................................................................................................17
102.13 VOLUNTARY WITHDRAWAL..................................................................................................18
103 PROVIDER RULES AND REQUIREMENTS ..............................................................................1
103.1 MEDICAL NECESSITY .................................................................................................................1
103.2 AUTHORIZATION .........................................................................................................................2
103.3 PROVIDER REPORTING REQUIREMENTS ..............................................................................4
103.4 CONDITIONS OF REPORTING....................................................................................................4
103.5 EMPLOYEE EDUCATION ABOUT FALSE CLAIMS ................................................................5
103.6 COVERAGE AND LIMITATIONS ...............................................................................................6
103.7 SAFEGUARDING INFORMATION ON APPLICANTS AND RECIPIENTS ............................6
103.8 MEDICAL AND PSYCHOLOGICAL INFORMATION ..............................................................7
103.9 NON-DISCRIMINATION AND CIVIL RIGHTS COMPLIANCE ..............................................7
103.10 ADVANCED DIRECTIVE ...........................................................................................................10
103.11 ADMINISTRATION OF ADVANCED DIRECTIVES ...............................................................11
103.12 MUTUAL AGREEMENT IN PROVIDER CHOICE...................................................................12
104 THIRD PARTY LIABILITY (TPL) – OTHER HEALTH CARE COVERAGE ...........................1
104.1 PAYMENT LIMITS AND EXCEPTIONS .....................................................................................2
104.2 SUBROGATION – COST SAVINGS PROGRAM........................................................................4
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DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
104.3 HEALTH INSURANCE PREMIUM PAYMENTS (HIPP) ...........................................................4
105 MEDICAID BILLING AND PAYMENT.......................................................................................1
105.1 MEDICAID PAYMENTS TO PROVIDERS .................................................................................2
105.1A EXTENDED SERVICES ................................................................................................................3
105.2 REIMBURSEMENT .......................................................................................................................4
105.2A LIMITATIONS ................................................................................................................................4
105.2B BILLING TIME FRAMES (STALE DATES) ................................................................................6
105.2C DISPUTED PAYMENT ..................................................................................................................7
105.3 BILLING MEDICAID RECIPIENTS .............................................................................................8
106 CONTRACT TERMINATIONS ....................................................................................................1
106.1 TERMINATION FOR CONVENIENCE........................................................................................1
106.2 CONDITIONS OF CONTRACT TERMINATIONS .....................................................................1
106.3 SANCTION PERIODS ....................................................................................................................3
106.4 PROCEDURES FOR TERMINATION AND NON-RENEWAL ..................................................7
106.4A ADMINISTRATIVE CONTRACT TERMINATIONS ..................................................................7
106.5 MEDICAID AGENCY ACTION AFTER REVIEW, AUDIT OR INVESTIGATION.................8
106.5A CORRECTIVE ACTIONS ..............................................................................................................8
106.6 SUSPENSION ...............................................................................................................................10
106.6A PROCEDURES FOR SUSPENSION ...........................................................................................10
107 RE-ENROLLMENT ........................................................................................................................1
107.1 CONDITIONS OF RE-ENROLLMENT ........................................................................................1
108 REFERENCES ................................................................................................................................1
109 RESERVED .....................................................................................................................................1
110 NEVADA MEDICAID PROVIDER TYPES .................................................................................1
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100 INTRODUCTION
The purpose of this chapter is to provide an overview and description of the Nevada Medicaid
program administered under the authority of the Nevada Department of Health and Human
Services (DHHS) and the Division of Health Care Financing and Policy (DHCFP) and to establish
program policies and procedures.
A. The mission of the Nevada DHCFP (Nevada Medicaid) is to:
1. purchase and provide quality health care services to low-income Nevadans in the
most efficient manner;
2. promote equal access to health care at an affordable cost to the taxpayers of Nevada;
3. restrain the growth of health care costs; and
4. review Medicaid and other State health care programs to maximize potential federal
revenue.
B. For the purposes of this chapter, individuals and/or entities that have never been enrolled with
Nevada Medicaid as a provider who submit an initial enrollment application and former
Nevada Medicaid providers who submit a re-enrollment application are considered
applicants. The term “Applicant” includes:
1. individuals;
2. groups and/or entities;
3. owners having 5% direct or indirect ownership or controlling interest in a group and/or
entity; and/or
4. authorized agents, authorized users or managing employees acting with authority on
behalf of an individual, group, entity and/or owner.
C. For the purposes of this chapter and the Nevada Medicaid and Nevada Check Up Provider
Contract, individuals and/or entities actively enrolled with Nevada Medicaid are considered
providers. The term “Provider” includes:
1. individual providers;
2. groups and/or entity providers;
3. owners having 5% direct or indirect ownership in a group and/or entity; and/or
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4. authorized agents, authorized users or managing employees acting with authority on
behalf of an individual, group, entity and/or owner.
100.1 AUTHORITY
The Medicaid program in Nevada is authorized to operate under the DHHS and the DHCFP per
Nevada Revised Statutes (NRS) Chapter 422. Nevada Medicaid has a federally approved State
Plan to operate a Medicaid program under Title XIX of the Social Security Act (SSA). Regulatory
and statutory oversight of the program is found in Chapter 42 of the Code of Federal Regulations
(CFRs) as well as Chapter 422 of the NRS.
This Medicaid Services Manual (MSM) along with the Medicaid Operations Manual (MOM) is
the codification of regulations adopted by Nevada Medicaid based on the authority of NRS
422.2368, following the procedure at NRS 422.2369. These regulations supplement other
Medicaid program requirements including laws, all applicable Federal requirements and
requirements in the Nevada State Plan for Medicaid. The regulations provide the additional
conditions which limit Medicaid providers’ program participation and payment. The regulations
also provide additional limitations on services provided to Medicaid recipients. The Division
administrator has authority under NRS 422.2356 to establish policies and exceptions to policy for
administration of the programs under Medicaid.
A. Below is a list (not all inclusive) of specific Authorities:
1. Eligibility for Medicaid assistance is regulated by Section 1901(a) of the SSA, 42
CFR, Part 435, and Nevada Medicaid State Plan Section 2.1.
2. Payment for Medicaid services is regulated by Sections 1902(a) and 1923 of the
SSA, 42 CFR, Part 447, and Nevada Medicaid State Plan Sections 4.19 and 4.21.
3. Provider contracts/relations are regulated by 42 CFR 431, Subpart C; 42 CFR Part
483 and Nevada Medicaid State Plan Section 4.13.
4. Safeguarding and disclosure of information on applicants and recipients is
regulated by 42 United States Code (USC) 1396a(a)(7), and the associated
regulations: 42 CFR 431, Subpart F; the Health Insurance Portability and
Accountability Act (HIPAA) and associated regulations: 45 CFR 160, 162 and 164
and the Health Information Technology for Economic and Clinical Health
(HITECH) Act of 2009; Nevada Medicaid State Plan Section 4.3, and NRS
422.290. Penalties for unauthorized use or disclosure of confidential information
are found within the HITECH Act and NRS 193.170.
5. Prohibition against reassignment of provider claims is found in 42 CFR 447.10 and
Nevada Medicaid State Plan Section 4.21.
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6. Exclusion and suspension of providers is found in 42 CFR 1002.203 and Nevada
Medicaid State Plan 4.30.
7. Submission of accurate and complete claims is regulated by 42 CFR 455.18 and
444.19.
8. Nevada Medicaid assistance is authorized pursuant to State of NRS, Title 38, Public
Welfare, Chapter 422, Administration of Welfare Programs.
9. Third Party Liability (TPL) policy is regulated by Section 1902 of the SSA, 42
CFR, Part 433, Subpart D, and the Nevada Medicaid State Plan Section 4.22.
10. Assignment of insurance benefits by insurance carriers is authorized pursuant to
State in NRS, Title 57, Insurance, based on the type of policy.
11. Subrogation of medical payment recoveries is authorized pursuant to NRS 422.293.
12. “Advance Directives” are regulated by 42 CFR 489, Subpart I.
13. Worker’s compensation insurance coverage is required for all providers pursuant
to NRS Chapter 616A through 616B.
14. Section 1902(a)(68) of the SSA establishes providers as ‘entities’ and the
requirement to educate their employees, contractors and agents on false claims
recovery, fraud and abuse.
15. Offering gifts and other inducements to beneficiaries is prohibited pursuant to
Section 1128A(a)(5) of the SSA, enacted as part of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).
16. Section 6401(b) of the Affordable Care Act (ACA) amended Section 1902 of the
SSA to require states to comply with procedures established by the Secretary of
Health and Human Services for screening providers and suppliers. Section 6401(c)
of the ACA amended Section 2107(e) of the SSA to make the provider and supplier
screening requirement under Section 1902 applicable to the Children’s Health
Insurance Program (CHIP). The Centers for Medicare & Medicaid Services (CMS)
implemented these requirements with federal regulations at 42 CFR 455 Subpart E.
17. Provider Categorical Risk Levels are assigned, in part, under 42 CFR §424.518.
18. Enhanced provider screening can be found under 42 CFR §455.432 for site visits
and 42 CFR §455.434 for criminal background checks.
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19. Citizenship/Lawfully Residing: Statute SSA 2105(c)(9); SSA 2107(e)(1)(M);
CHIPRA 2009 Sections 211 and 214; 8 U.S.C. Sections 1612, 1613 and 1641; 42
CFR §457.320(b)(6), (d) and (e); and §457.380(b).
20. Suspension of payments in cases of fraud as required in 42 CFR §455.23.
100.2 CONFIDENTIAL INFORMATION
All individuals have the right to a confidential relationship with the DHCFP. All information
maintained on Medicaid and CHIP applicants and recipients (“recipients”) is confidential and must
be safeguarded.
Handling of confidential information on recipients is restricted by 42 CFR§ 431.301 – 431.305,
the HIPAA of 1996, the HITECH Act of 2009, NRS 422.290, and the Medicaid State Plan, Section
4.3.
Any ambiguity regarding the definition of confidential information or the release thereof will be
resolved by the DHCFP, which will interpret the above regulations as broadly as necessary to
ensure privacy and security of recipient information.
A. Definition of Confidential Information
For the purposes of this manual, confidential information includes:
1. Protected Health Information (PHI)
a. All individually identifiable health information held or transmitted by the
DHCFP or its business associates, in any form or media, whether electronic,
paper or oral.
1. “Individually identifiable health information” is information,
including demographic data, that relates to:
a. the individual’s past, present or future physical or mental
health or condition;
b. the provision of health care to the individual;
c. the past, present or future payment for the provision of health
care to the individual; or
d. identifies the individual or for which there is a reasonable
basis to believe it can be used to identify the individual.
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b. Information which does not meet the requirements of de-identified data
defined in 45 CFR 164 § 514(b). This includes all elements of dates (such
as date of service, data dispensed, claim paid date) and identifiers (including
internal control numbers (ICN)).
2. Information on social and economic condition or circumstances.
3. Division/Department evaluation of personal information.
4. Any information received for verifying income eligibility and amount of medical
assistance payments.
5. Any information received in connection with the identification of legally liable
third party resources.
6. Medicaid Provider Numbers or other identifiers defined by NRS 603A.040.
B. Limitations on Use and Disclosure
Disclosures of identifiable information are limited to purposes directly related to State Plan
administration. These activities include, but are not limited to:
1. Establishing eligibility;
2. Determining the amount of medical assistance; payment activities as defined by
HIPAA;
3. Determining third party liability;
4. Providing services (medical and non-medical) for recipients; treatment as defined
by HIPAA;
5. Conducting or assisting an investigation, prosecution, or civil or criminal
proceeding related to the administration of the Plan;
6. Health care operations as defined by HIPAA, which includes, but is not limited to:
quality assessment and improvement activities, including case management and
care coordination, competency assurance activities, medical reviews, audits, fraud
and abuse detection, rate setting, business management and general administration;
7. For public interest and benefit activities within limits set under HIPAA, including,
but not limited to: disclosures required by law, public health activities, health
oversight activities, judicial and administrative proceedings, essential government
functions, to comply with worker’s compensation laws and to avoid serious threats
to the health and safety of recipients and others.
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8. Per authorizations (as defined by HIPAA) from the recipient or their designated
representative.
C. Release of Information
Except as otherwise provided in these rules, no person shall obtain, disclose or use, or
authorize, permit or acquiesce the use of any client information that is directly or indirectly
derived from the records, files or communications of the DHCFP, except for purposes
directly connected with the administration of the Plan or as otherwise provided by federal
and state law.
1. Disclosure is permitted for purposes directly connected with the administration of
Medicaid between covered entities (as defined by HIPAA) for the purposes of
treatment, payment and health care operations and may, in certain circumstances,
be done in the absence of an authorization or agreement. Such situations include,
but are not limited to: verifying information with Medicaid program staff in other
states to verify eligibility status, disclosure to Medicare staff for coordination of
benefits or communications with providers for payment activities.
2. Access to confidential information regarding recipients will be restricted to those
persons or agencies whose standards of confidentiality are comparable to those of
the DHCFP.
a. Those standards of confidentiality will be outlined in appropriate
agreements which the DHCFP may require, including business associate
agreements and limited data set use agreements (as defined by HIPAA) data
sharing agreements, and other agreements deemed necessary by the
DHCFP.
3. In accordance with NRS 232.357, an individual’s health information may be shared
without an Authorization for Disclosure among the divisions of the DHHS in the
performance of official duties and with local governments that help the Department
carry out official duties as long as the disclosure is related to treatment, payment or
health care operations.
4. The DHCFP will make reasonable efforts to follow HIPAA’s “minimum
necessary” standard when releasing confidential information.
5. Detailed policies and procedures are found in the DHCFP HIPAA Privacy and
Security Manuals, available for reference in hard copy form in the District Office
and on the DHCFP Intranet.
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D. Penalties
Penalties for inappropriate use and disclosure of confidential information are:
1. The HITECH Act imposes civil and criminal penalties depending upon the nature
and scope of the violation, which range from $100 to $1.5 million dollars and up to
ten years in prison. This is enforced by the Office for Civil Rights. State Attorneys
General have the authority to bring civil actions on behalf of state residents for
violations of HIPAA Privacy and Security Rules.
2. Penalties under Nevada state law are found at NRS 193.170.
E. Ownership
All recipient information contained in the DHCFP records is the property of the DHCFP,
and employees of the DHCFP shall protect and preserve such information from
dissemination except as provided within these rules
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101 OVERVIEW OF PROGRAMS
Health care coverage for low-income individuals and families in Nevada is provided through
Medicaid and Nevada Check Up (NCU). For purposes of this manual, Medicaid and NCU are
referred to as Medicaid. However, there are some differences in coverage between the two
programs. Please refer to the NCU Manual for an explanation of these differences.
A. Medicaid
Medicaid applicants must apply for and meet the criteria of the appropriate assistance
program. Every person has the right to apply for assistance. A deceased person may have
an application filed on his or her behalf.
Requests for medical assistance under the Temporary Assistance for Needy Families
(TANF)-Related Medicaid (TRM), Child Health Assurance Program (CHAP), Medical
Assistance for the Aged, Blind, and Disabled (MAABD) programs and the Child Welfare
Services (as provided by NRS 432.075 are processed at one of the local Nevada Division
of Welfare and Supportive Services (DWSS) offices depending on the applicant’s
residence. Eligibility is established based on regulations stated in the DWSS policy
manuals. Inquiries are made at the nearest DWSS office and may be made verbally, in
writing, in person or by a representative. District Office staff will assist with applications
if necessary. DWSS policy manuals are located on their website at: www.dwss.nv.gov.
Children may also be covered by Medicaid through child welfare programs authorized
through the Division of Children and Family Services (DCFS).
B. Nevada Check Up (NCU)
The NCU program is Nevada’s name for the Federal Title XXI benefits administered under
the Children’s Health Insurance Program (CHIP). NCU provides low-cost, health care
coverage to uninsured children who do not meet the conditions of Medicaid eligibility.
Applicants must apply for and meet the criteria for this program. The services for NCU
recipients generally duplicate the services outlined for Nevada Medicaid and the program
uses the Nevada Medicaid Provider Panel. Refer to the NCU Manual for a description of
program differences.
C. State Plan Services under 1915(c) of the SSA
Section 1915(c) State Plan of the SSA known as Home and Community- Based Waiver
(HCBW) services which permits the option to waive certain Medicaid statutory
requirements in order to offer an array of Home and Community-Based Services (HCBS)
to eligible individuals who may require such services in order to remain in their
communities and avoid institutionalization. Each 1915(c) Waiver is designed to provide
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eligible Medicaid waiver recipients access to both state plan services, as well as certain
extended Medicaid covered services unique to this waiver. The goal is to allow recipients
to live in their own homes, or community settings, when appropriate.
D. State Plan Services under 1915(i) of the SSA
Section 6086 of the Deficit Reduction Act of 2005, established a new benefit of the SSA
called 1915(i) State Plan HCBS which allows states to provide traditional 1915(c) services
as a covered state plan benefit. 1915(i) services are available to certain Medicaid recipients
who meet the needs based criteria and who reside in the community.
101.1 OUT OF STATE SERVICES
Nevada Medicaid may authorize payment for both mandatory and optional services if determined
to be medically necessary.
Section 1902(a)(16) of the SSA requires the out-of-state service equal in amount, duration and
scope to in-state service be reimbursed for eligible Nevada residents who are absent from the state
when:
A. needed because of a medical emergency.
B. recipients’ health would be in danger by travel back to Nevada.
C. Nevada Medicaid determines, on the bases of medical advice, that the needed medical
service or necessary supplementary resources are readily available in another state; or
D. provided to the children in out-of-state placement for whom Nevada makes adoption
assistance or foster care maintenance payments.
E. it is general practice for a recipient in a particular locality to use medical resources in
another state:
1. Nevada residents living near state lines or borders may be geographically closer to
out-of-state providers than in-state providers for both primary and specialty care.
In such cases, covered medically necessary services may be routinely provided by
out-of-state providers in what the DHCFP refers to as the “primary catchment
areas.” Such services are treated the same as those provided within the state borders
for purposes of authorization and transportation. Refer to the billing manual for a
list of catchment areas.
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2. The same services that are covered within the state of Nevada are available for
payment for any qualified provider, in the catchment area, who is or will be enrolled
with the plan.
Nevada Medicaid does not pay for medical services rendered by health care
providers outside of the United States.
101.2 NEVADA MEDICAID AND NCU CARD
Medicaid and NCU recipients are issued a plastic identification card upon approval for benefits,
through the State Medicaid Management Information System (MMIS). The card is issued with
his/her full eleven-digit billing number, last name, first name, sex and date of birth. The card does
not identify the category of eligibility nor does it carry photographic or other individual identifying
information and it does not guarantee eligibility for benefits. The recipient is not responsible to
return the card when the case is closed and they may use the same card for any subsequent
eligibility.
101.2A ELIGIBILITY VERIFICATION AND CARD USE
1. Information regarding the recipient, category of eligibility, managed care, recipient
restrictions and third-party payers is accessible, for any of the most recent 60 months,
through the fiscal agent’s Eligibility Verification System (EVS), by phone using the Voice
Response Unit (VRU), or by using a swipe card vendor. Providers may contact the Fiscal
Agent to receive information about enrolling for EVS system access and alternative sources
of eligibility verification.
EVS will identify individuals eligible for full Medicaid, full Medicare, full Medicaid and
Medicare coverage, and Qualified Medicare Beneficiary (QMB) coverage. Note: Medicaid
pays only the deductibles and co-insurance for QMB recipients up to Medicaid allowable
amounts.
2. Eligibility is determined on a month to month basis. Providers must always verify recipient
eligibility prior to providing services, as well as the identity of the individual through a
driver’s license, Social Security card or photo identification. Recipients must be prepared
to provide sufficient personal identification to providers and shall not allow any individual
to use their card to obtain medical services.
3. Newly approved Medicaid recipients may present a Notice of Decision (NOD) from the
DWSS as proof of eligibility, prior to the EVS update.
4. Individuals may have more than one active billing number on file at the same time; e.g., a
child may be eligible through Child Welfare services and have a Welfare case at the same
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time. When this happens, the Division’s Provider Support Unit can advise the provider
which number to use for billing.
5. Medicaid and NCU have contracts with Managed Care Organizations (MCOs) to provide
medical coverage to eligible categories of individuals in Clark and Washoe County.
Nevada Medicaid and NCU reimburse managed care providers a capitated monthly rate for
each enrollee and cannot reimburse any other provider independently for covered,
contracted services. Refer to MSM Chapter 3600 for detailed information about the
Managed Care program.
6. Recipients enrolled in a Medicaid managed care plan must be sure to seek services only
from plan providers. Recipients should notify their providers as soon as they become
eligible for managed care. Refer to MSM Chapter 3600 on Managed Care.
7. In most cases, managed care eligibility begins the first of the month after the date of
approval. Medicaid prior medical months are covered under Fee-for-Service (FFS). Refer
to MSM Chapter 3600 for additional information on Managed Care.
101.2B CHILD WELFARE RECIPIENTS
Payment for emergent or necessary medical services or care provided to a child who is in the
custody of a Public Child Welfare Agency may be covered by Nevada Medicaid or guaranteed by
the custodial public agency. A child eligible for coverage through one of these sources will receive
a Medicaid number and card.
If a child requires medical care before a Medicaid number and/or a Medicaid card is issued, the
custodial agency may prepare a letter verifying demographic information including the child’s
name, date of birth, Social Security number and the services requested. (If a Medicaid number has
been assigned but a card has not yet been issued, the letter should also contain the Medicaid
number.) The letter must be signed by an authorized staff member of the Public Child Welfare
Agency in whose custody the child is placed and must be printed on the agency’s official
letterhead.
101.2C RESTRICTIONS
1. Certain recipients who have inappropriately used medical services may have their access
to Medicaid services restricted by Medicaid Staff.
2. Before any non-emergency service is provided to a recipient, whose benefits have been
restricted, phone authorization must be obtained from the Quality Improvement
Organization (QIO)-like vendor. Providers will be asked to document the necessity of all
services provided which are not emergent. If approval is granted, a specific authorization
number will be issued to the provider. This number must then appear on the provider’s
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claim for payment for the service dispensed. Claims submitted for a recipient whose
benefits have been restricted without an authorization number or documentation of an
emergency will not be paid.
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102 PROVIDER ENROLLMENT
All individuals/entities providing services to Medicaid recipients under the FFS or Medicaid
Managed Care program must be enrolled as a Medicaid provider in order to receive payment for
services rendered. All healthcare providers shall obtain a National Provider Identifier (NPI)
number and provide this NPI to Medicaid at the time of their provider enrollment application. To
obtain an NPI or further information regarding NPI, see the National Plan and Provider
Enumeration System (NPPES) website at https://nppes.cms.hhs.gov.
A. Medicaid may reimburse a provider who meets the following conditions:
1. Provides their NPI number on the application and requests for payment, maintains
their NPI in “Active” status in the NPPES Registry and updates all data elements,
per NPPES guidelines, when changes occur;
2. Meets all the professional credentialing requirements or other conditions of
participation for the provider type;
3. Completes and submits electronically the Nevada Medicaid Provider Application
and Contract, and if applicable, submits to and completes the Fingerprint-based
Criminal Background Check (FCBC) process;
4. Receives notice from Nevada Medicaid that the credentialing requirements have
been met and the provider agreement has been accepted; and
5. Electronically submits complete and accurate claims.
B. CHANGE OF OWNERSHIP (CHOW)
A CHOW typically occurs when a Medicaid provider is purchased or leased by another
organization. The following list indicates examples (not all inclusive) of a CHOW:
1. Partnership: In the case of a partnership, the removal, addition or substitution of a
partner as permitted by applicable State law.
2. Unincorporated sole proprietorship: Transfer of title and property to another party.
3. Corporation: The merger of the provider corporation into another corporation, or
the consolidation of two or more corporations, resulting in the creation of a new
corporation.
4. Leasing: The lease of all or part of a provider facility.
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5. Sale/Transfer: The sale, gifting, purchase or transfer of an existing provider or the
assets of an existing provider to an individual, relative and/or group.
C. CHOW enrollment:
1. is not guaranteed,
2. is considered a new enrollment, and
3. must meet all enrollment requirements for the specified provider type.
Providers or applicants having (or formerly holding) a direct or indirect ownership or
controlling interest who purchase, sell and/or transfer such interest in an entity in
anticipation of (or following):
4. a conviction;
5. an imposition of a payment suspension, civil money penalty or assessment; and/or
6. an imposition of an exclusion and/or a “for cause” termination
shall be terminated or have enrollment denied and will serve, at minimum, a Tier 4 – 12-
Month Sanction, unless a higher tier sanction is applicable.
D. PROHIBITED FROM ENROLLMENT CONSIDERATION
Applicants who are found to have provided false, untrue or misleading/deceptive
information and/or who have omitted relevant information are prohibited from enrollment
consideration for a period of 12 consecutive months from the date of application denial.
Examples may include, but are not limited to:
1. criminal conviction(s);
2. information regarding direct or indirect ownership or controlling interest of 5% or
more; and/or
3. falsified documentation.
E. Actively enrolled providers who submit an enrollment application which is found to meet
any of the criteria in Section 102(D) may be terminated and sanctioned.
Providers who request to voluntarily terminate while under any form of suspension,
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investigation, audit and/or review may be sanctioned based on the results of the suspension,
investigation, audit and/or review.
Prior to receiving reimbursement, providers must meet the participation standards specified
for the program service area for which they are applying, and comply with all federal, state
and local statutes, rules and regulations relating to the services being provided.
Providers who provide services outside of the United States will not receive reimbursement
per MSM 101.1(e)(2)
A moratorium may be implemented at the discretion of the federal DHHS or the DHCFP.
A new enrollment application is required for enrollment after it is lifted.
102.1 REQUEST FOR ENROLLMENT, RE-ENROLLMENT AND REVALIDATION
A request for enrollment means an applicant, who has never been a Nevada Medicaid provider,
submits an initial enrollment application; re-enrollment means a former Nevada Medicaid
provider, whose contract was terminated or deactivated and who is now eligible to “re-enroll,”
submits an initial enrollment application; and, revalidation means an active Nevada Medicaid
provider, who must validate their current enrollment to extend their agreement with Nevada
Medicaid, submits a revalidation application.
An applicant and/or provider may request enrollment, including re-enrollment and revalidation, in
the Nevada Medicaid Program by completing the Enrollment Application and providing the
required verifications for their requested provider type. All applications and supporting documents
must be submitted online through the Provider Portal.
The DHCFP is not obligated to enroll all eligible providers, and all types of enrollment are at the
discretion of the DHCFP. For additional information regarding enrollment, the provider may
contact the Provider Enrollment Unit of the Fiscal Agent. Refer to Section 108 for contact
information.
The effective date of the provider contract is the date a complete enrollment request is received,
all verifications are completed and it is determined the applicant meets all conditions of
participation. Exceptions may be allowed for up to six months of retroactive enrollment to
encompass dates on which the otherwise eligible provider furnished services to a Medicaid
recipient. All approved Provider Contracts, unless otherwise withdrawn or terminated, shall expire
60 months from enrollment date, with the exception of Durable Medical Equipment (DME)
Contracts which shall expire 36 months from enrollment date, unless withdrawn or terminated.
If the provider does not meet all State and Federal requirements at the time of the initial request
for participation, the effective date of the provider contract will be the date all requirements are
met. If the Provider is serving a sanction period, they are not eligible for enrollment.
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A. If discrepancies are found to exist during the pre-enrollment period, the DHCFP and/or the
Fiscal Agent may conduct additional inspections prior to enrollment. Failure to provide
complete and accurate information, or to resolve discrepancies as prescribed by the DHCFP
and/or the Fiscal Agent, may result in denial of the application.
The Fiscal Agent may complete additional screenings on applicants for the purpose of
verifying the accuracy of information provided in the application and in order to prevent
fraud and abuse.
The screening may include, but is not limited to, the following:
1. on-site inspection prior to enrollment;
2. review of business records;
3. data searches; and/or
4. provisional enrollment.
102.2 CONDITIONS OF PARTICIPATION – ALL PROVIDERS AND APPLICANTS
As a condition of new or continued enrollment, providers and applicants shall consent and submit
to criminal background checks, including fingerprinting, when required to do so under State law
or by the level of screening based on risk of fraud, waste or abuse as determined for the provider.
The DHCFP and/or Fiscal Agent shall screen all initial applications, applications for a new practice
location and any applications received in response to a re-enrollment or revalidation of enrollment
request based on a categorical risk level of “Limited,” “Moderate” or “High.” This screening also
applies to providers who the DHCFP has adjusted to the highest level of risk after enrollment and
providers deemed “High” risk who add a person(s) with five percent or more direct or indirect
ownership interest in the provider. If a provider could be placed within more than one risk level,
the highest level of screening is applicable, and the DHCFP has the authority to adjust a provider’s
risk level to ensure the fiscal integrity of the Medicaid program.
A. The following indicates categorical risk levels for providers:
1. Limited categorical risk:
a. Physician or non-physician practitioners, including nurse practitioners,
Certified Registered Nurse Anesthetists (CRNAs), occupational therapists,
speech/language pathologists, and audiologists, and medical groups or
clinics.
b. Ambulatory surgical centers.
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c. End-stage renal disease facilities.
d. Federally qualified health centers.
e. Histocompatibility laboratories.
f. Hospitals, including critical access hospitals, Department of Veterans
Affairs hospitals and other federally owned hospital facilities.
g. Health programs operated by an Indian Health Program or an urban Indian
organization that receives funding from the Indian Health Service pursuant
to Title V of the Indian Health Care Improvement Act.
h. Mammography screening centers.
i. Mass immunization roster billers.
j. Organ procurement organizations.
k. Pharmacies newly enrolling or revalidating via the CMS-855B application.
l. Radiation therapy centers.
m. Religious non-medical health care institutions.
n. Rural Health Clinics.
o. Skilled nursing facilities.
2. Moderate categorical risk:
a. Ambulance service suppliers.
b. Community mental health centers.
c. Comprehensive outpatient rehabilitation facilities.
d. Hospice organizations.
e. Independent clinical laboratories.
f. Independent diagnostic testing facilities.
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g. Physical therapists enrolling as individuals or as group practices.
h. Portable x-ray suppliers.
i. Revalidating home health agencies.
j. Revalidating Durable Medical Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) suppliers.
k. Provisionally enrolled providers, unless placement in the “High”
categorical risk is applicable.
3. High categorical risk:
a. Newly enrolling home health agencies.
b. Newly enrolling DMEPOS suppliers.
B. The Fiscal Agent shall not enroll any provider or applicant (individual or entity having a
person with a five percent or greater direct or indirect ownership interest in the provider,
including management personnel) who has been convicted of a felony or misdemeanor
under Federal or State law for any offense which the State agency determines is
inconsistent with the best interest of recipients under the State plan. The following list,
though not exhaustive, provides examples of crimes and/or offenses which indicate a
provider or applicant is not eligible for participation:
1. Murder, voluntary manslaughter or mayhem;
2. Sexual assault, sexual seduction or any sexually related crime;
3. Robbery, attempt to kill, battery with intent to commit a crime or administration of
a drug to aid commission of the crime;
4. Abuse or neglect of a child or contributory delinquency;
5. False imprisonment, involuntary servitude or kidnapping;
6. Abuse, neglect, exploitation or isolation of any older persons or vulnerable persons,
including a violation of any provisions of NRS Section 200, or a law of any other
jurisdiction that prohibits the same or similar conduct;
7. Any offense involving assault or battery, domestic or otherwise;
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8. Conduct hostile or detrimental to the public health, morals, welfare and safety of
the people of the State of Nevada in the maintenance and operation of the premises
for which a provider contract is issued;
9. Conviction of a criminal offense related to that person’s involvement in any
program established under Medicare, Medicaid, CHIP (NCU) or the Title XX
services program or any other state or federally funded assistance program;
10. Any entity or individual who has an existing overpayment with an outstanding
balance with the DHCFP and has not entered into a State approved re-payment
plan;
11. Is on the Office of the Inspector General (OIG) or Excluded Parties List System
(EPLS) exclusion list;
12. Has been terminated for cause, excluded or is under any form of suspension from
Medicare, Medicaid, CHIP (NCU), Title XX services program or any other State
or Federally funded assistance program;
13. Uses a financial institution outside of the country (excluding Guam, Puerto Rico,
Mariana Islands and American Samoa);
14. Is serving a sanction period; or
15. The Fiscal Agent shall not enroll a provider or applicant who has been convicted
within the preceding ten years of (not all inclusive):
a. any offense involving arson, fraud, theft, embezzlement, burglary,
fraudulent conversion or misappropriation of property;
b. a violation of any federal or state law regulating the possession, distribution
or use of any controlled substance or any dangerous drug as defined in
Chapter 454 of the NRS;
c. any offense involving the use of a firearm or other deadly weapon; or
d. Conviction of a criminal offense related to that person’s involvement in any
state or federally funded assistance program, this includes providers,
applicants, owners, managing employees and/or agents.
C. The Fiscal Agent shall not enroll a public institution unless it is a medical institution. The
Fiscal Agent shall never enroll a penal or correctional institution.
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D. All providers must provide and maintain workers’ compensation insurance as required by
law and provided proof of insurance as required through 616D, inclusive, of the NRS.
E. All Nevada Medicaid providers must comply with information reporting requirements of
the Internal Revenue Code (26 U.S.C. 6041) which requires the filing of annual
information (1099) showing aggregate amount paid to provider’s service identified by
name, address, Social Security Number (SSN) or Federal Identification Number (FEIN).
A FEIN is the preferred identifier, but a SSN may be used by those self-employed
individuals in a sole proprietorship who do not have a FEIN.
F. The provider is responsible for understanding the requirements of their provider type as
stated in the Nevada MSM. The provider should also be familiar with Chapter 3100 –
Hearings and Chapter 3300 – Surveillance, Utilization and Review (SUR).
G. Providers are required to keep patient records that adhere to basic standards of practice and
in accordance with the DHCFP Operations Service Manuals, state and federal statutes and
regulations at a minimum of six years from the date of payment for the specified service.
Electronic health records must include a verifiable date of service time stamp, record who
is making the entry and who actually saw the patient.
H. Any provider who is providing services to foster children, in any setting, must submit to a
full, fingerprint-based criminal history and Child Abuse and Neglect Screening (CANS) in
order to comply with the Adam Walsh Child Protection Act of 2006.
These reports are legally mandated and maintained by the Nevada Division of Child and
Family Services (DCFS), Central Office, 4126 Technology Way, 1st Floor, Carson City,
Nevada 89706. Names of individuals are checked against names in the central registry to
identify any substantiated perpetrators of abuse. CANS employer information is limited to
provision of the substantiated status of a report and is released only by the Nevada DCFS
(NRS 432.100). Information may be released to an employer under NRS 432.100(3).
The completion of a request form and Authorization to Release Information must be
submitted to:
Nevada Division of Child and Family Services
Attn: Child Abuse and Neglect Records Check
4126 Technology Way, 1st Floor
Carson City, NV 89706
For additional information and authorization forms please contact:
Nevada Division of Child and Family Services
(775) 684-7941
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I. Site visits shall be conducted on all providers and/or applicants designated as “Moderate”
or “High” categorical risk. The purpose of the site visit is to verify that the information
submitted to the Fiscal Agent or the DHCFP is accurate, the facility is operational and to
determine compliance with Federal and State enrollment requirements. Site visits may be:
1. conducted pre- or post-enrollment;
2. announced and/or unannounced; and/or
3. conducted as needed in conjunction with a Corrective Action Plan.
J. In addition to any other authority it may have, the DHCFP may exclude an individual or
entity (applicant or provider) from participation in the Medicaid program for any reason
for which the secretary could exclude that individual or entity from participation in
Medicare.
102.3 ENHANCED PROVIDER SCREENING
A. CATEGORICAL RISK
Providers shall be placed in one of the following risk levels and submit to the necessary
screening, not all inclusive, for each risk level as follows:
1. Limited categorical risk:
a. provider meets applicable federal regulations and/or state requirements for
the provider type;
b. provider’s license(s) is current, including in states other than Nevada;
c. there are no current limitations or restrictions on the provider’s license; and
d. provider initially and continues to meet enrollment criteria for their provider
type.
2. Moderate categorical risk:
a. provider meets the “Limited” screening requirements; and
b. site visits, whether announced or unannounced, for any and all provider
locations.
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3. High categorical risk:
a. provider meets the “Limited” and “Moderate” screening requirements;
b. provider consents to a criminal background check; and
c. provider submits a set of fingerprints in accordance with instructions from
the DHCFP.
B. RISK LEVEL ADJUSTMENT
Once enrolled, providers or any person with a five percent or more direct or indirect
ownership interest in the provider, may have their categorical risk level adjusted from
“Limited” or “Moderate” to “High” for the following reason and/or reasons (not all
inclusive):
1. A payment suspension on the individual or entity was imposed based on a credible
allegation of fraud, waste or abuse. The provider’s risk remains “High” for 10 years
beyond the date of the payment suspension.
2. A provider (individual or entity) incurs a Medicaid overpayment.
3. The DHCFP or the CMS in the previous six months lifted a temporary moratorium
for the particular provider type and a provider that was prevented from enrolling
based on the moratorium applies for enrollment as a provider at any time within six
months from the date the moratorium was lifted.
C. Within 30 days of notification, providers and/or individuals or any person with five percent
or more direct or indirect ownership interest in the provider whose risk level is elevated to
“High” and any out of state provider required to submit to FCBC shall consent to and
provide proof of fingerprint capture and submission per the instructions provided by the
DHCFP.
D. Approved providers whose categorical risk level is “High” shall complete the FCBC
requirements for any new person(s), having five percent or more direct or indirect
ownership, who is added and/or not previously screened.
E. Providers subject to FCBC will be responsible for all costs associated with fingerprint
collection.
F. Providers screened and placed in the “High” risk category by the Fiscal Agent or the
DHCFP may be found to have met the FCBC requirements when the provider enrolled
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with Medicare. The DHCFP may rely upon Medicare’s screening if all of the following are
verified:
1. The date of Medicare’s last screening of the provider occurred within the last five
years.
2. The provider’s Medicaid enrollment information is a “positive match” with the
Medicare enrollment record.
102.4 PROVISIONAL ENROLLMENT
A. At the discretion of the DHCFP, the Fiscal Agent may provisionally enroll applicants who
meet one or more of the following conditions (not all inclusive):
1. The applicant is part of an approved repayment program for an outstanding debt
owed to:
a. any State or the Federal Government;
b. Medicare;
c. Medicaid;
d. an MCO; and/or
e. a Prepaid Ambulatory Health Plan (PAHP).
2. The applicant discloses a conviction which would not automatically preclude the
applicant from enrollment.
3. The applicant is under investigation by any law enforcement, regulatory or state
agency at the time of application.
4. The applicant has an open or pending court case which is reported on the enrollment
application.
5. The applicant has been denied malpractice insurance or has ever had any
professional business or accreditation license/certificate denied, suspended,
surrendered, restricted or revoked.
6. All applicants for a provider type for which a moratorium was lifted in the
preceding 12 months.
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7. Other circumstances which would not preclude enrollment but would require
additional oversight as documented.
B. The DHCFP may elevate an active provider to provisionally enrolled status if one or more
of the following occurs (not all inclusive):
1. The outcome of an open or pending court case or investigation by any law
enforcement, regulatory or state agency reported on the enrollment application
indicates a conviction for an offense not listed in MSM Chapter 100, Section
102.2(B).
2. The provider’s Categorical Risk level is elevated to “Moderate” or “High” after
enrollment has occurred.
3. The provider’s license required for enrollment with Medicare and/or Medicaid (in
Nevada or any other State) is restricted by the issuing Board or agency.
4. A Change of Ownership is reported and any of the purchasing and/or new
owners/officers report any conditions noted in Section 102.4, all inclusive.
5. Preliminary information is discovered where conditions under Section 102.4 would
not warrant termination but would require provisional enrollment.
C. At the discretion of the DHCFP, the Fiscal Agent may provisionally enroll a re-validating
provider who meets one or more of the following (not all inclusive):
1. The provider is part of an approved repayment program for an outstanding debt
owed to:
a. any State or the Federal Government;
b. Medicare;
c. Medicaid;
d. an MCO; and/or
e. a PAHP
2. The provider discloses a conviction which would not automatically preclude the
provider from enrollment.
3. The provider is under investigation by any law enforcement, regulatory or state
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agency at the time of re-validation.
4. The provider has an open or pending court case.
5. The provider has been denied malpractice insurance or has ever had any
professional, business or accreditation license/certificate denied, suspended,
restricted or revoked.
D. Provisional enrollment will be for a period not less than 30 days and not more than 24
consecutive months for each enrollment application. During the provisional enrollment
period, the provider shall be required to comply with all requirements within the MSM,
including, but not limited to, the following:
1. Permit site visits (announced or unannounced);
2. Provide any and all requested information regarding billing, billing practices and/or
policies and procedures in a complete and accurate manner by due date;
3. Attend provider training recommended by the DHCFP;
4. Cooperate and comply with all terms of a corrective action plan by the due date;
and/or
5. Cooperate and comply with all quality of care compliance reviews.
E. Providers who fail to meet provisional enrollment requirements will be terminated “for
cause” and serve a Tier 4 – 12-Month Sanction, unless termination criteria require a higher
level of sanction.
F. Backdating for provisionally enrolled providers shall not be permitted.
G. Revalidation date shall be the first day of full enrollment.
102.5 OUT OF STATE PROVIDER PARTICIPATION
Out-of-state providers may request enrollment in the Nevada Medicaid program. Provider types
that require Medicare and/or national certification, as defined in Federal regulations, must have
the required certifications. In addition, all providers must meet all licensure, certification or
approval requirements in accordance with state law in the state in which they practice. Additional
conditions of participation may apply depending on where the services are provided.
Out of state providers requesting enrollment to provide ongoing services to Nevada Medicaid
recipients must meet one of the following criteria:
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A. The provider is providing a service which is not readily available within the state; and
B. The provider is providing services to Medicaid recipients in a catchment (border) area; or
C. The provider is providing services to Medicare cross over recipients only.
Nevada Medicaid does not enroll providers to provide mail order delivery of
pharmaceutical or durable medical equipment or gases, except those providing services to
Medicare crossover recipient’s only.
102.6 EMERGENCY SERVICES OUTSIDE THE STATE OF NEVADA
A provider outside of the State of Nevada who furnishes authorized goods and services under the
Nevada medical assistance program to eligible Nevada residents visiting another state and urgently
requiring care and services shall be exempt from the full enrollment process as long as that provider
is properly licensed to provide health care services in accordance with the laws of the provider’s
home state and enrolled as a Medicaid provider in the provider’s home state to furnish the health
care services rendered. Refer to the Provider Enrollment Information Booklet for enrollment
instructions.
102.7 FACILITY DISCLOSURE
Section 1902(a)(36) requires Nevada Medicaid to make available, for inspection and copying by
the public, pertinent findings from surveys made by the State survey agency, the Bureau of Health
Care Quality and Compliance (BHCQC). Such surveys are made to determine if a health care
organization meets the requirements for participation in the Medicare/Medicaid program.
Federal regulations require the disclosure by providers and fiscal agents of ownership and control
information and information on a facility’s owners and other persons convicted of criminal
offenses against Medicare, Medicaid, CHIP, NCU or the Title XX services program.
A. Documents subject to disclosure include:
1. survey reports, including a statement of deficiencies;
2. official notifications of findings based on the survey;
3. written plans of correction submitted by the provider to the survey agency;
4. ownership and contract information specified below; and
5. reports of post-certification visits and summaries of uncorrected deficiencies.
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Within the context of these requirements, the term “provider” or “discloser” excludes an
individual practitioner or group of practitioners unless specifically mentioned.
B. At the time of a periodic survey or renewal of a contract to participate in the program,
providers and fiscal agents must disclose:
1. name and address of each person with an ownership or control interest in the
discloser, or in any subcontractor in which discloser has direct or indirect ownership
of five percent or more;
2. whether any of the persons named is related to another as spouse, parent, child or
sibling; and
3. name of any other disclosing entity in which a person with an ownership or
controlling interest in the discloser also has ownership or controlling interest.
C. Within 35 days of the date of request by the Secretary of Department of Health and Human
Services (DHHS), or the Medicaid agency, a provider must submit full and complete
information about:
1. ownership of any contractor with whom the provider has had business transactions
totaling more than $25,000 during the 12-month period ending on the date of the
request; and
2. any significant business transactions between the provider and any wholly owned
supplier, or between the provider and any subcontractor, during the five-year period
ending on the date of request.
102.8 PROVIDER DISCLOSURE
A. To enter into and/or maintain a provider contract with the Medicaid or NCU programs, the
provider or any person who has ownership or a controlling interest of five percent or more,
or who is an agent or managing employee of the provider must disclose and/or report (if
status changes during enrollment) any information listed below including, but not limited
to the following:
1. conviction of any offense related to that individual’s or entity’s involvement in any
program established under Medicare, Medicaid, CHIP (NCU) or Title XX services
program since the inception of the programs;
2. denial of enrollment or termination for cause, exclusion or any form of suspension
from Medicare, Medicaid, CHIP (NCU), any federal health care program or Title
XX services program since the inception of the programs;
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3. conviction of any offense. Providers and/or applicants reporting convictions other
than those listed in 102.2(B) are not automatically precluded from enrollment. The
Fiscal Agent will forward these applications or change forms to the DHCFP
Provider Enrollment Unit for consideration on a case-by-case basis. Providers
and/or applicants must provide information, documentation and explanation
regarding their conviction;
4. any current or previous investigation by any law enforcement, regulatory agency,
or state agency, or restricted professional license. The Fiscal Agent will forward
these applications or change forms to the DHCFP Provider Enrollment Unit for
consideration on a case-by-case basis. Providers and/or applicants must provide
information, documentation and explanation, regarding the investigation;
5. any current open/pending court cases;
6. any current or previous affiliation with a provider, supplier or other State that has
uncollected debt with no attempt to resolve;
7. if billing privileges have ever been denied or revoked with a federal or state health
care program; or
8. if the provider’s and/or applicant’s license(s) required for enrollment with Medicare
and/or Nevada Medicaid has ever been suspended, surrendered, inactivated and/or
revoked by any licensing Board or State.
102.9 DISPOSITION OF CONTRACT FOR PROVIDERS
The Fiscal Agent and/or the DHCFP will review the completed provider application to determine
if the applicant meets all the conditions of participation as stated in the Nevada MSM for the
specified provider type/specialty and Nevada MSM Chapter 100, all inclusive.
Provisional licensure will be allowed based on Nevada State Board requirements of the specific
specialties within the scope of practice for licensed professionals. Provisional licensure will apply
only to licensed level professionals. Credentialed and paraprofessional level providers do not meet
the requirement for provisional licensure.
102.10 CERTIFICATION STATEMENT
A. By signing the enrollment application, the provider attests to the following:
1. That payment will be from federal and state funds and that any falsification, or
concealment of a material fact, may be prosecuted under federal and state laws; and
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2. Under penalty of perjury, certifies as “true” information on the enrollment
application and/or Change Form to become enrolled in, maintain enrollment in
and/or update enrollment information with the Nevada Medicaid program.
3. With regard to submission of claims for payment:
a. I certify that all information is true, accurate and complete and that I am
responsible for any and all claims submitted by employees and other
person(s) acting on my behalf.
b. I certify that no individual other than the one whose NPI number appears
on the claim provided the services for the submitted claim.
4. With regard to remittance and receipt of payment, the provider agrees and
acknowledges:
a. to accept Medicaid payments as payment in full for services rendered and
under no condition, except for lawful patient liability, contact the patient or
members of the patient’s family for additional sums; and
b. that they have examined the remittance advice that accompanied the
payment, the payment represents amounts due and the services listed
thereon have been rendered by the provider whose NPI number was noted
on the claim.
102.11 CONTRACT APPROVAL
If conditions of participation are met, Nevada Medicaid will obtain the necessary signatures to
bind the contract.
An enrollment approval letter, which will include the provider’s NPI, will be sent to the provider.
If the provider has been approved to provide more than one type of medical service, the provider
type will be identified for each service type.
102.12 CONTRACT DENIAL
Denial means denial of an enrollment application submitted to Nevada Medicaid from any
applicant, including an individual, entity or group.
A. The DHCFP will refuse to enter into a contract with an applicant for provider enrollment
in the Medicaid program if the provider:
1. does not meet the conditions of participation as stated in this Chapter, all inclusive;
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2. does not meet all the professional credentialing requirements or other conditions of
participation as required by the Nevada MSM for the specified provider type;
3. has been terminated for cause, excluded or suspended, leading to revocation of an
agreement or contract with a provider by any other governmental or State program;
4. fails to submit information requested by the DHCFP and/or Fiscal Agent;
5. submits false information;
6. fails to consent to the FCBC process and/or submit FCBC forms and fingerprints
as requested and instructed by the Fiscal Agent and/or the DHCFP.
B. The Fiscal Agent or the DHCFP Provider Enrollment Unit will notify the provider of the
contract denial. Individuals and/or entities who have their enrollment denied do not have
appeal or hearing rights.
102.13 VOLUNTARY WITHDRAWAL
Nevada Medicaid may impose a sanction on any provider as defined in this chapter who requests
to voluntarily terminate while under investigation, audit, review, survey or payment suspension.
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103 PROVIDER RULES AND REQUIREMENTS
Under a program such as Medicaid, providers of medical services have responsibilities that may
not exist in a private patient relationship. The provider accepts a degree of responsibility not only
to the recipient but also to the paying agency, which in the end, is the community as a whole.
A. If the provider has knowledge of over-utilization, inappropriate utilization, use of the
Nevada Medicaid card by a person not listed on the card, unreasonable demands for
services or any other situation that the provider feels is a misuse of medical services by a
recipient, he shall inform the Nevada Medicaid office.
B. A Medicaid provider who accepts a Medicaid recipient for treatment accepts the
responsibility to make certain the recipient receives all medically necessary Medicaid
covered services. This includes, but is not limited to, the following assurances:
1. referrals to other Medicaid providers are appropriate.
2. ancillary services are delivered by an actively enrolled Medicaid provider.
3. recipient(s) receives all medically necessary Medicaid covered services at no cost
to the recipient(s).
4. claims submitted are only for services rendered.
C. In addition, when the services require a Prior Authorization (PA) and a PA number is
obtained, the provider must give that number to other relevant providers rendering service
to the recipient.
D. All Medicaid providers who accept Medicaid reimbursement for treatment accept
responsibility for understanding and comprehending their provider contract and all
chapters of the MSM that pertain to their individual provider type and services they
provide. This applies to all institutions and medical groups as well.
103.1 MEDICAL NECESSITY
Medical Necessity is a health care service or product provided for under the Medicaid State Plan
and is necessary and consistent with generally accepted professional standards to:
A. diagnose, treat or prevent illness or disease;
B. regain functional capacity; or
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C. reduce or ameliorate effects of an illness, injury or disability.
The determination of medical necessity is made on the basis of the individual case and takes into
account:
D. the type, frequency, extent, body site and duration of treatment with scientifically based
guidelines of national medical or health care coverage organizations or governmental
agencies.
E. the level of service that can be safely and effectively furnished, and for which no equally
effective and more conservative or less costly treatment is available.
F. that services are delivered in the setting that is clinically appropriate to the specific physical
and mental/behavioral health care needs of the recipient.
G. that services are provided for medical or mental/behavioral reasons, rather than for the
convenience of the recipient, the recipient’s caregiver or the health care provider.
Medical necessity shall take into account the ability of the service to allow recipients to remain in
a community-based setting, when such a setting is safe, and there is no less costly, more
conservative or more effective setting.
103.2 AUTHORIZATION
Titles XI and XVIII of the Act provide the statutory authority for the board objectives and
operations of the Utilization and Quality Control QIO program. The Peer Review Improvement
Act of the Tax Equity and Fiscal Responsibility Act of 1982 established Utilization and Quality
Control QIO.
QIOs operate under contract with the Secretary of Health and Human Services (HHS) to review
Medicaid services, once so certified by CMS. They may also contract with Medicaid agencies and
private insurers. The utilization review/control requirements of 42 CFR 456 are deemed met if a
state Medicaid agency contract with a Medicare certified QIO, designated under Part 475 to
perform review/control services (42 CFR 431.630).
PA review is conducted to evaluate medical necessity, appropriateness, location of service and
compliance with Medicaid’s policy, prior to the delivery of service.
A. Some services covered by Nevada Medicaid require PA for payment. When the provider
learns that a patient has been approved for Medicaid, authorization, as appropriate, must
be requested for services provided and/or being provided.
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For Medicaid recipients who have been discharged from an inpatient facility and are
approved for Medicaid eligibility retroactively, the provider has 90 days from the date of
the eligibility decision to submit a request for authorization, with the complete medical
record, to the QIO-like vendor. For recipients, still in the hospital when the eligibility date
of decision is determined, the facility is responsible for initiating the admission and
concurrent review authorization within ten working days.
B. For Medicare and Medicaid dual eligible, there is no requirement to obtain Medicaid PA
for Medicare covered services. If services are non-covered for Medicare, the provider must
follow Medicaid’s PA guidelines. PAs are not necessary for recipients who are eligible for
QMB only since Medicaid pays only the co-pay and deductible. If Medicare benefits are
exhausted (i.e. inpatient) a PA from Medicaid’s QIO-like vendor must be obtained within
30 days of the receipt of the Medicare Explanation of Benefits (EOB).
C. Medicaid Eligibility may be determined for up to three months prior to an application for
assistance. Services provided during a period of retroactive eligibility are evaluated on a
case-by-case basis. Provider can verify eligibility through the EVS. Covered services that
meet the definition of “emergency services” reimbursed. A retrospective review for
services which require prior authorization by Medicaid’s QIO-like vendor will determine
authorization for payment based on clinical information that supports medical necessity
and/or appropriateness of the settings.
D. If a PA is required, it is the responsibility of the provider to request before providing
services. Waiting until the claim is due before securing an approved PA will not override
the stale date. The PA number is required on the claim. See the appropriate MSM chapter
for program specific retro-authorization policy. All prior authorizations and supporting
documents must be submitted online through the Provider Portal.
E. Once an approved PA request has been received, providers are required to notify the
recipient in a timely manner of the approved service units and service period dates.
F. Each authorization is for an independent period of time as indicated by the start and end
date of the service period. If a provider believes it is medically necessary for services to be
rendered beyond the scope (units, time period or both) of the current authorization, the
provider is responsible for the submission of a new PA request. It is recommended that the
new request be submitted 15 days prior to the end date of the existing service period so the
newly authorized service may start immediately following the expiration of the existing
authorization. Exception: the 15-day recommendation does not apply to concurrent,
inpatient hospital stay authorizations.
G. It is the provider’s responsibility to submit the necessary paperwork to support the PA
request. PA requests submitted lacking the required information for the service/item will
be denied with a Notice of Decision (NOD) to the recipient.
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103.3 PROVIDER REPORTING REQUIREMENTS
A. Medicaid providers are required to report in writing, on the form prescribed in the online
Provider Enrollment Information Booklet, within five working days, any change and/or
correction to address, addition or removal of practitioners or any other information
pertinent to the receipt of Medicaid funds. Change in ownership, including but not limited
to the removal, addition and/or substitution of a partner, must be reported within five
working days by completing and submitting an initial enrollment application along with all
required documentation. Failure to do so may result in termination of the contract at the
time of discovery.
B. Within five working days, providers are required to report changes which may affect
enrollment status. All changes are to be reported on the form prescribed in the online
Provider Enrollment Booklet. Below are examples of changes effective after enrollment
which shall be reported (not all inclusive):
1. change to licensure status;
2. indictment, arrest, criminal charge and/or conviction;
3. open and/or pending court case;
4. change in familial association with regard to ownership, managing employee and/or
authorized user or agent;
5. enrollment/disenrollment in another State’s Medicaid program;
6. enrollment/disenrollment with Medicare;
7. denial of malpractice insurance;
8. open investigation by any law enforcement, regulatory or state agency; and/or
9. provider becomes a state or government employee.
103.4 CONDITIONS OF REPORTING
A. All changes, with the exception of change in ownership, must be reported in writing on the
form prescribed in the online Provider Enrollment Information Booklet and require the
signature of the provider. If the provider is a business, the change must include the
signature of the owner or administrator. Medicaid will not change any provider record
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without proper signatures. Annual 1099 forms reflect the information in Medicaid’s
records and may be incorrect if changes are not reported timely.
B. Correct address, including email, banking information, phone numbers and other
information are necessary to assure receipt of all payments and provider notifications from
Nevada Medicaid. Address changes are required for any change, including the suite
number. Returned mail may be used by Medicaid to administratively terminate the provider
due to “loss of contact.”
C. When there is a change in ownership, the contract may be automatically assigned to a new
owner, as well as the payment amounts that may be due or retrospectively become due to,
or from Nevada Medicaid, by the prior owners. The assigned contract is subject to all
applicable statutes and regulations and to the terms and conditions under which it was
originally issued.
If there is a change in ownership, the provider must provide a copy of the bill of sale, copies
of new licenses/certifications and/or verification of a change in the Federal Employer
Identification Number (FEIN). The provider must also complete/submit an initial
enrollment application.
D. For a change in name only, the provider must provide copies of new license/certifications
and verification of change in FEIN. For a change in FEIN, the provider must provide
verification from the Treasury Department of the new number.
103.5 EMPLOYEE EDUCATION ABOUT FALSE CLAIMS
The DHCFP is required to ensure entities receiving annual payments from Medicaid of at least
$5,000,000 have written policies for educating their staff on federal and state regulations pertaining
to false claims and statements, the detection and prevention of fraud and abuse, and whistleblowers
protections under law for reporting fraud and abuse in Federal health care programs. (1396a(a)(68)
of Title 42, United States Code).
These providers are required to:
A. adhere to federal and state regulations, and the provider agreement or contract, to establish
written policy of dissemination to their staff;
B. ensure policies are adopted by any contractor or agent acting on their behalf;
C. educate staff on the regulations. Dissemination to staff should occur within 30 days from
the date of hire, and annually thereafter;
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D. provide signed Certification Form, signed provider agreement, copies of written policy and
employee handbook, and documentation staff has been educated, within the required
timeframes;
E. maintain documentation on the education of staff, and make it readily available for review
by state or federal officials; and
F. provide requested re-certification within required timeframes to ensure ongoing
compliance.
103.6 COVERAGE AND LIMITATIONS
A. The DHCFP has a program to identify providers that fit the criteria of being an entity and
will identify additional or new providers fitting the criteria at the beginning of each federal
fiscal year.
B. The DHCFP will issue a letter advising an entity of the regulations and require the entity
to:
1. submit a certification stating they are in compliance with the requirements;
2. sign a provider agreement or Managed Care Contract Amendment incorporating
this requirement;
3. provide copies of written policies developed for educating their staff on false
claims, fraud and abuse and whistleblowers protections under law; and
4. provide documentation of employees having received the information.
C. Re-certification of existing entities will be done annually for ongoing compliance.
D. The DHCFP is authorized to take administrative action for non-compliance through non-
renewal of provider or contract or suspension or termination of provider status.
103.7 SAFEGUARDING INFORMATION ON APPLICANTS AND RECIPIENTS
Federal and state regulations including HIPAA of 1996, the HITECH Act of 2009 and
confidentiality standards within 42 CFR § 431.301 – 431.305 restrict the use or disclosure of
information concerning applicants and recipients. The information providers must safeguard
includes, but is not limited to, recipient demographic and eligibility information, social and
economic conditions or circumstances, medical diagnosis and services provided and information
received in connection with the identification of legally liable third-party resources.
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In accordance with HIPAA, protected health information may be disclosed for the purposes of
treatment, payment or health care operations. Most other disclosures require a signed
Authorization for Disclosure from the participant or designated representative. Details about
allowable uses and disclosures are available to participants in the DHCFP Notice of Privacy
Practices, which is provided to all new Medicaid enrollees.
For penalties associated with impermissible use and disclosure of recipient information, see
Section 100.2(d).
103.8 MEDICAL AND PSYCHOLOGICAL INFORMATION
A. Any psychological information received about an applicant or recipient shall not be shared
with that person. This ruling applies even if there is a written release on file from his or her
physician. If the applicant/recipient wishes information regarding his or her psychological
condition, he or she must discuss it with his or her physician.
B. Medical information, regardless of source, may be shared with the applicant or recipient
upon receipt of their written request. However, any other agency needing copies of medical
information must submit a Medicaid release stating what information is requested and
signed by the applicant or recipient in question or their authorized representative.
The exception to this policy is in the case of a fair hearing. Agency material presented at a
fair hearing constituting the basis of a decision will be open to examination by the
applicant/recipient and/or his or her representative.
C. The HIPAA of 1996 Privacy Rules permit the disclosure of a recipient’s health information
without their authorization in certain instances (e.g. for treatment, payment, health care
operations or emergency treatment; to make appointments to the DHCFP business
associates; to recipient’s personal representatives; as required by law; for the good of public
health; etc.)
D. The HIPAA Privacy Rules assure the recipient certain rights regarding their health
information (e.g. to access/copy, to correct or amend, restrict access, receive an accounting
of disclosures and confidential communications).
E. A provider may not disclose information concerning eligibility, care or services given to a
recipient except as specifically allowed by state and federal laws and regulations.
103.9 NON-DISCRIMINATION AND CIVIL RIGHTS COMPLIANCE
Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age
Discrimination Act of 1975 and the Americans with Disabilities Act (ADA) of 1990, prohibit
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discrimination on the basis of race, color, national origin, religion, sex, age, disability (including
AIDS or related conditions) or any other class status protected by federal or state law or regulation
by programs receiving Federal Financial Participation (FFP). The DHCFP service providers must
comply with these laws as a condition of participation in the Nevada Medicaid program in offering
or providing services to the Division’s program beneficiaries or job applicants and employees of
the service providers.
All service providers are required to follow and abide by the DHCFP’s non-discrimination
policies. In addition, hospitals, nursing facilities and Intermediate Care Facilities for Individuals
with Intellectual Disabilities (ICF/IID) will be reviewed by Medicaid periodically to assure they
follow requirements specific to them. Requirements for compliance:
A. Hospitals, nursing facilities and ICF/IIDs must designate an individual as having
responsibility for civil rights coordination, handling grievances and assuring compliance
with all civil rights regulations. This person will serve as coordinator of the facility’s
program to achieve nondiscrimination practices, as well as be the liaison with Medicaid for
Civil Rights compliance reviews.
B. Notices/signs must be posted throughout a facility, as well as information contained in
patient and employee handouts, which notifies the public, patients and employees that the
facility does not discriminate with regards to race, color, national origin, religion, gender,
age or disability (including AIDS and related conditions) in:
1. admissions;
2. access to and provisions of services; or
3. employment.
There must, also, be posted a grievance procedure to assure patients and employees of the
facility are provided notice of how to file a grievance or complaint alleging a facility’s
failure to comply with applicable civil rights and non-discrimination laws and regulations.
C. Medical facilities may not ask patients whether they are willing to share accommodations
with persons of a different race, color, national origin, religion, age or disability (including
AIDS and related conditions) or other class protected by federal law. Requests for transfers
to other rooms in the same class of accommodations must not be honored if based on
discriminatory considerations. (Exceptions due to valid medical reasons or compelling
circumstances of the individual case may be made only by written certification of such by
the attending physician or administrator).
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D. Medical facilities must have policies prohibiting making improper inquiries regarding a
person’s race, color, national origin, religion, sex, age or disability (including AIDS and
related conditions) prior to making the decision to admit the person. Supervisory staff must
be aware of this policy and enforce it.
Admission to a facility and all services rendered and resources routinely used by all persons
in the facility (e.g., nursing care, social services, dining area, beauty salon, barber shop,
etc.) must be provided without regard to race, color, national origin, religion, sex, age or
disability (including AIDS and related conditions). An acute hospital must have a
Telecommunications Device (TTY or TDD) for use by patients and staff who are deaf to
assure that its emergency room services are made equally available. All other hospitals,
Nursing Facilities (NF) and ICF/IIDs, which do not have a TDD, must have access to a
TDD at no cost or inconvenience to the patient or staff member wishing to use it.
The facility must assure equal availability of all services to persons with Limited English
Proficiency (LEP), hearing and sight-impaired patients and persons with other
communication limitations. For example, when a provider determines that a particular non-
English language must be accommodated, vital documents must be available at no charge.
With regard to sight-impaired individuals, the provider’s library or other reading service
must be made equally available through Braille, Large Print books or Talking books.
The facility must include assurances of nondiscrimination in contracts it maintains with
non-salaried service providers and consultants (e.g., physicians, lab or x-ray services, and
respiratory, occupational or physical therapists).
E. Displacement of a resident after admission to a facility on the basis of a change in payment
source is prohibited. A Medicaid participating facility cannot refuse to continue to care for
a resident because the source of payment has changed from private funds to Medicaid. A
facility must not terminate services to a resident based on financial rather than medical
reasons when payment changes from private funds to Medicaid.
A facility must not require a Medicaid-eligible resident or his or her legal guardian to
supplement Medicaid coverage. This includes requiring continuation of private pay
contracts once the resident becomes Medicaid eligible, and/or asking for contributions,
donations, or gifts as a condition of admission or continued stay. Complaints regarding
alleged economic discrimination should be made to the Aging and Disability Services
Division (ADSD) Long Term Care Ombudsman or to the DHCFP.
F. Medical facilities must have policies that prevent making improper inquiries regarding
race, color, national origin, religion, sex, age or disability (including AIDS and related
conditions) prior to making a decision to employ a person. Supervisory personnel must be
knowledgeable with regard to these policies and practices and must enforce them.
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The facility must assure that educational institutions which place students with the facility
do not discriminate regarding the selection or treatment of minority groups, disabled
(including AIDS and related conditions) or other protected classes of students. Facilities
must also assure they do not discriminate in their selection and placement of student
interns.
G. All service providers (including medical facilities) must maintain a list of in-house and/or
community-based sign language interpreters. This list must be reviewed and revised, if
necessary, at least annually. Facilities must also have policies outlining how persons with
hearing impairments are identified as needing interpretation services, and how these
services can be accessed at no cost to them.
H. All service providers (including medical facilities) must provide persons who have LEP
with access to programs and services at no cost to the person. Services providers must:
1. identify the non-English languages that must be accommodated among the
population served and identify the points of contact where language assistance is
needed;
2. develop and implement a written policy that ensures accurate and effective
communication;
3. take steps to ensure staff understands the policy and is capable of carrying it out;
and
4. annually review the LEP program to determine its effectiveness.
Service providers in need of additional guidance should refer to the LEP policy
guidance document provided by the CMS and the U.S. Office of Civil Rights
(OCR). Among other things, the document explains the criteria for identifying
languages that must be accommodated and includes methods of providing language
assistance. A link to the policy document is available via the Division’s Civil Rights
web pages accessible from its Internet website: www.dhcfp.nv.gov.
I. The facility must maintain, in systematic manner, and provide upon request to Medicaid,
information regarding race, color, national origin, and disability of patients and employees.
103.10 ADVANCED DIRECTIVE
An Advanced Directive (AD) is a written instruction by an individual, 18 years of age or older and
done in advance of a serious illness or condition. The AD allows the individual to direct health
care decisions in the event they become incapacitated. It may be in the form of a Living Will or
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Durable Power of Attorney, and includes provisions allowing the individual to make decisions
regarding the use or refusal of life sustaining treatment.
103.11 ADMINISTRATION OF ADVANCED DIRECTIVES
A. Hospitals, Nursing Facilities, home health agencies, Personal Care Attendants (PCA)
providers and hospices must maintain written policies and procedures concerning ADs and
provide written information to all adult individuals (age 18 or older) upon admission or
service delivery concerning the:
1. individual’s rights under state law to make decisions concerning their medical care,
including the right to accept or refuse medical or surgical treatment, and the right
to formulate ADs.
2. written policies of the service provider respecting implementation of such rights,
including a clear and precise statement of limitation if the service provider cannot
implement an AD on the basis of conscience.
At a minimum, a service provider’s statement of limitations must:
a. clarify any differences between institution-wide conscience objections and
those that may be raised by individual physicians;
b. identify the state legal authority permitting such objections (which in
Nevada is NRS 449.628); and
c. describe the range of medical conditions or procedures by the conscience
objection.
B. Document in the individual’s medical records whether or not the individual has an AD.
C. Service providers cannot apply conditions to provisions of care or otherwise discriminate
against an individual based on whether or not they have executed an AD.
D. Ensure compliance with the requirements of state law regarding ADs and inform
individuals any complaints concerning AD requirements may be filed with the state survey
and certification agency.
E. Provide for the education of staff concerning its policies and procedures on ADs (at least
annually).
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F. Provide for community education regarding issues concerning ADs (at least annually). At
a minimum, education presented must define what constitutes an AD, emphasize an AD is
designed to enhance an individual’s control over medical treatment, and describe
applicable state law concerning ADs. A provider must be able to document its community
education efforts.
Nevada Medicaid is responsible for monitoring/reviewing service providers periodically to
determine whether they are complying with federal and state AD requirements.
103.12 MUTUAL AGREEMENT IN PROVIDER CHOICE
Any individual eligible for Medicaid has free choice of provider from among those who have
signed a participating contract. Such choice is a matter of mutual agreement between the recipient
and provider and in no way abrogates the right of the professional to accept or reject a given
individual as a private patient or to limit his or her practice as he or she chooses.
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THIRD PARTY LIABILITY (TPL)
MEDICAID SERVICES MANUAL OTHER HEALTH CARE
COVERAGE
104 THIRD PARTY LIABILITY (TPL) – OTHER HEALTH CARE COVERAGE
Medicaid is generally the payer of last resort whenever there are any other responsible resources
for payment of health care services. Other Health Care Coverage (OHC) includes, but is not limited
to: Medicare, worker’s compensation insurance, private or group insurance and any self-insured
plans.
Recipients who have major medical insurance cannot participate in the NCU program. If a provider
discovers a participant in NCU has major medical insurance, they must report to the DHCFP.
A. Providers should question all patients carefully regarding any other possible medical
resources. If coverage has lapsed, or if insurance is discovered when none is indicated on
the EVS, VRU or swipe card, an explanatory note attached to the claim will enable the
fiscal agent to update the Third-Party Liability (TPL) file.
B. Providers are required to bill a recipient’s OHC prior to billing Medicaid.
C. Medicaid MCO is not considered an OHC. Providers should refer recipients enrolled in a
Medicaid MCO plan to the contact that is identified by the Fiscal Agent’s EVS or swipe
card vendor unless the provider is authorized to provide services under the plan.
D. If the provider does not participate in a recipient’s OHC plan, the provider must refer the
recipient to the OHC. Nevada Medicaid will deny payment for OHC services if the
recipient elects to seek treatment from a provider not participating in the OHC plan. If the
Medicaid recipient is informed by a provider not authorized by the OHC that both the OHC
and Medicaid may deny payment for the services, and the recipient then voluntarily elects
to receive services from a provider who does not participate in the recipient’s OHC plan,
the recipient assumes the responsibility to pay for the services personally.
E. The provider must inform the recipient, or responsible individual, before services are
provided that they will be financially responsible for the cost of services. If the recipient
chooses to continue with the service, the provider must secure a written and signed
statement at the time of the agreement which includes the date, type of services, cost of
service and the fact that the recipient, or responsible individual, has been informed
Medicaid will not pay for the services and agrees to accept full responsibility for the
payment. This agreement may not be in the form of a blanket authorization secured only
once (for example, at the time of consent for all treatment). It must be specific to each
incident or arrangement for which the recipient, or responsible individual, accepts financial
responsibility.
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MEDICAID SERVICES MANUAL OTHER HEALTH CARE
COVERAGE
F. A Medicaid provider cannot refuse to provide Medicaid covered services to a Medicaid
eligible recipient due to potential TPL coverage.
G. Providers are required to bill Medicare for services provided to Medicare beneficiaries and
must accept assignment if the recipient is a Medicare beneficiary and eligible for Medicaid,
including Medicare/Medicaid (dual eligible) and QMBs.
H. If providers are unable to pursue TPL, assistance may be requested within one year from
the date of service through the Fiscal Agent’s TPL Unit. See Reference Section of this
chapter. Providers are requested to contact the Fiscal Agent’s TPL Unit within four weeks
after the date of service or TPL date of discovery. In many instances this prompt action
will result in additional insurance recoveries.
I. Providers should not release itemized bills to Medicaid patients. This will help prevent
prior resources from making payment directly to the patient. Providers are encouraged to
accept assignment whenever possible to lessen insurance problems by receiving direct
payments.
104.1 PAYMENT LIMITS AND EXCEPTIONS
The total combined payment of other insurance and Medicaid cannot exceed the Medicaid
maximum allowable. For Medicare services which are not covered by Medicaid, or for which
Nevada does not have an established rate, Medicaid will pay the Medicare co-insurance and
deductible amounts. In all instances, Medicaid payment, even a zero-paid amount, is considered
payment in full and no additional amount may be billed to the recipient, his or her authorized
representative or any other source.
Medicare recipients covered by Medicaid as QMB are entitled to have Medicaid pay their
Medicare premiums, co-insurance and deductible amounts for regular Medicare benefits. Some
individuals may have this coverage as well as full Medicaid benefit coverage.
Some QMB only recipients may have a Health Management Organization (HMO) for their
Medicare benefits. Any services provided to a QMB only recipient by the HMO which exceed the
standard Medicare benefit package (i.e., prescription drugs) will not have co-payments and
deductible amounts paid by Medicaid for those added benefits.
Co-pays and/or deductibles, set forth by the OHC, cannot be collected from a Medicaid recipient
for a Medicaid covered service. Rather, the provider must bill Medicaid for the co-pay and/or
deductible. In no instance will Medicaid’s payment be more than the recipient’s co-pay and/or
deductible. Medicaid can make payments only where there is a recipient legal obligation to pay,
such as a co-pay and/or deductible. EXCEPTION: Medicaid pays only co-payments and
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deductibles for regular Medicare benefits, even if provided through a Medicare HMO.
Nevada Medicaid is not liable for payment of services if the recipient elects to seek treatment from
a provider outside the OHC network, or if the provider fails to follow the requirements of the OHC.
Exceptions to Medicaid liability policy for OHC coverage are:
A. the service(s) is/are not covered by the OHC plan;
B. the service is an emergency and the recipient is not given an option to choose/select where
they are taken; or
C. the recipient resides outside the service area of the OHC and accesses the nearest Nevada
Medicaid provider.
Providers who have entered into an OHC agreement agree to accept payment specified in these
agreements and must bill Medicaid for the recipient’s co-pay and/or deductible. In no instance can
the provider bill Medicaid for an amount that exceeds the patient’s legal obligation to pay under
the OHC agreement.
After receiving payment or a denial letter from the OHC, if the provider is submitting a paper
claim, they must also submit the OHC’s EOB, computer screen print-out or denial letter to the
fiscal agent. All attached documents must reflect the name of the patient, date of service, service
provided, the insurance company, the amounts billed, approved and paid.
It is not necessary to bill the OHC if it is known the specific service provided is not a covered
benefit under the OHC policy. In this instance, the provider must note on the claim the date, phone
number and name of the person from whom the coverage information on the insurance was
obtained and submit the claim to the Medicaid fiscal agent for processing. If the recipient’s OHC
is Medicare and the service is not a covered Medicare service, the provider is not required to
contact Medicare.
Providers must bill Medicaid for all claims, regardless of the potential for tort actions, within the
specified time frame from the date of service or date of eligibility determination, whichever is
later. Time frames are according to the Medicaid stale date period when no third-party resource
has been identified; or 365 days, when a third-party resource exists.
Not all medical benefit resources can be discovered prior to claims payment. Therefore, a post
payment program is operated. In these instances, Medicaid payment is recovered from the provider
and the provider is required to bill the OHC resource. If OHC has been identified by the Medicaid
system and the other resource has not been billed and the service(s) is/are a covered benefit of the
OHC, the payment will be denied. The insurance carrier information will appear on the Medicaid
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remittance advice to enable the provider to bill the OHC.
Exceptions to the TPL rule are:
D. Indian/Tribal Health Services (IHS);
E. Children with Special Health Care Needs; and
F. State Victims of Crime.
Medicaid is primary payer to these three programs; however, this does not negate the provider’s
responsibility to pursue OHC. For specific information on IHS billing, refer to MSM Chapter 600,
Section 603.8.
104.2 SUBROGATION – COST SAVINGS PROGRAM
In certain trauma situations, there may be a source of medical payments other than regular health
insurance. This source could be through automobile insurance, homeowner’s insurance, liability
insurance, etc. A provider may elect to bill or file a lien against those sources, or Medicaid may be
billed.
Nevada Medicaid will allow providers who accept(ed) a Medicaid payment for services directly
related to injuries or accidents to subsequently return that payment to Medicaid in order to seek
reimbursement directly from a liable third party.
Pursuant to NRS 422.293, subrogation cases are considered to be recovery of medical cost incurred
and are unusual in that collection is often not a straight-forward process. Subrogation is a Cost
Savings Program and resides in the Nevada MOM Chapter 800.
http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MOM/MOMHome/
104.3 HEALTH INSURANCE PREMIUM PAYMENTS (HIPP)
Nevada Medicaid may pay insurance premiums through Employer-Based Group Health Plans for
individuals and families when it is cost effective for the agency. The HIPP program outline can be
found in the DHCFP MOM 900.
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105 MEDICAID BILLING AND PAYMENT
Medicaid payment must be made directly to the contracted person, entity or institution providing
the care or service unless conditions under #B. below are met. Federal regulations prohibit
factoring or reassignment of payment.
A. A provider may use a billing agent to complete Medicaid billing only if the compensation
for this service is:
1. related to the actual cost of processing the billing;
2. not related on a percentage or other basis to the amount that is billed or collected;
and
3. not dependent on the collection of the payment.
B. Medicaid payment for an individual practitioner may be made to:
1. the employer of a practitioner if the practitioner is required, as a condition of
employment, to turn over his fees to his employer;
2. the group if the practitioner and the group have a contract in place under which the
group submits the claims;
3. the facility in which the services are provided, if the practitioner has a contract
under which the facility submits the claims; or
4. a foundation, plan or similar organization operating an organized health care
delivery system if the practitioner has a contract under which the organization
submits the claims. An “organized health care delivery system” may be a public or
private HMO.
C. Payments will be from federal and state funds and any falsification, or concealment of a
material fact, may be prosecuted under federal and state law. Providers agree and accept
responsibility to:
1. accept Medicaid payments as payment in full for services rendered and under no
condition, except for lawful patient liability, contact the patient or members of the
patient’s family for additional monies;
2. examine all remittance advices for accuracy and report to Medicaid within five days
any discrepancy found.
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105.1 MEDICAID PAYMENTS TO PROVIDERS
A. As specified in federal regulations and the terms of all provider agreements, Medicaid
payment is payment in full. Providers may not attempt to collect additional money directly
from recipients. This includes, but is not limited to, situations where the provider’s claim
is denied by Medicaid for failure to bill timely, accurately or when Medicaid payment
equates to zero because a third party’s payment exceeds Medicaid’s allowable amount.
B. Medicaid utilizes the CMS developed National Correct Coding Initiative (NCCI) to control
improper coding that leads to inappropriate payments. The NCCI edits are defined as edits
applied to services performed by the same provider for the same beneficiary on the same
date of service. Section 6507 of the Affordable Care Act requires each State Medicaid
program to implement compatible methodologies of the NCCI, to promote correct coding
and to control improper coding leading to inappropriate payment.
C. Nevada Medicaid utilizes a clinical claims editor program to enhance the adjudication
process for Nevada Medicaid/Check Up claims for professional services. The claims editor
program employs a nationally recognized standardized method of processing claims for
professional services using clinical logic based on the most current Current Procedural
Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS),
International Classification of Diseases (ICD), American Medical Association (AMA),
CMS and specialty societal guidelines. The claim editor results in consistent claims
adjudication for all providers of professional services and increased claims payment
turnaround time.
D. If an individual is pending Medicaid, it is requested the provider await an eligibility
decision before billing for the service. If the provider decides not to wait for the decision,
he or she may request payment from the recipient while the decision is pending. Once the
recipient is found eligible for Medicaid, and the date of service for which payment was
collected is covered, the provider must return the entire amount collected to the recipient
before billing Medicaid. The payment subsequently received from Medicaid is payment in
full and no additional payment may be requested from the recipient, and no part of the
payment made by the recipient may be retained by the provider.
E. Providers are to bill their usual and customary fees unless otherwise specified in Medicaid
policy. For exceptions, refer to individual chapters. Billings are submitted according to
established Medicaid policies.
F. Appropriate billings must include the current year procedure codes and ICD diagnostic
codes or the HIPAA of 1996 compliant codes. Complete billing information may be
obtained by contacting the Medicaid Field Representative at Medicaid’s fiscal agent. Refer
to Section 108 of this chapter for additional contact information.
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G. Claims for payment are to be submitted electronically to Nevada Medicaid’s fiscal agent.
Refer to Section 108 of this chapter for addresses and other information.
H. It is the provider’s responsibility to submit clean, accurate and complete claims to assure
accurate payment within Medicaid time frames.
Claims not meeting this criterion will be returned from the fiscal agent to the provider.
I. Nevada Medicaid will neither accept nor reimburse professional billings for services
rendered by anyone other than the provider under whose name and provider number the
claim is submitted (e.g., a claim for an office visit submitted by a physician when a
psychologist or other personnel actually provided the service). Individuals who do not meet
Medicaid criteria for provider numbers must not have their services billed as through a
physician/dentist to the Medicaid program for payment.
J. Medical residents do not meet Medicaid criteria for provider status. No service provided
by a medical resident is to be submitted by another licensed physician/dentist to the
Medicaid program for payment except by the teaching physician under the policy guidance
in MSM Chapter 600.
K. Payments are made only to providers. (Recipients who provide transportation for
themselves and/or other recipients may be reimbursed as providers under certain
circumstances.) A provider cannot request payment from Medicaid recipients assuming
Medicaid will reimburse the recipient. Optional reimbursement to a patient is a
characteristic of the Medicare program, not the Medicaid program.
L. Providers are required to keep any records necessary to disclose the extent of services the
provider furnishes to recipients and to provide these records, upon request, to the Medicaid
agency, the Secretary of HHS, or the state Medical Fraud Control Unit (MFCU).
M. When payment appears to be unduly delayed, a duplicate billing labeled “duplicate” or
“tracer” may be submitted. Failure to indicate “duplicate” or “tracer” may be interpreted
as a fraudulent practice intended to secure improper double payment.
Group practices should make certain that rebilling shows the same service codes, the same
physician’s name and the same Medicaid provider number. If it should be necessary to alter
the billing to show different codes or descriptors, a copy of the previous claim should be
attached to the revised billing.
105.1A EXTENDED SERVICES
Services or treatment provided over an extended period of time require interim billing so that
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claims will be received no later than the stale date:
1. The discharge date or the last day of the month which service was provided, whichever
comes first, is considered the date of service for inpatient/residential claims. Each interim
monthly billing must be received no later than the stale date.
2. Physicians, individual practitioners and clinics providing prolonged or extended treatment
should submit interim billings for each calendar month; e.g., therapists whose services have
been prior authorized for several months; and home health agencies authorized for ongoing,
long-term care.
3. A global payment will be paid to the delivering obstetrician when the pregnant woman has
been seen seven or more times by the delivering obstetrician and must be billed following
the delivery. The delivery date is considered the date of service in this instance. Bill all
other obstetrical claims as follows:
a. Prenatal laboratory panels must be billed before the stale date under rules of clinical
laboratory services;
b. Prenatal visits (three or fewer) must be itemized and submitted before the stale date;
c. Prenatal visits (four to seven or more) must be billed using appropriate obstetrical
codes and submitted before the stale date; and
d. If delivery is performed by someone other than the prenatal provider, prenatal care
is billed as above before the stale date.
105.2 REIMBURSEMENT
Nevada Medicaid reimburses qualified enrolled providers for services provided within program
limitations to Medicaid-eligible persons. Reimbursement rates and methodologies are established
by the Rates Unit at the DHCFP. Rates and methodologies are based on, but not limited to, federal
regulations and fee studies prior to billed charges. Providers may appeal their rate of payment to
the DHCFP, submit appropriate documentation and receive administrative review. Refer to
Chapter 700 in this manual for specific information.
105.2A LIMITATIONS
1. Medicaid pays global or per diem rates to facilities.
2. Most individual practitioners are paid computer-generated maximum allowable amounts
that are the result of multiplying a specific dollar amount times the relative unit value
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assigned to a specific procedure code. Procedure code value lists and/or dollar factors are
available on the DHCFP website at http://dhcfp.nv.gov.
3. Reimbursement for most providers is Medicaid’s maximum allowable amount or billed
charges, whichever is less.
4. Provider Preventable Conditions
If a Provider Preventable Condition (PPC) is discovered that has caused or will cause an
increase in incurred cost, the DHCFP or its agents may deny payment, or recover any
payments already made, for such condition. The term ''Provider Preventable Condition’’ is
defined as an undesirable and preventable medical condition that the patient did not have
upon entering a health care facility but acquired while in the medical custody of the facility.
Known risks associated with a procedure will not be considered to be a PPC; however, any
primary or secondary diagnosis code(s) caused by the care provided in the facility will be
subject to this policy. Examples of PPCs include, but are not limited to:
a. Wrong surgical or other invasive procedure performed on a patient.
b. Surgical or other invasive procedure performed on the wrong body part.
c. Surgical or other invasive procedure performed on the wrong patient.
d. Foreign object retained after surgery.
e. Air embolism.
f. Blood incompatibility.
g. Surgical site infection following:
1. Coronary artery bypass graft.
2. Bariatric surgery (laparoscopic gastric bypass, gastroenterostomy,
laparoscopic gastric restrictive surgery).
3. Orthopedic procedures (spine, neck, shoulder and elbow).
h. State III and IV pressure ulcers.
i. Falls and trauma (fractures, dislocations, intracranial injuries, crushing injuries,
burns and electric shock).
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j. Manifestations of poor glycemic control (diabetic ketoacidosis, nonketotic
hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis,
secondary diabetes with hyperosmolarity).
k. Catheter-associated urinary tract infection.
l. Vascular catheter-associated infection.
m. Deep vein thrombosis/pulmonary embolism associated with total knee replacement
or hip replacement surgery other than in pediatric and/or obstetric patients.
If a PPC is caused by one provider or facility (primary) and is then treated by a
different facility or provider (secondary), payment will not be denied to the
secondary provider. The DHCFP will make appropriate payments to the secondary
provider and may pursue recovery of all money in full, including legal expenses
and other recovery costs from the primary provider. This recoupment may be
recovered directly from the primary provider, or through subrogation of the injured
recipient's settlement. The anticipated costs of long-term health care consequences
to the recipient may also be considered in all recoveries.
Providers can request an appeal via the fiscal agent if they disagree with an adverse
determination related to a PPC. The fiscal agent’s appeal process must be exhausted
before pursuing a Fair Hearing with the DHCFP. Refer to MSM Chapter 3100,
Section 3105 for additional information on Fair Hearings.
Individual agreements between managed care organizations and their providers
may vary from fee-for-service limitations.
5. Nevada Medicaid may suspend Medicaid payments to a provider after the agency
determines there is a credible allegation of fraud for which an investigation is pending
under the Medicaid program against an individual and/or entity. This action may be taken
without first notifying the provider. Further information on payment suspensions is detailed
in MSM Chapter 3300 – Program Integrity.
105.2B BILLING TIME FRAMES (STALE DATES)
Providers must bill Medicaid for all claims within the specific time frame set by Medicaid. To be
considered timely, claims must be received by the fiscal agent within 180 days from the date of
service or the date of eligibility decision, whichever is later. For out-of-state providers or when a
third-party resource exists, the timely filing period is 365 days.
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Stale date criteria are strictly adhered to whether the claim is initially received or being appealed
for a stale date override.
In order to submit claims for which eligibility was determined after the date of service within the
required time frame, providers should query the EVS every 30 days until the determination of
eligibility is obtained.
105.2C DISPUTED PAYMENT
The Fiscal Agent is responsible for research and adjudication of all disputed payments. This
includes claims for which the provider is requesting an override even though the claim has not
been previously submitted and denied.
Requests for adjustments to paid claims, including zero-paid claims, must be received by the Fiscal
Agent no later than the Medicaid stale date period.
Providers can request an appeal of denied claims through the Fiscal Agent. All requests shall be
submitted electronically through the Provider Portal. Claim appeals must be requested no later
than 30 days from the date of the initial Remittance Advice (RA) listing the claim as denied. An
additional 30 days to appeal a denied claim will not be allowed when an identical claim has been
subsequently submitted.
Claims that have denied due to a system error, as identified by web announcement on the Fiscal
Agent website, do not need to be resubmitted or appealed.
1. Providers who request an appeal must follow the appeal process outlined in the Billing
Manual.
2. A NOD will be sent by the fiscal agent to the provider advising them of the appeal decision.
3. Claims appealed due to a provider’s dissatisfaction with reimbursement for specific
procedure codes are first researched by the fiscal agent. If there is a need for policy
clarification or a question of policy change, is the fiscal agent will send the appeal, along
with the full documentation of research, to Medicaid’s Chief of Compliance.
4. Providers must exhaust the fiscal agent’s appeal process prior to pursuing a Fair Hearing
with the Division.
Refer to Section 108 for contact information for filing an appeal and MSM Chapter 3100 for
additional information on Fair Hearings.
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105.3 BILLING MEDICAID RECIPIENTS
A. A provider may bill a recipient when a Medicare/Medicaid patient elects not to use lifetime
reserve days for hospital inpatient stays. In these cases, the patient must be informed that,
due to this election, Medicaid coverage will not be available.
B. When a service is provided by a Medicaid provider, which is not a Medicaid covered
service, the recipient is only responsible for payment if a signed written agreement is in
place prior to the service being rendered.
C. When all of the criteria under a. and b. below are met, a patient may be billed for all or a
portion of an acute hospital admission.
1. Preadmission Denial – The QIO-like vendor issues a denial for the admission as
not being medically necessary or not a Medicaid benefit; and
a. The physician chooses to admit the patient, nonetheless;
b. The recipient is notified in writing before services are rendered that he or
she will be held responsible for incurred charges; and
c. A document signed by the recipient or designee acknowledging the
responsibility is accepted by a recipient.
2. Denial of a portion of the admission – the QIO-like vendor issues a denial for a
portion of the admission as no longer medically necessary for acute care; and
a. The recipient is furnished with the denial notice prior to services being
rendered which are to be billed;
b. The physician orders the discharge of the patient;
c. No requested administrative days have been approved by the QIO-like
vendor; and
d. The recipient refuses to leave.
D. Recipients may not be billed for acute hospital admissions or a portion of the stay if certain
conditions exist. The following are examples and may be all inclusive:
1. The admitting physician fails to acquire a prior authorization from the QIO-like
vendor in cases other than emergency, except when the hospital admission comes
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directly from the emergency department.
2. The QIO-like vendor has reduced the level of care from acute to an administrative
level.
3. The hospital and patient receive a retrospective denial by the QIO-like vendor after
service has been rendered.
In any case where the hospital neglects to follow Medicaid policies, courts have
upheld the position that hospitals should be knowledgeable of rules and regulations
and may not look to Medicaid or the recipient for payment when the rules or
regulations are not followed.
E. If the payment for services is made by the recipient’s other health care coverage directly to
the recipient or his or her parent and/or guardian, he or she is responsible to submit the
payment to the provider. If the recipient, or his or her guardian, fails to do so, the provider
may bill the recipient for the services, but may not collect more than the exact dollar
amount paid by the OHC for services rendered.
F. Providers may bill Medicaid recipients when the recipient does not disclose Medicaid
eligibility information at the time the service is provided. As a rule, all providers seek
payment source information from recipients/patients before services are rendered. Any
recipient not declaring their Medicaid eligibility or pending eligibility, and thus denying
the provider the right to reject that payment source, is viewed as entering into a “private
patient” arrangement with the provider.
G. If a provider has billed a Medicaid recipient erroneously, the provider must refund the
money to the recipient and bill Medicaid for the amount. Medicaid claims showing a
"patient paid" amount, when the recipient was not responsible for payment, will be returned
to the provider. Once the refund has been made to the recipient, the claim may be
resubmitted with a copy of the refund check and the fiscal agent will process the claim for
payment.
H. Providers are prohibited from billing Medicaid or the recipient when no service has been
provided. This includes billing a deposit for a scheduled appointment or for a missed
appointment.
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106 CONTRACT TERMINATIONS
Termination means termination of the Medicaid Contract between Nevada Medicaid and the
actively enrolled provider.
A provider whose contract is terminated may request a fair hearing in accordance with NRS
422.306 and MSM Chapter 3100. Refer to Chapter 3100, Section 3105 of the MSM for additional
information on how to request a hearing.
Nevada Medicaid will not reimburse the provider for services rendered to Medicaid recipients on
or after the Medicaid contract has been terminated or suspended.
Individuals/entities enrolled with Nevada Medicaid who are terminated or who voluntarily
terminate must be terminated by all Medicaid MCO(s) and PAHP.
106.1 TERMINATION FOR CONVENIENCE
The Medicaid provider contract can be terminated for convenience by either party upon 90 days’
prior written notification of the other party.
106.2 CONDITIONS OF CONTRACT TERMINATIONS
A. Immediate Terminations
The DHCFP may decide to immediately terminate a provider contract if any of the
following occurs, is discovered or reported:
1. The provider is convicted of a criminal offense related to the participation in the
Medicare/Medicaid program.
2. The provider’s professional license, certification, accreditation or registration is
suspended, revoked or expired.
3. The DHCFP is notified the provider is placed on the OIG’s Exclusion List (42 CFR
1002).
4. The provider is deceased.
5. The DHCFP has determined that the quality of care of services rendered by the
provider endangers the health and safety of one or more recipients.
6. Mail is returned from the post office and a forwarding address is not provided.
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7. The provider has failed to disclose information listed in MSM Chapter 100, Section
102 and all sub sections.
8. Identity of the provider cannot be proven.
9. The provider has been terminated for cause by a MCO and/or PAHP contracted
with the DHCFP.
10. The Provider, or any person with a five percent or greater direct or indirect
ownership interest in the Provider, fails to consent to FCBC and/or to submit sets
of fingerprints in the form and manner as instructed by the Fiscal Agent and/or the
DHCFP.
11. Credible allegations of fraud, waste or abuse of such a nature and extent have been
discovered and/or reported that immediate and permanent action is deemed
necessary.
12. The provider has been convicted of a misdemeanor and/or felony that is
incompatible with the mission of the DHCFP.
13. The DHCFP becomes aware that the provider failed to provide required information
and/or provided false information on the enrollment application.
14. The provider is convicted of any offense related to the participation in any Social
Services program administered by any State or the Federal Government, including,
but not limited to, Supplemental Nutrition Assistance Program (SNAP) or
Temporary Assistance to Needy Families (TANF).
15. The seller and/or buyer having 5% or more direct or indirect ownership of any
active provider entity/group is found to have sold, transferred or purchased the
provider entity/group in anticipation of (or following) a conviction, imposition of a
civil money penalty or assessment or imposition of an exclusion.
B. Advance Notice of Termination
An advance Notice of Intent (NOI) to terminate must be mailed no less than 20 days from
the intended action date if the DHCFP determines to terminate the contractual relationship.
Advance notice is required for the following reasons (not all inclusive):
1. Termination, exclusion or suspension of an agreement or contract by any other
governmental, state or county program is reported or discovered.
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2. The provider no longer meets the conditions of participation as stated in Chapter
100 all-inclusive of the Nevada MSM.
3. The provider no longer meets all of the requirements or other conditions of
participation as required by the Nevada MSM for the specified provider type.
4. The provider fails to submit requested information by the required due date.
5. The provider is under investigation by a law enforcement or state agency for
conduct that it is deemed incompatible with the mission of the DHCFP.
6. The Division has determined that the results of any investigation, audit, review or
survey necessitate termination;
7. An administrative contract termination has been performed; and/or
8. The provider’s NPI number is deactivated and/or the provider’s data elements in
NPPES are no longer current.
106.3 SANCTION PERIODS
Providers who are terminated or denied from Nevada Medicaid for cause will serve a sanction
period that begins with the effective date of the termination or denial. Sanctioned providers will
not be reimbursed for any services provided on or after the date of termination. Providers who
have not been permanently sanctioned from the Nevada Medicaid program may resubmit a new
Provider Enrollment Application at the end of the sanction.
Sanctions apply to entities when individuals meet the criteria below who have a 5% or greater
ownership or control interest or are an agent or managing employee. Sanctions also apply to
individual owners, having 5% or more direct or indirect ownership, and agents/managing
employees when the group/entity meets any of the criteria listed in this section. A person who
assists to submit prior authorization requests or claims is an agent for purposes of MSM Chapter
100.
If an entity is excluded, the length of the individual owner’s exclusion will be for the same period
as the sanctioned entity. If an individual owner is excluded, the entity will also be excluded and
the length of the entity’s exclusion will be for the same period as the sanctioned owner.
A. Tier 1 – Permanent Sanction
1. Provider is on the OIG exclusion list.
2. Provider has been convicted of a felony offense related to that person’s involvement
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in any program established under Medicare, Medicaid, Children’s CHIP (NCU),
the Title XX services program or any other state or federally funded assistance
program.
3. Provider has been terminated for cause, excluded or is under any form of
suspension from Medicare, Medicaid, CHIP (NCU), the Title XX services program
or any other state or federally funded assistance program.
4. Provider has been convicted of any offense listed below:
a. Murder, voluntary manslaughter, mayhem or kidnapping;
b. Sexual assault, sexual seduction or any sexually related crime;
c. Robbery, attempt to kill, battery with intent to commit a crime or
administration of a drug to aid commission;
d. False imprisonment or involuntary servitude;
e. Criminal neglect of patients per the NRS 200.495;
f. Abuse or neglect of children per NRS 200.508 through 200.5085;
g. Abuse, neglect, exploitation or isolation of older persons;
h. Any offense against a minor under NRS 200.700 through 200.760;
i. Any offense against public decency and good morals under a provision NRS
201.015 through NRS 201.56;
j. A violation of any federal or state law regulating the possession, distribution
or use of any controlled substance or any dangerous drug as defined in
chapter 454 of NRS.
The DHCFP may choose to allow re-enrollment if the United States DHHS or Medicare
notifies the DHCFP that the provider may be reinstated.
B. Tier 2 – 10-Year Sanction
1. Provider has been terminated due to quality of care issues or inappropriate and/or
fraudulent billing practices as identified as a result of an investigation, audit, review
or survey.
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2. Provider has been convicted of any offense listed below:
a. Assault or battery;
b. Any offense involving arson, fraud, theft, embezzlement, burglary,
fraudulent conversion or misappropriation of property;
c. Harassment or stalking;
d. Any offense against the executive power of the State in violation of NRS
197;
e. Any offense against the legislative power of the State in violation of NRS
198;
f. Any offense against public justice in violation of NRS 199;
g. Any other felony involving the use of a firearm or other deadly weapon
within the immediately preceding seven years.
h. Provider has been convicted of a misdemeanor offense related to that
person’s involvement in any program established under Medicare,
Medicaid, Children’s CHIP (NCU), the Title XX services programs or any
other State or Federally funded assistance program.
C. Tier 3 – Three-Year Sanction
1. Provider was terminated at revalidation due to omitting information regarding
criminal background or ownership and/or supplying false information on the
Provider Enrollment Application;
2. Provider was terminated as a result of an investigation, audit, review or survey not
related to quality of care or inappropriate fraudulent billing practices;
3. Provider was terminated due to not meeting the conditions of participation as stated
in Chapter 100 all-inclusive of the Nevada MSM or other conditions of
participation as required by the Nevada MSM for the specified provider type;
4. Provider was terminated due to being under investigation by a law enforcement or
state agency for conduct that is deemed incompatible with the mission of the
DHCFP;
5. Provider was terminated due to conviction of a misdemeanor, gross misdemeanor
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or felony, not listed in Tier 1 or Tier 2, which is incompatible with the mission of
the DHCFP;
6. It is reported or discovered that the provider falsified information on and/or
supplied false information/documentation with any Enrollment Application, unless
a higher sanction tier is applicable; and/or
7. It is reported or discovered that the provider omitted information on any Enrollment
Application, unless a higher sanction tier is applicable.
D. Tier 4 – 12-Month Sanction
1. Provider has failed to follow through with their DHCFP approved corrective action
plan;
2. Provider has a restriction placed on their professional license which is incompatible
with the mission of the DHCFP;
3. Provider failed to successfully meet Provisional Enrollment conditions of
participation;
4. Provider failed to report/provide required information in the time frame set forth in
the Enrollment Application, Provider Contract and/or the MSM (all inclusive), such
as:
a. CHOW;
b. indictment, arrest, criminal charge and/or conviction of any provider,
owner, agent and/or authorized user (unless a higher tier sanction is
applicable); and/or
c. result(s) of a pending legal case or investigation (as reported on the
Enrollment Application or Change Form) resulted in a “for cause”
termination not listed in Tier 1, Tier 2 or Tier 3.
5. Provider failed to consent and submit to Enhanced Provider Screening
requirements, such as a site visit and/or FCBC.
6. Provider fails to provide required and/or requested information specific to
participation for their provider type, or a provider voluntarily terminates without
providing required and/or requested information specific to participation for their
provider type.
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E. Immediate Re-Application
Providers whose contracts have been terminated for the following reasons may reapply at
any time:
1. Loss of contact;
2. No payments made to provider within the prior 24 months;
3. When the sole issue is a change in federal law and the law has been repealed; or
106.4 PROCEDURES FOR TERMINATION AND NON-RENEWAL
If the DHCFP decides to terminate or not renew a provider contract in the Nevada Medicaid
Program:
1. A Notice of Intent to Terminate or Non-renew will be sent to the provider at the last known
mailing address via U.S. mail. The notice will include:
1. a description of proposed action;
2. the effective date of the proposed action;
3. the basis for the proposed action, citing the appropriate Medicaid policy, federal
regulation and/or state law;
4. the effect of the action on the provider’s participation in the Nevada Medicaid
Program;
5. the provider’s right to a fair hearing, in accordance with NRS 422.306; and
6. the tier and length of sanction imposed, if applicable.
106.4A ADMINISTRATIVE CONTRACT TERMINATIONS
Administrative contract terminations are not based on a disciplinary action or program deficiency.
An administrative termination is required to ensure accurate statistics within the agency.
A Provider contract can be terminated for administrative reasons when deemed necessary and
includes:
1. death of the provider;
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2. loss of contact;
3. no payments made to provider within the prior 24 months; and/or
4. when the sole issue is a change in federal law.
106.5 MEDICAID AGENCY ACTION AFTER REVIEW, AUDIT OR INVESTIGATION
The DHCFP may initiate a corrective action plan against a provider as the result of an
investigation, audit and/or review.
Investigations, audits or reviews may be conducted by one or more of the following (not all
inclusive):
A. U.S. DHHS;
B. U.S. Department of Justice;
C. Nevada Medicaid (SUR) staff;
D. MFCU;
E. Nevada Medicaid program Provider Support staff;
F. Nevada Medicaid audit staff;
G. DHCFP Audit Contractors;
H. Fiscal agent staff;
I. ADSD staff; or
J. Other state and/or county agencies.
Refer to MSM Chapter 3300 for information regarding SUR investigations.
106.5A CORRECTIVE ACTIONS
1. In determining appropriate action to be taken, the following will be considered:
a. Corrective action necessary to eliminate the problem(s);
b. Seriousness of the problem(s);
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c. Number of current and past violations;
d. Past sanctions applied; and
e. Other available services.
2. The DHCFP may take one or a combination of the possible corrective actions such as:
a. Educational contact may be used when minor errors are detected and may be in the
form of a telephone call, on-site visit or a letter by the DHCFP or fiscal agent staff.
Educational contact is made for the purpose of instructing a provider in policy
compliance, correct billing procedures, program benefit limitations and to correct
identified errors in billing or requests for services not covered by Medicaid.
b. Warning letters may be prepared by the DHCFP staff in cases where an
investigation or program compliance review has revealed a violation occurred but
the extent of the violation is not substantial enough to warrant stronger
administrative action or referral for civil/criminal action. Warning letters are
intended to assist the provider in rectifying the problem and will include notice of
potential consequence if the problem reoccurs.
c. The agency may impose special requirements on a Medicaid provider as a condition
of participation. These include, but are not limited to the following:
1. All services provided to Medicaid recipients must be prior authorized by the
DHCFP to be eligible for Medicaid reimbursement.
2. Selected provider services must be prior authorized to be eligible for
Medicaid reimbursement;
3. Medical records must be submitted with all claims; and/or
4. A second opinion from an independent peer must be obtained to confirm
the need for the service to be eligible for Medicaid reimbursement.
d. Suspending the provider from accepting and billing for new Medicaid recipients.
If corrective action is initiated against a provider, the provider is required to cooperate and
comply with the terms of the corrective action plan. Failure to cooperate and/or comply
with the terms of the corrective action plan may result in the termination of the provider’s
contract.
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If the provider disagrees with the action recommended, they may request a fair hearing.
Refer to MSM Chapter 3100, Section 3105 for additional information.
106.6 SUSPENSION
Suspension means Nevada Medicaid will not reimburse payment for rendered services for a
specified period of not more than one year. In addition, a provider may be suspended from
accepting and billing for new Medicaid recipients as the result of an audit, review or investigation
until corrective action is initiated.
A. A provider may be suspended from the Medicaid program when:
1. found to be providing items or services at a frequency or amount not medically
necessary;
2. found to be providing items or services of a quality that does not meet
professionally recognized standards of health care in a significant number of cases;
or
3. an audit, review or investigation reveals failure to comply with program policies.
B. Suspension may be applied to any person who has ownership or controlling interest in the
provider or who is an agent or managing employee of the provider. All persons affected by
the exclusion must be notified in the original notice of exclusion.
C. A provider whose contract is suspended may request a fair hearing pursuant to MSM
Chapter 3100. Refer to Chapter 3100, Section 3105 for additional information.
106.6A PROCEDURES FOR SUSPENSION
If the DHCFP decides to suspend a provider contract, a notice of the intended action will be mailed
to the provider via U.S. mail to the last known address.
The notice will include:
1. a description of proposed action;
2. the effective date of the proposed action;
3. the length of suspension;
4. basis for the proposed action, citing the appropriate Medicaid policy, federal regulation
and/or state law;
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CONTRACT TERMINATIONS
5. the effect of the action on the provider’s participation in the Nevada Medicaid Program;
and
6. the provider’s right to a fair hearing in accordance with NRS 422.306.
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Subject:
MEDICAID SERVICES MANUAL RE-ENROLLMENT
107 RE-ENROLLMENT
A Medicaid provider who has been previously terminated, excluded or suspended may be re-
enrolled upon completion of the Provider Enrollment Application, Medicaid Provider Contract,
submission of the required verifications and meeting all conditions of participation noted
elsewhere in this chapter. Re-enrollment is at the discretion of the Division.
A provider who voluntarily terminates enrollment is not eligible for re-enrollment for a period of
365 days from the date of termination, unless an access to care issue exists, or a sanction is
applicable.
107.1 CONDITIONS OF RE-ENROLLMENT
A. If a termination was for administrative reasons (e.g., loss of contact, failure to return
updated agreement, failure to provide requested information to determine whether
conditions of participation are met, etc.) Nevada Medicaid may reinstate the provider upon
receipt of a completed updated agreement, information request form and/or any other
information requested to determine that conditions of participation are met.
B. If termination, suspension, exclusion or non-renewal was due to fraud, abuse, falsification
of information, etc., the length of the sanction will be in accordance to the letter of
notification and the provider is eligible to apply for re-enrollment after serving their
sanction period.
Nevada Medicaid may re-enroll the provider only if it is reasonably certain the fraudulent
and/or abusive acts which led to the adverse action by Nevada Medicaid will not be
repeated. Factors which will be considered include, but are not limited to:
1. Whether the provider has been convicted in a federal, state or local court of other
offenses related to participation in the Medicare or Medicaid programs which were
not considered in the development of the Medicaid suspension, exclusion or
termination; and
2. Whether the state or local licensing authorities have taken any adverse action
against the provider for offenses related to participation in the Medicare or
Medicaid programs which was not considered in the development of the Medicaid
suspension, exclusion or termination.
C. If the provider has been suspended, excluded or terminated from Medicare or at the
direction of the Secretary of HHS, Nevada Medicaid will not re-enroll the provider until
federal HHS notifies Nevada Medicaid it is permissible to do so and the provider completes
all enrollment applications and contracts.
D. If Nevada Medicaid approves the request for re-enrollment, it must give written notice to
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the suspended, excluded or terminated provider and to all others who were notified of the
adverse action and specify the date on which Medicaid program participation may resume.
E. Nevada Medicaid Fiscal Agent will give written notice to the suspended, excluded or
terminated provider of the status of their re-enrollment request.
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MEDICAID SERVICES MANUAL REFERENCES
108 REFERENCES
FISCAL AGENT CONTACT INFORMATION
PROVIDER RELATIONS UNITS (Enrollment/Claims Issues/Questions)
DXC Technology
Phone: (877) 638-3472
Customer Service Center
Claim inquiries, claim appeals and general information
Phone: (877) 638-3472
ELECTRONIC BILLING
DXC Technology
EDI Coordinator
Telephone: (877) 638-3472 (select option for "Electronic Billing")
PRIOR AUTHORIZATION FOR DENTAL AND PERSONAL CARE AIDE
Telephone: (800) 525-2395
PRIOR AUTHORIZATION FOR ALL OTHER SERVICE TYPES (except Pharmacy)
Telephone: (800) 525-2395
PHARMACY
Telephone: (877) 455-3311
Technical Call Center
General pharmacy inquiries
Telephone: (866) 244-8554
Please refer to the Contact Us Page on the Nevada Medicaid Website:
https://www.medicaid.nv.gov/contactinfo.aspx
THIRD PARTY LIABILITY (TPL) UNIT
HMS – NV Casualty Recovery
PO Box 844648
Los Angeles, CA 90084-4648
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Email: [email protected]
MANAGED CARE ORGANIZATIONS
ANTHEM BLUE CROSS AND BLUE SHIELD HEALTHCARE SOLUTIONS
Claims Address:
Anthem Blue Cross and Blue Shield Healthcare Solutions
Attn: Nevada Claims
P.O. Box 61010
Virginia Beach, VA 23466-1010
Anthem Blue Cross and Blue Shield Healthcare Solutions
Provider Contracting
Phone: (702) 228-1308
Fax: (866) 495-8711
E-mail: [email protected]
Provider Customer Service (for eligibility, claims and pre-certification)
Phone: (844) 495-8711 (except re-certification)
Pre-certification
Fax: (800) 694-3627 (for all other pre-certification requests, including ALL elective inpatient or
outpatient service)
Fax: (866) 920-8362 (for durable medical equipment (DME), outpatient rehabilitation
(PT/OT/ST), pain management, home care, home infusion, hyperbaric treatment and wound care)
Provider Self-Service Website
https://mediproviders.anthem.com/nv
Anthem Nevada Member Services
Phone: (844) 396-2329
Website: www.anthem.com/nvmedicaid
HEALTH PLAN OF NEVADA (HPN)
Phone: (800) 962-8074
Fax: (702) 242-9124
Claims Address:
Health Plan of Nevada
P.O. Box 15645
Las Vegas, NV 89114
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SILVER SUMMIT (CENTENE)
Physician Contracting
Phone: (844) 366-2880
Email: [email protected]
Provider Inquiry Line (for eligibility, claims and pre-certifications)
Phone:
Medical/Behavioral Health: (844) 366-2880
Pharmacy: (844) 366-2880
Pharmacy (Prior Authorization): (855) 565-9520
Vision: (855) 896-8572
Claims Address:
Medical/Behavioral Health:
P. O. Box 5090
Farmington, MO 63640
Pharmacy:
5 River Park Place E, Suite 210
Fresno, CA 93720
Vision:
Attn: Claims Processing
P. O. Box 7548
Rocky Mount, NC 27804
PREPAID AMBULATORY HEALTH PLAN (PAHP)
LIBERTY DENTAL
6385 South Rainbow Blvd, Suite 200
Las Vegas, NV 89118
Phone: (888) 700-0643
FIELD OFFICES – Division of Welfare and Supportive Services
Carson City (775) 684-0800
Elko/Winnemucca (775) 753-1233
Ely (775) 289-1650
Fallon and Lovelock (775) 423-3161
Hawthorne (775) 945-3602
Henderson (702) 486-1001
Las Vegas – Belrose (702) 486-1646
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Las Vegas – Cambridge (702) 486-1646
Las Vegas – Cannon Center (702) 486-1646
Las Vegas – Charleston (702) 486-1646
Las Vegas – Craig Road (702) 631-3386
Las Vegas – Decatur (702) 486-5000
Las Vegas – Durango (702) 631-3212
Las Vegas – Flamingo (702) 486-9400
Las Vegas – Nellis (702) 486-4828
Las Vegas – Owens (702) 486-1899
Las Vegas – Southern Investigations & Recovery (702) 486-1875
Las Vegas – Spring Mountain (702) 631-3077
Pahrump (775) 751-7400
Reno – Bible Way (Investigations & Recovery) (775) 688-2261
Reno – District Office (775) 684-7200
Sparks (775) 824-7400
Yerington (775) 463-0800
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MEDICAID SERVICES MANUAL RESERVED
109 RESERVED
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Section:
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Subject:
NEVADA MEDICAID
MEDICAID SERVICES MANUAL PROVIDER TYPES
110 NEVADA MEDICAID PROVIDER TYPES
10 - Outpatient Surgery
11 - Hospital, Inpatient
12 - Hospital, Outpatient
13 - Psychiatric Hospital, Inpatient
14 - Mental Health, Outpatient/Public
16 - Intermediate Care Facility/MR
17 - Special Clinics
18 - Nursing Facility/Skilled Level
19 - Nursing Facility/Intermediate Level
20 - Physician/Osteopath
21 - Podiatrist
22 - Dentist
23 - Hearing Aid Dispenser & Related Supplies
24 - Certified Registered Nurse Practitioner, Nurse
25 - Optometrist
26 - Psychologist
27 - Radiology & Noninvasive Diagnostic Centers
28 - Pharmacy
29 - Home Health Agency - (persons 21 years old and older)
30 - Personal Care Aide (Home Care) Provider Agency
32 - Ambulance - Air or Ground
33 - Durable Medical Equipment (DME), Disposables, Prosthetics
34 - Therapy - Physical, Occupational, Respiratory, Speech and Audiology
35 - Transportation
36 - Chiropractor
37 - Intravenous Therapy (TPN)
38 - Home and Community Based Waiver - MR Services
39 - Adult Day Health Care
40 - Primary Care Case Management (PCCM) Services
41 - Optician/Optical Businesses
42 - Out-Patient Psych Hosp/Private & Comm Mental Health Cntrs/Private
43 - Laboratory - Pathology/Clinical
44 - Swing-bed (Acute Hospitals)
45 - End Stage Renal Disease (ESRD) Facility
46 - Ambulatory Surgery Centers (Medicare Certified)
47 - Indian Health Services (IHS) & Tribal Clinics
48 - Senior Waiver
49 - IHS Transportation
51 - IHS Hospital (Inpatient)
52 - IHS Hospital (Outpatient)
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Subject:
NEVADA MEDICAID
MEDICAID SERVICES MANUAL PROVIDER TYPES
54 - Case Management (DHR)
55 - Transitional Rehabilitative Center
56 - Medical (Rehabilitation Center or Specialty) Hospital - Inpatient
57 - Adult Group Care Waiver
58 - Physically Disabled Waiver
60 - School Based Services
61 - Mental Health Rehab Treatment Services / Residential
62 - Health Maintenance Organization (HMO)
63 - Residential Treatment Center (RTC)
64 - Hospice
65 - Hospice, Long Term Care
68 - Intermediate Care Facilities for Mentally Retarded / Private
72 – Nurse Anesthetist
74 – Nurse Midwife
75 – Critical Access Hospital (CAH), Inpatient
76 – Audiologist
77 – Physician’s Assistant
78 – Indian Health Service Hospital, Inpatient (Non-Tribal)
79 – Indian Health Service Hospital Outpatient (Non-Tribal)
80 – IHS Travel (Non-Tribal)
82 – Mental Health Rehabilitative Treatment Services / Non-Residential
83 – Personal Care Aide – Intermediary Service Organization
84 – Personal Care Aide – Independent Contractor
October 1, 2015 MEDICAID PROGRAM Section 110 Page 2
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
January 28, 2020
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: CODY L. PHINNEY, DEPUTY ADMINISTRATOR /Cody L. Phinney/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 200 – HOSPITAL SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 200 – Hospital Services are being
proposed to add policy language regarding the Neonatal Intensive Care Unit (NICU); clarification
for elective vs. medically necessary cesareans; change in submission of authorization requirements
for emergency inpatient admissions, emergency in-state or out-of-state transfers, emergency
change in level of care (LOC) that require authorization and concurrent reviews; additions to
exceptions to inpatient hospital admission authorizations; removal of patient liability; removal of
the Initial Emergency Dialysis Case Certification (FA-100) form requirement.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: Provider Types (PT) Hospital Based Outpatient Surgery (PT 10),
Inpatient Hospital (PT 11), Outpatient Hospital (PT 12), Birth Centers (PT 17-169), Swing-bed
Acute Hospital (PT 44), End Stage Renal Disease (ESRD) Facility (PT 45), Ambulatory Surgical
Centers (PT 46), Inpatient Rehabilitation and Long-Term Acute Care (LTAC) Specialty Hospital
(PT 56), Critical Access Hospital (CAH) Inpatient (PT 75) and Hospital Based ESRD Provider
(PT 81).
Financial Impact on Local Government: None anticipated.
These changes are effective February 1, 2020.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 05/20 MTL 17/15
Chapter 200 – Hospital Services Chapter 200 – Hospital Services
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
200 Introduction Added new policy language regarding hospital
services to include inpatient, swing-bed, outpatient,
ambulatory surgical, long term acute care (LTAC),
inpatient rehabilitation specialty hospital, birth
centers, federal emergency services program
including dialysis and outpatient observation
services.
203(C) Inpatient Hospital Added LTAC specialty.
Services Policy
203(D) Added new policy language regarding Newborns
and Neonatal Intensive Care Unit (NICU) to include
the utilization of InterQual, MCG, and the Uniform
Billing (UB) Editor to define the levels of care
needed for each infant and the corresponding
revenue codes.
203.1(A) Coverage and Removed avoidable and/or avoidable scheduled to
Limitations all areas referencing cesareans to reflect only
elective and/or non-medically necessary for clarity
throughout the MSM section.
203.1(B)(1) Added supporting information guidelines.
203.1(B)(5) Defines in-state and out-of-state authorization
determinations.
203.1(B)(6) Added a new line for “Inpatient Admissions
Requiring Prior Authorization” and indicated
additional inpatient days needed on admissions
requiring prior authorization must be requested
within five business days of the last day of the
current/existing authorization period.
203.1(B)(6)(g) Added a new line for possible denial of out-of-state
non-emergency admissions by the QIO-like vendor
if the service is available in Nevada.
203.1(B)(7)(a-g) Changed inpatient admissions requiring
authorization to indicate the submission requirement
of within five business days instead of one business
day.
203.1(B)(8)(a-b) Added exceptions for inpatient hospital admissions
requiring authorization; Medicare and Medicaid dual
Page 2 of 4
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
eligible recipients, Qualified Medicare Beneficiary
(QMB), and length of stays not exceeding three
obstetric and newborn inpatient days for a vaginal
delivery performed at or after 39 weeks gestation or
four obstetric and newborn days for a medically
necessary cesarean delivery. Added guidelines for
inpatient hospital admissions.
203.1(B)(9)(a) Changed concurrent reviews to indicate additional
inpatient review days must be requested within five
business days of the last day of the current/existing
authorization period instead of prior to or by the last
day of the current/existing authorization period.
203.2(1) Provider Removed patient liability section.
Responsibilities
203.2(B) Updated CFR reference from 456.24 to 456.145.
203.2(K)(7) Added a new line that the day of discharge is not
reimbursed except when discharge/death occurs on
the day of admission.
203.2(P)(2) Updated one to five business days.
203.2(R)(b) Removed paragraph on verbal information as part of
an initial authorization.
204.1(A)(4)(c) Coverage and Remove criteria for recipient waiting for medical
Limitations assisted transportation.
204.1(B)(3) Added language “Legally Authorized
Representative.”
207.3(A) Authorization Removed language “or request prior authorizations
Process telephonically.”
207.3(G)(1) Removed “reference Accredited Standards
Committee (ASC) Physician’s Assistant list.”
Attachment A, Federal Emergency Expanded the definition for Federal Emergency
Policy #02-02 Services Program Service (FES).
(B)(1) Definitions
Page 3 of 4
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Attachment A, Expanded the definition for “chronic”.
Policy #02-02
(B)(4)
Attachment A, Added language “This chronic condition is covered.”
Policy #02-02
(B)(5)
Attachment A, Coverage and Added a line for acute emergency medical condition
Policy 02-02 Limitations meeting the definition of FES Program.
(C)(1)
Attachment A, Prior Authorization Added a new line for Authorization requirements.
Policy #02-02
(D)(1)
Attachment A, Non-Covered Updated language to read “The “FA 100 – Initial
Policy #02-02 Services Emergency Dialysis Case Certification” form is
(E)(3)(a) incomplete and/or missing from the FES recipient’s
medical record.”
Attachment A, Updated language to read “The “FA 101 – Monthly
Policy #02-02 Emergency Dialysis Case Certification” form is
(E)(3)(b) incomplete and/or missing from the FES recipient’s
medical record.”
Attachment A, ESDR Provider Updated language to read “Treating physicians must
Policy #02-02 Requirements complete and sign the “FA 100 – Initial Emergency
(F)(1) Dialysis Case Certification” form and the FA 101 –
“Monthly Emergency Dialysis Case Certification”
form. These forms must be maintained in the FES
recipient’s medical record. These forms are found on
the QIO-like vendor website.
Attachment A, Removed this section.
Policy #02-02
(F)(2)
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DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
HOSPITAL SERVICES
200 INTRODUCTION ...........................................................................................................................1
201 AUTHORITY ..................................................................................................................................1
202 RESERVED .....................................................................................................................................1
203 INPATIENT HOSPITAL SERVICES POLICY .............................................................................1
203.1 COVERAGE AND LIMITATIONS ...............................................................................................3
203.2 PROVIDER RESPONSIBILITIES ...............................................................................................11
204 ADMINISTRATIVE DAY POLICY ..............................................................................................1
204.1 COVERAGE AND LIMITATIONS ...............................................................................................1
204.2 AUTHORIZATION REQUIREMENTS ...............................................................................................2
204.3 PROVIDER RESPONSIBILITIES ........................................................................................................2
205 SWING BED SERVICES POLICY ................................................................................................1
206 OUTPATIENT HOSPITAL SERVICES POLICY .........................................................................1
206.1 COVERAGE AND LIMITATIONS ...............................................................................................1
207 AMBULATORY SURGICAL CENTER SERVICES POLICY ....................................................1
207.1 COVERAGE AND LIMITATIONS ...............................................................................................1
207.2 PROVIDER RESPONSIBILITIES .................................................................................................2
207.3 AUTHORIZATION PROCESS ......................................................................................................2
208 LONG TERM ACUTE CARE (LTAC) SPECIALTY HOSPITAL SERVICES POLICY ............1
208.1 COVERAGE AND LIMITATIONS ......................................................................................................1
208.2 PRIOR AUTHORIZATIONS ................................................................................................................2
208.3 PROVIDER RESPONSIBILITIES ........................................................................................................2
209 INPATIENT REHABILITATION SPECIALTY HOSPITAL SERVICES POLICY...........................1
209.1 COVERAGE AND LIMITATIONS ......................................................................................................1
209.2 PRIOR AUTHORIZATIONS ................................................................................................................3
209.3 PROVIDER RESPONSIBILITIES ........................................................................................................3
210 HEARINGS .....................................................................................................................................1
ATTACHMENT A ....................................................................................................................................................1
02-01 BIRTH CENTERS .................................................................................................................................1
02-02 FEDERAL EMERGENCY SERVICES PROGRAM............................................................................3
02-03 HOSPITAL WITH SWING BEDS ........................................................................................................5
02-04 OUTPATIENT OBSERVATION SERVICES ......................................................................................8
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200 INTRODUCTION
Inpatient and outpatient hospital services are a federally mandated Medicaid benefit. A hospital is
an inpatient medical facility licensed as such to provide services at an acute Level of Care (LOC)
for the diagnosis, care, and treatment of human illness primarily for patients with disorders other
than mental diseases.
Medicaid Services Manual (MSM) Chapter 200, describes the following hospital services:
inpatient, swing-bed, outpatient, ambulatory surgical, long-term acute care, inpatient rehabilitation
specialty hospital, birth centers, federal emergency services program including dialysis, and
outpatient observation services.
The Division of Health Care Financing and Policy (DHCFP) may reimburse hospitals for
providing medically necessary services, as defined in MSM Section 100 under Medical Necessity,
including, but not limited to: medical/surgical/intensive care, maternity, newborn, neonatal
intensive care, pediatric care, emergency care, trauma level I, inpatient rehabilitation, long-term
acute care specialty, administrative skilled or intermediate days, emergency psychiatric, substance
abuse treatment, and acute medical detoxification.
In Nevada, hospitals are licensed by the Bureau of Health Care Quality and Compliance (HCQC)
within the Nevada Division of Public and Behavioral Health (DPBH).
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), except those listed in the NCU Manual, Chapter 1000.
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201 AUTHORITY
A. In 1965, the 89th Congress added Title XIX of the Social Security Act authorizing varying
percentages of federal financial participation for states that elect to offer medical programs.
The states must offer at least 11 basic required medical services. Two of these services are
inpatient hospital services (42 Code of Federal Regulations (CFR) 440.10) and outpatient
hospital services (42 CFR 440.20).
B. Other authorities include:
1. Sections 1861 (b) and (e) of the Social Security Act (Definition of Services);
2. 42 CFR Part 482 (Conditions of Participation for Hospitals);
3. 42 CFR Part 456.50 to 456.145 (Utilization Control);
4. Nevada Revised Statutes (NRS) 449 (Classification of Hospitals in Nevada);
5. 29 CFR Part 2590.711 (Standards Relating to Benefits for Mothers and Newborns);
6. Section 2301 of the Affordable Care Act (ACA) (Federal Requirements for Birth
Centers);
7. NRS Chapter 449 (Hospitals, Classification of Hospitals and Obstetric/Birth Center
Defined);
8. Nevada Administrative Code (NAC) Chapter 449 (Provision of Certain Special
Services-Obstetric Care);
9. 42 CFR Part 440.255;
10. NRS Chapter 422 Limited Coverage for certain aliens including dialysis for kidney
failure;
11. 42 CFR 435.406 (2)(i)(ii) (permitting States an option with respect to coverage of
certain qualified aliens subject to the five-year bar or who are non-qualified aliens
who meet all Medicaid eligibility criteria);
12. 42 CFR 441, Subpart F (Sterilizations) and
13. 42 CFR 447.253(b)(1)(ii)(B) Other requirement.
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202 RESERVED
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203 INPATIENT HOSPITAL SERVICES POLICY
A. Inpatient hospital services are services ordinarily furnished in a hospital for the care and
treatment of an inpatient under the direction of a physician or dentist and furnished in an
institution that:
1. Is maintained primarily for the care and treatment of patients with disorders other
than mental disease;
2. Is licensed as a hospital by an officially designated authority for state standard-
setting;
3. Meets the requirements for participation in Medicare; and
4. Has in effect a Utilization Review (UR) plan, applicable to all Medicaid recipients,
that meets the requirements of 42 CFR 482.30 and 42 CFR 456.50-456.145.
Inpatient hospital services do not include Skilled Nursing Facility (SNF) or Intermediate Care
Facility (ICF) services furnished by a hospital with a swing-bed approval (42 CFR 440.10).
A hospital is an inpatient medical facility licensed as such to provide services at an acute LOC for
the diagnosis, care and treatment of human illness primarily for patients with disorders other than
mental diseases. For purposes of Medicaid, a hospital meets the requirements for participation in
Medicare as a hospital and does not include an Institution for Mental Diseases (IMD), a Nursing
Facility (NF), or an ICF for Individuals with Intellectual Disabilities (IID), regardless of name or
licensure.
B. Out-of-State Acute Hospital Services
Non-emergency out-of-state acute inpatient hospital care requires prior authorization by
the Quality Improvement Organization (QIO)-like vendor for Medicaid eligible recipients.
Out-of-state inpatient hospital services may be authorized for specialized medical
procedures not available in Nevada. The referral for out-of-state services must come from
the referring/transferring Nevada physician and/or hospital. Reference MSM Chapter 100,
Out-of-State Services and Out-of-State Provider Participation.
C. In-State and Out-of-State Acute Hospital Transfers
The attending physician who is transferring a Medicaid recipient from an acute hospital to
any other acute hospital (general, medical/surgery, psychiatric, long-term acute care
(LTAC) specialty, inpatient rehabilitation specialty) in or out-of-state is responsible to
request authorization prior to the transfer. It should be noted that inherent in the decision
to authorize transfers to another in-state or out-of-state hospital, the QIO-like vendor must
make a determination regarding the availability of such services at the referring hospital or
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within another facility in the state. This decision is also based on the appropriate level or
quality of medical care not being available at the transferring facility.
It is always the receiving hospital’s responsibility to confirm with the QIO-like vendor
whether the transferring physician/hospital obtained authorization for a non-emergent
transfer from the QIO-like vendor prior to the transfer and prior to the receiving hospital’s
agreeing to accept/admit the recipient.
D. Newborns and Neonatal Intensive Care Unit (NICU)
The DHCFP utilizes InterQual1, MCG2 and the Uniform Billing (UB) Editor3 to define
LOCs needed for each infant and revenue billing codes4. These LOCs and revenue codes
indicate the nursing care provided to newborn and premature infants in nursery
accommodations. These revenue codes range from a healthy newborn to intensive care.
The following newborn UB revenue codes are utilized by the DHCFP to reimburse
hospitals for the LOC provided to newborns for inpatient hospital stays. The LOC should
be clinically evaluated on a daily basis, typically based on the resources provided to the
infant. Please note that the levels identified below reference the LOC provided and not
licensure level of the facility. Licensure level of hospitals for newborn care is per Nevada
Administrative Codes 442.380, 442.390, 442.401, and 442.405. LOCs are defined in the
UB Editor. Levels III and IV are paid at the same rate due to the fluctuation of a newborn’s
health status. The revenue code of the newborns’ highest LOC reached during a calendar
day shall be billed by the hospital for that day. The intention of the DHCFP is to reimburse
for the highest LOC per day based upon clinical documentation and review.
1. 0170 = General.
2. 0171 = Newborn – UB Level I: This level reflects routine care of apparently normal
full-term or preterm neonates (considered to be newborn nursery).
3. 0172 = Newborn – UB Level II: This level reflects low birth-weight neonates who
are not sick but require frequent feeding, and neonates who require more hours of
nursing than do normal neonates (considered to be continuing care).
4. 0173 = Newborn – UB Level III: This level reflects sick neonates who do not
require intensive care but require six to 12 hours of nursing each day (considered
to be intermediate care).
5. 0174 = Newborn – UB Level IV: This level reflects newborns who need constant
nursing and continuous cardiopulmonary and other support for severely ill infants
(considered to be intensive care).
The following table is a crosswalk from InterQual and MCG LOCs, to the UB Editor for
LOCs and revenue codes for reimbursement. Hospitals will submit authorization requests
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in the Provider Web Portal at the most appropriate InterQual or MCG LOC and UB revenue
code(s) based upon the table below:
LOCs LOCs UB Revenue Codes4
by InterQual1, MCG2 by UB Editor3 by UB Editor3
Newborn Nursery Level I 0170 / 0171
InterQual I / MCG Level I / Transitional Care Level II 0172
InterQual II / MCG Level II Level III 0173
InterQual III & IV / MCG Level III & IV Level IV 0174
1
InterQual is published by Change Healthcare. All rights reserved.
2
MCG. All rights reserved.
3
Uniform Billing Editor is published by Optum360 0. All rights reserved.
4
Correspond with National Uniform Billing Committee revenue code descriptions and guidelines by the Uniform Billing Editor
published by Optum3600.
InterQual is proprietary, nationally recognized standard utilized by Nevada Medicaid’s QIO-like vendor to perform utilization
management, determine medical necessity and appropriate LOC. Many hospitals in Nevada also use this same selected tool for self-
monitoring. However, hospitals may also use MCG to perform the same tasks.
203.1 COVERAGE AND LIMITATIONS
A. Admission
1. Admission Criteria
The DHCFP considers the recipient admitted to the hospital when:
a. A physician provides the order for admission at the time of admission or
during the hospital stay, as verified by the date and time;
b. Acute care services are rendered;
c. The recipient has been transferred to, or is awaiting transfer to, an acute care
bed from the emergency department, operating room, admitting department,
or other hospital services; and
d. The admission is certified by the QIO-like vendor based on pertinent
supporting documentation/submitted by the provider with the admission
authorization request.
Before admission to any in-state or out-of-state acute inpatient hospital (e.g. general,
critical access, inpatient rehabilitation, or LTAC specialty hospitals) or before
authorization of payment, a physician and other personnel involved in the care of the
recipient must establish a written plan of care for each applicant or recipient. Reference
MSM Chapter 200, Admission Medical Record Determination, Plan of Care.
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2. Admission Order
Physician orders for admission must be written and signed at the time of admission
or during the hospital stay. Admission orders written after discharge are not
accepted. Verbal and telephone orders written by other allied personnel must be co-
signed by the physician within the timeframes required by law.
The role of the QIO-like vendor is to determine whether an admission is medically
necessary based on the medical record documentation, not to determine physician
intent to admit.
3. Admission Date
The admission date must be reflected on the authorization as the date and time the
admission order was written during hospitalization. If the date and time of the
physician admission orders are not clear or available, the QIO-like vendor applies
provision of acute care services. The QIO-like vendor makes every effort to identify
the documented admission date; however, it is ultimately the hospital’s
responsibility to provide complete and accurate admission information.
4. Planned and Transfer Admissions
For those instances in which the admission order was written (as defined above)
before the recipient arrives at the hospital (planned elective admission), a signed
physician order meets the requirements for admission. For transfers from other
acute care hospitals, a signed physician order (as defined above) must be contained
in the accepting facility’s record. The admission date and time for the authorization
is based on documentation most relevant and available to the admission
determination contingent upon provision of acute care services and admission
certification by the QIO-like vendor. Reference MSM Chapter 200, Provider
Responsibilities, In-State or Out-of-State Hospital Transfers regarding provider
responsibilities related to in-state and out-of-state acute hospital transfers.
5. Inpatient Admission from Observation
Inpatient admission from observation begins at the time and on the calendar date
that a physician writes an inpatient admission order.
6. Veterans’ Hospitals
Inpatient hospital admission at a Veteran’s Hospital is not a Medicaid benefit.
7. Obstetric Admissions for Early Induction of Labor (EIOL) Prior to 39 Weeks
Gestation.
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To be eligible for reimbursement, an obstetric hospital admission for EIOL prior to
39 weeks gestation must be prior authorized by the QIO-like vendor.
8. Obstetric Admissions for Elective Cesarean Delivery
Coverage/reimbursement of non-medically necessary obstetric admissions for
elective cesarean section (e.g. performed for the convenience of the physician or
recipient) is limited to the minimum federal requirement (two days) for a normal
vaginal delivery and must be prior authorized.
B. Authorization Requirements
Authorization review is conducted to evaluate medical necessity, appropriateness, location
of service, and compliance with the DHCFP’s policy. All inpatient hospital admissions
must be authorized by the QIO-like vendor for reimbursement by the DHCFP. The QIO-
like vendor certifies LOC and length of stay.
Reference MSM Chapter 100, Medical Necessity regarding criteria related to medical
necessity.
1. All inpatient QIO-like vendor determinations are based on pertinent medical
information documented initially by the requesting physician and provided to the
QIO-like vendor by a hospital with the request for admission. Pertinent information
supporting the medical necessity and appropriateness of an inpatient admission
must be submitted in the format and timeframes required by the QIO-like vendor
as part of the authorization request. Failure of a provider to submit the required
medical documentation in the format and within the timeframes specifically
required by the QIO-like vendor will result in an authorization denial.
2. Authorization refers only to the determination of medical necessity and
appropriateness. Authorization does not guarantee service reimbursement. Service
reimbursement is also dependent upon the recipient’s eligibility status and is subject
to all other coverage terms and conditions of the Nevada Medicaid and NCU
programs.
3. Services requiring authorization which have not been authorized by the QIO-like
vendor are not covered and will not be reimbursed. An authorization request
inappropriately submitted for inpatient admission after an unauthorized, planned,
elective inpatient procedure or surgery is performed, will be rejected and returned
without consideration. Concurrent services related to these unauthorized
admissions will also be rejected and returned without consideration, unless the
services are specifically related to stabilization of an emergency medical condition
that develops. Once the emergency medical condition is stabilized, no additional
services related to this unauthorized elective admission will be reimbursed.
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4. An authorization is only valid for the dates of service authorized. If the service
cannot be provided for any reason during authorized service dates (e.g. a recipient
has a change of condition), the authorization becomes invalid. A new or updated
authorization must be obtained for reimbursement of corresponding dates of
service.
5. When available, in-state providers and facilities should be utilized. Out-of-state
inpatient admission authorization determinations will be considered when
appropriate services are not available in-state or when out-of-state resources are
geographically and/or fiscally more appropriate than in-state resources. Reference
MSM Chapter 100, Out-of-State Services.
6. Inpatient Admission Requiring Prior Authorization
Prior authorization is authorization obtained before services are delivered.
Additional inpatient days must be requested within five business days of the last
day of the current/existing authorization period.
Providers must submit pertinent clinical information and obtain prior authorization
from the QIO-like vendor for the following non-emergent services:
a. Any surgery, treatment, or invasive diagnostic testing unrelated to the
reason for admission; or days associated with unauthorized surgery,
treatment, or diagnostic testing.
b. Hospital admissions for EIOL prior to 39 weeks gestation.
c. Hospital admissions for elective/non-medically necessary cesarean
sections.
d. Antepartum admissions for the purpose of delivery when an additional
elective procedure is planned (excluding tubal ligations).
e. Dental admissions. Two prior authorizations for inpatient hospitalization
for dental procedure are necessary:
1. The Medicaid dental consultant must prior authorize the dental
procedure; and
2. The QIO-like vendor must authorize it is medically necessary for
the recipient to be hospitalized for the dental procedure.
f. An admission for a family planning procedure (e.g. a tubal ligation or
vasectomy).
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g. Non-emergency admissions to in-state and out-of-state facilities. An out-of-
state non-emergency admission may be denied by the QIO-like vendor if
the service is available in Nevada.
h. Psychiatric admissions to a free-standing psychiatric hospital IMD for
recipients age 65 or older or under age 21 or to a psychiatric wing of a
general acute hospital, regardless of age. Reference MSM Chapter 400 for
authorization requirements.
i. All changes in LOC and/or transfer between units (e.g. medical/surgical,
intensive care, obstetrics, newborn, neonatal intensive care, trauma level 1,
psychiatric/detoxification, inpatient rehabilitation, administrative, and
outpatient observation.) Per diem reimbursement amounts are based on the
LOC authorized by the QIO-like vendor.
j. Substance abuse detoxification and treatment (inpatient) admissions. This
includes transfers from detoxification to treatment within the same hospital.
Reference MSM Chapter 400 for authorization requirements.
k. Swing bed admissions in a rural or critical access hospital (CAH).
Reference MSM Chapter 200, Attachment A, Policy #02-03, Hospital with
Swing Beds.
l. A leave of absence or therapeutic pass from an acute or inpatient
rehabilitation specialty hospital expected to last longer than eight hours or
involving an overnight stay. Reference MSM 200, Leave of Absence.
m. Admission when Third Party Liability (TPL) insurance, other than
Medicare Part A, is the primary payment source. Reference MSM Chapter
100, Third Party Liability (TPL), Other Health Care Coverage.
n. Non-Medicare covered days within 30 days of the receipt of the Medicare
Explanation of Benefits (EOB) indicating Part A Medicare benefits are
exhausted. Reference MSM Chapter 100, Authorization.
o. Admissions resulting from Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) screening.
7. Inpatient Admission Requiring Authorization Within Five Business Days of
Admission
Providers must submit pertinent clinical information and request authorization from
the QIO-like vendor within five business days for the following services:
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a. An emergency inpatient admission, emergency transfer to another in-state
and/or out-of-state facility or unit, or emergency change in LOC. Reference
MSM Chapter 400 regarding emergency psychiatric or alcohol/substance
use disorder treatment admission requirements.
b. An obstetric admission which, from date of delivery, exceeds three calendar
days for vaginal or four calendar days for a medically necessary or
emergency cesarean delivery. After each scenario has been exceeded, the
authorization must be submitted within five business days.
c. A newborn admission which, from date of delivery, exceeds three calendar
days for vaginal or four calendar days for a medically necessary or elective
cesarean delivery. After each scenario has been exceeded, the authorization
must be submitted within five business days.
d. When delivery of a newborn occurs immediately prior to arrival at a hospital
for an obstetric/newborn admission.
e. Any newborn/neonate admission or transfer to a NICU.
f. A direct inpatient admission initiated through an emergency department
and/or observation status as part of one continuous episode of care
(encounter) at the same facility when a physician writes an acute inpatient
admission order (rollover admissions).
The following criteria applies:
1. Observation and ancillary services resulting in a direct inpatient
admission provided as part of one continuous episode of care on the
same calendar date and at the same facility as the inpatient
admission are included in the first inpatient day per diem rate.
Observation and ancillary services rendered on a calendar date
preceding the rollover inpatient admission date can be billed
separately.
2. Emergency department services resulting in a direct inpatient
admission at the same facility and provided as part of one continuous
episode of care are included in the first inpatient hospital day per
diem rate, even if the emergency services are provided on the
calendar date preceding the admission date.
g. Admission to hospitals without a Psychiatric Unit or Alcohol/Substance
Abuse Treatment Unit. Refer to MSM Chapter 400.
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8. All inpatient hospital admissions must be authorized by the QIO-like vendor,
except for:
a. Medicare and Medicaid dual eligible, there is no requirement to obtain
Medicaid authorization for Medicare covered services. If services are non-
covered for Medicare, the provider must follow Medicaid’s authorization
guidelines. Authorizations are not necessary for recipients who are eligible
for Qualified Medicare Beneficiary (QMB) only since Medicaid pays only
the co-pay and deductible. If Medicare benefits are exhausted (i.e.
inpatient), an authorization from Medicaid’s QIO-like vendor must be
obtained within 30 days of the receipt of the Medicare EOB. Reference
MSM 100 for authorization timeframes related to non-Medicare covered
days for a dual eligible recipient.
b. A length of stay not exceeding either three obstetric and newborn inpatient
days for a vaginal delivery performed at or after 39 weeks gestation or four
obstetric and newborn days for a medically necessary cesarean delivery.
This does not apply to neonatal intensive care days. All NICU days must be
authorized. Reference MSM 200, Inpatient Admission Requiring
Authorization Within Five Business Days regarding newborn authorization
requirements.
9. Utilization Review (UR) Process
The QIO-like vendor evaluates the medical necessity, appropriateness, location of
service and compliance with the DHCFP’s policy related to inpatient admission
requests. The QIO-like vendor reviews if services furnished or proposed to be
furnished on an inpatient basis could (consistent with provision of appropriate
medical care) be safely, effectively and more economically furnished on an
outpatient basis, in a different type of inpatient health care facility or at a lower
LOC within a general hospital. Once the QIO-like vendor is provided pertinent
clinical admission information, a review of the medical information from the
facility is conducted to determine the appropriate LOC and authorized time period
for the length of stay.
a. Concurrent Review
Concurrent Review is a review of clinical information to determine whether
the services will be approved during the time period services are being
provided. Initially the QIO-like vendor assigns a length of stay based on the
diagnosis and condition of the recipient. For complex cases, additional days
may be authorized to manage the medical condition through the concurrent
review process. Additional inpatient review days must be requested within
five business days of the last day of the current/existing authorization
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period. If the clinical condition does not support the medical necessity or
appropriateness of the setting, services are denied or reduced.
b. Retrospective Review
Retrospective review is a review of clinical information to determine
whether the services will be approved after services are delivered.
Retrospective review, for the purpose of this chapter, refers to cases in
which eligibility is determined after services are provided. If the clinical
information does not support the medical necessity or appropriateness of
the setting, services are denied or reduced. The provider is notified when
the QIO-like vendor’s reviewer determines clinical information supports
either a reduction in LOC, discharge or denial of days.
C. Leave of Absence
1. Absences from an acute hospital inpatient or rehabilitation specialty hospital are
allowed:
a. In special circumstances, such as when a recipient is in the hospital on a
long-term basis and needs to be absent for a few hours for a trial home visit
or death of an immediate family member; or
b. Up to, but not exceeding 32 hours from an inpatient rehabilitation specialty
hospital for therapeutic reasons, such as preparing for independent living.
2. Prior authorization must be obtained for a leave of absence expected to:
a. Last longer than eight hours from an acute hospital; or last longer than eight
hours or involving an overnight stay from an inpatient rehabilitation
specialty hospital.
3. A leave of absence from an acute hospital is not covered if a recipient does not
return to the hospital by midnight of the day the leave of absence began (a reserved
bed).
4. For a therapeutic leave of absence, the following information must be documented
in a recipient’s medical record:
a. A physician’s order specifying the number of hours for the pass;
b. The medically appropriate reason for the pass prior to issuance of the pass;
and
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c. An evaluation of the therapeutic effectiveness of the pass when the recipient
returns.
203.2 PROVIDER RESPONSIBILITIES
A. Conditions of Participation
1. To be enrolled with the DHCFP, providers must:
a. Be in compliance with applicable licensure requirements.
b. Be certified to participate in the Medicare program. Hospitals currently
accredited by the Joint Commission or by the American Osteopathic
Association (AOA) are deemed to meet all of the conditions of participation
in Medicare. Centers for Medicare and Medicaid Services (CMS) makes the
final determination of whether a hospital meets all Medicare criteria based
on the recommendation of the state certifying agency (42 CFR Part 482).
c. Have a Provider Contract with the DHCFP. Refer to MSM Chapter 100,
Provider Enrollment.
2. Termination
The DHCFP may terminate a provider contract for failure of a hospital to adhere to
the conditions of participation, reimbursement principles, standards of licensure, or
to conform to federal, state and local laws. Either party may terminate its agreement
without cause at any time during the term of agreement by prior written notice to
the other party.
Loss of Medicare certification results in concomitant loss of a Medicaid contract.
Refer to MSM Chapter 100, for termination, lockout, suspension, exclusion and
non-renewal of Medicaid provider enrollment.
B. Utilization Review (UR)
Parts 456.100 through 456.145 of Section 42 CFR prescribe the requirements for a written
UR plan for each hospital providing Medicaid services. The UR plan is deemed met for
Medicare and Medicaid if a QIO-like vendor is conducting binding review.
CFR 482.30 provides that hospitals participating in the Medicaid program must have in
effect a UR program under a QIO-like or CMS has determined the UR procedures
established by the Medicaid program are superior to the procedures under the QIO-like
vendor and meet the UR Plan requirements under 42 CFR 456.50 through 456.145.
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C. Quality Assurance – Hospital Medical Care Evaluation Studies
The purpose of hospital medical care evaluation studies is to promote the most effective
and efficient use of available health facilities and services consistent with recipient needs
and professionally recognized standards of care. (CFR 456.141 to 456.145)
As part of the conditions of participation in the Medicaid Title XIX program, a minimum
of one medical care evaluation study must be in progress at any time. Additionally, one
study must be completed each year. The completed study must be submitted to the QIO-
like vendor at the end of each calendar year along with the study in progress topic. (A
report summarizing the study topics will be submitted to Nevada Medicaid by the QIO-
like vendor.)
Hospitals may design and choose their own study topic or, at the request of Medicaid,
perform a topic designed by Medicaid and forward a copy of the completed study to the
QIO-like vendor office within the specified time frames.
D. Civil Rights Compliance
As recipients of federal funding, hospitals must assure compliance with the provisions of
Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973
(including HIV, AIDS and AIDS-related conditions), the Age Discrimination Act of 1975
and the Americans with Disabilities Act (ADA) of 1990.
E. Patient Self-Determination Act (Advance Directives) Compliance
Pursuant to the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) and federal
regulations at 42 CFR 489.100, hospitals which participate in and receive funding for
Medicare and/or Medicaid must comply with the Patient Self Determination Act (PSDA)
of 1990, including Advance Directives. The DHCFP is responsible for
monitoring/reviewing hospitals periodically to determine whether they are complying with
federal and state advance directive requirements.
F. Form 3058 (Admit/Discharge/Death Notice)
All hospitals are required to submit Form 3058 to their local Nevada Division of Welfare
and Supportive Services (DWSS) District Office whenever a hospital admission, discharge
or death occurs.
Failure to submit this form could result in payment delay or denial. To obtain copies of
Form 3058, please contact the local DWSS.
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G. Patient Rights
Pursuant to 42 CFR 482.13, a hospital must protect and promote each patient’s rights.
Hospitals are also required to comply with Nevada Revised Statues (NRS) 449.730
pertaining to patient’s rights.
H. Claims for Denied Admissions
After having an inpatient service authorized by the QIO-like vendor, hospitals are not
permitted to submit the claim to the fiscal agent as an outpatient service. The only exception
to this is if an outpatient or non-inpatient related service was truly rendered prior to the
inpatient admission order by the physician but the inpatient stay was denied by the QIO-
like vendor (e.g., admit from ED or rollover from observation days).
I. Hospital Responsibilities for Services
Any hospital receiving authorization from the QIO-like vendor to admit and provide
services for a recipient is responsible for the recipient’s service and treatment needs. If a
hospital does not have the proper or functional medical equipment or services and must
transfer a recipient temporarily to another hospital or other medical service provider
(generally for only a portion of that day) for testing, evaluation and/or treatment, it is the
transferring hospital’s responsibility to fund the particular services and transportation if
necessary.
J. Admission Medical Record Documentation
1. Pre-Admission Authorization
The physician (or his/her staff) must obtain prior authorization from the QIO-like
vendor for all non-emergency, elective, planned hospital procedures/admissions.
Lack of a prior authorization for an elective procedure or admission results in an
automatic denial which cannot be appealed. Reference MSM Chapters 200 and 600.
Dental, oral and maxillofacial surgeons must also secure prior authorization from
the DHCFP dental consultant to assure payment for the procedure. Reference MSM
Chapter 200, Inpatient Hospital Services Policy, Coverage and Limitations,
Authorization Requirements and MSM Chapters 600 and 1000 regarding covered
dental benefits.
2. Physician Certification
A physician’s order, written prior to or at the time of admission, is required for all
inpatient admissions. If a recipient applies for assistance while in the hospital, a
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physician’s order for inpatient admission is required before reimbursement is
authorized.
A physician, physician’s assistant, or advanced practice registered nurse acting
within the scope of practice, as defined by state law and under the supervision of a
physician, must re-certify for each applicant or recipient that inpatient services in a
hospital are medically necessary. Re-certification must be made at least every 60
calendar days after the initial order. (42 CFR 456.60)
3. Plan of Care
Before admission to a hospital or before authorization for payment, a physician and
other personnel involved in the recipient’s care must establish a written plan of care
for each applicant or recipient. (42 CFR 456.80)
The plan of care must include:
a. Diagnoses, symptoms, complaints and complications indicating the need for
admission;
b. A description of the functional level of the recipient;
c. Any orders for medications, treatments, restorative and rehabilitative
services, activities, social services and diet;
d. Plans for continuing care, as appropriate; and
e. Plans for discharge, as appropriate.
K. Discharge Planning
A hospital must ensure the following requirements are met:
1. There is documented evidence that a discharge evaluation is initiated as soon as
practical after admission and in a manner to prevent discharge delays for: a recipient
identified as likely to suffer an adverse health consequence upon discharge if
adequate discharge planning is not initiated and completed; a recipient or a person
acting on the behalf of a recipient requesting a discharge evaluation; or when
requested by a physician.
2. A registered nurse, social worker or other appropriately qualified personnel reviews
all Medicaid admissions and develops or supervises the development of a discharge
plan. The discharge plan must specify goals and resolution dates, identify needed
discharge services, and be developed with input from the primary care staff,
recipient and/or family, and physician as applicable.
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3. Re-evaluation of a recipient’s condition and needs is conducted, as necessary,
during the discharge planning process and the plan must be updated with changes
identified.
4. The discharge plan includes documented evidence of:
a. All attempts to discharge the recipient to an alternative appropriate setting,
when applicable, and reasons and timeframes for unavoidable delays (e.g.,
awaiting assignment of a court-appointed guardian or for a court hearing
related to out-of-state placement). Dates of service lacking documented
evidence of comprehensive discharge planning or unavoidable delay
reasons and timeframes, when applicable, are not reimbursed.
b. An alternate plan when a specific discharge intervention or placement effort
fails.
c. Significant contacts with the recipient, family, or legally authorized
representative, when applicable.
d. A recipient’s understanding of his/her condition, discharge evaluation
results and discharge plan.
e. Reasonable efforts seeking alternatives to NF placement (e.g., home health
services, homemaker services, placement with family, subsidized housing,
meals programs, group care, etc.), when applicable.
f. NF contacts and contact results, when NF placement is required NF
placement efforts need to concentrate on facilities capable of handling a
recipient’s needs. Resolution of the placement problem must be briefly
described before the medical record is closed.
g. Refusal by a recipient or recipient’s family, physician, or legally responsible
representative to cooperate with discharge planning efforts to either find or
accept available appropriate placement. Inpatient acute or administrative
days are not reimbursed effective the date of the refusal.
h. A physician’s discharge order. Any readmission following a discharge is
treated as a new/separate admission, even if the readmission occurs within
24 hours of the discharge.
5. Prior to NF placement, the following documents are completed and in recipient’s
medical record:
a. A LOC, a pre-admission screening and resident review (PASRR) Level 1
screening.
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b. A PASRR Level II screening and a Summary of Findings letter, when
applicable.
Refer to MSM Chapter 500 for NF screening requirements.
6. Hospitals must be in compliance with discharge planning requirements specified in
42 CFR 482.43.
7. The day of discharge is not reimbursed except when discharge/death occurs on the
day of admission.
L. Financial and Statistical Data Reports
Providers must maintain sufficient financial records and statistical data for proper
determination of costs payable under the DHCFP program.
All providers shall permit any representative of the single state agency to examine the
records and documents necessary to determine the proper amount of payments due. These
records shall include, but are not limited to, provider ownership, organization and
operation; fiscal, medical and other record keeping systems; federal income tax status; asset
acquisition, lease, sale or other action; franchise or management arrangements; patient
service charge schedules; costs of operation; amounts of income received, by source and
purpose; flow of funds and working capital; statistical and other reimbursement
information.
M. Medicare/Medicaid Crossovers
Concurrent review is not conducted for Medicare/Medicaid crossover admissions unless
acute days have been exhausted and/or there has been a termination of Medicare benefits
and the recipient is at an acute or administrative LOC. Medicaid authorization is provided
for acute and administrative days only.
A provider must:
1. Notify the QIO-like vendor whenever there is a reason to believe that Medicare
coverage has been exhausted.
2. Attach a copy of the Medicare EOB (if obtained from Medicare) or other supporting
documentation that clearly indicates that acute care hospital days have been
exhausted when requesting a QIO-like vendor review.
3. Obtain prior authorization from the DHCFP’s QIO-like vendor in accordance with
the MSM Chapter 200, Coverage and Limitations, Authorization Requirements.
QMB claims denied by Medicare are also denied by the DHCFP.
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N. Maternity/Newborn Federal Length of Stay Requirements
A provider must allow a recipient receiving maternity care or a newborn infant receiving
pediatric care to remain in the hospital for no less than 48 hours after a normal vaginal
delivery or 96 hours after a cesarean section delivery except when an attending physician
makes a decision to discharge a mother or newborn infant prior to these timeframes.
O. Sterilization Consent Form
Providers must ensure a valid sterilization consent form meeting all federal requirements
is obtained prior to performing a sterilization procedure. Reference the QIO-like vendor’s
Sterilization and Abortion Policy under Provider, Billing Instructions, Billing Information
for requirements related to these procedures.
1. An inpatient day during which sterilization is performed without a valid
sterilization form is a non-covered service.
2. Medically necessary inpatient days within the same episode of care, not including
the day of the sterilization, may be reimbursed when the sterilization consent form
was not obtained. An episode of care is defined as the admission date to date of
discharge. All applicable inpatient coverage rules apply.
P. In-State or Out-of-State Hospital Transfers
1. Non-Emergency Transfers
a. It is the responsibility of the transferring physician/facility to obtain prior
authorization for nonemergent transfers between in-state and out-of-state
facilities, prior to the transfer of the recipient and to give the authorization
number to the receiving hospital.
b. A receiving hospital is responsible for verifying that the transferring
hospital obtained prior authorization for a non-emergency transfer, prior to
agreeing to accept or admitting the recipient and prior to the transfer.
2. Emergency Transfers
A receiving hospital is responsible for obtaining authorization for an emergency
transfer within five business days of the inpatient admission.
Q. Admissions to Hospitals Without a Psychiatric Unit or Alcohol/Substance Abuse
Treatment Unit
1. Reference MSM Chapter 400 – Mental Health and Alcohol/Substance Abuse
Services.
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2. Maintain and submit to the QIO-like vendor documentation demonstrating
comprehensive efforts to expeditiously transfer a recipient to an appropriate
alternate setting (e.g. a freestanding psychiatric hospital or a general hospital with
a psychiatric unit or to an alcohol/substance abuse treatment hospital or a general
hospital with a specialized alcohol/substance abuse treatment unit), upon request or
when applicable.
R. Submission of Medical Documentation
1. Providers must identify and submit all pertinent (relevant and significant)
supporting documentation for an inpatient admission with an authorization request
and/or with a request for a QIO-like vendor reconsideration review. This
information must be provided in the format required by the QIO-like vendor. In
addition, any documentation specifically requested by the QIO-like vendor must be
submitted within time frames specified by the QIO-like vendor. Failure to provide
all pertinent medical information in the format and within time frames required by
the QIO-like vendor will result in authorization denial.
S. Adverse Determination
An adverse action or determination includes, but is not limited to, a denied or reduced
authorization request.
1. If a provider does not agree with the DHCFP QIO-like vendor’s adverse
determination, a peer-to-peer review or a reconsideration review can be requested.
Reference the QIO-like vendor’s/DHCFP’s Billing Manual for details.
2. A provider must submit all additional pertinent documentation or information not
included with the authorization request supporting services requested (e.g.
documentation related to severity of illness, intensity of services, a physician’s risk
assessment) to the QIO-like vendor by the date of the reconsideration review. This
information must be provided in the format required by the QIO-like vendor.
3. Pertinent medical information not provided to the QIO-like vendor in the required
format by the reconsideration date of decision, will not be subsequently considered
by the QIO-like vendor.
a. Verbal information provided by an individual other than a recipient’s
attending physician must be supported by either written attestation of this
information in the medical record specifically provided to the QIO-like
vendor with the authorization or reconsideration review request.
b. If a provider disagrees with the results of the QIO-like vendor’s peer-to-
peer and/or reconsideration review, the provider may request a fair hearing
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through the DHCFP, within the required timeframe. A provider must utilize
internal grievance processes available through the QIO-like vendor.
T. Adherence to Requirements
To receive reimbursement for covered services, a hospital must adhere to all conditions
stated in the Provider Contract, all applicable DHCFP policies related to the specific
service provided, all state and federal requirements, the QIO-like vendor/DHCFP billing
requirements and current International Classification of Diseases, Current Procedural
Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) billing
guidelines.
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204 ADMINISTRATIVE DAY POLICY
Administrative days are inpatient hospital days reimbursed at a lower per diem rate when a
recipient’s status no longer meets an acute LOC. If discharge is ordered, a recipient’s medical
record must contain documentation that alternative appropriate placement is not available, despite
a hospital’s comprehensive discharge planning efforts.
204.1 COVERAGE AND LIMITATIONS
A. COVERED SERVICES
1. The DHCFP reimburses two levels of administrative days when authorized by the
QIO-like vendor in increments usually not exceeding seven calendar days per
request: a skilled nursing care level (skilled administrative days) and an
intermediate care level (intermediate administrative days).
2. At least one acute inpatient hospital day must immediately precede an initial request
for skilled or intermediate administrative days. Reimbursement is not available for
direct admission to an administrative LOC or for admission to an administrative
LOC from an outpatient setting (e.g., emergency department, observation status, a
physician’s office, urgent care or clinic).
3. Skilled administrative (Skilled Nursing Level) days are covered in an acute
inpatient hospital or CAH as a reduction in LOC for:
a. A recipient waiting for evaluation and/or placement in a NF/extended care
facility, group home, residential treatment center (RTC) IMD, psychiatric
or alcohol/substance abuse treatment hospital or unit or other treatment
settings (e.g., hospice) for continuity of medical services.
b. Delays in discharge related to durable medical equipment availability, home
equipment set up, home health, or hospice service arrangements.
c. A newborn with medical complications (not requiring acute care services)
waiting for placement.
d. A recipient requiring medical interventions not meeting acute care criteria
that prevents the recipient from leaving the hospital (e.g., monitoring
laboratory results, obtaining cultures, a specific treatment/workup).
e. Preparation for a surgery unrelated to the original reason for admission that
does not meet acute care criteria.
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4. Intermediate administrative (intermediate care level) days are covered in an
inpatient or CAH when:
a. Services do not meet an acute LOC;
b. The days are authorized by the QIO-like vendor; and
c. A recipient cannot be discharged for social reasons (e.g., a stable newborn
either waiting for adoption or for the mother to be discharged, a recipient
waiting for medical assisted transportation, a recipient requiring evaluation
after being a victim of crime).
B. NON-COVERED SERVICES
Administrative days are not covered when:
1. At least one acute inpatient hospital day did not immediately precede the initial
request for administrative days.
2. The days are only for the convenience of the recipient, recipient’s family or
physician.
3. A recipient, a recipient’s family, legally authorized representative, or physician
refuse to cooperate with discharge planning efforts or refuse placement at a NF,
psychiatric facility or other available alternative setting.
4. A discharge order is written, and a hospital has not provided documented evidence
of a comprehensive discharge plan or an acceptable reason and timeframe for an
unavoidable delay, such as awaiting a specifically identified court date for court
appointed guardianship related to out-of-state NF placement.
204.2 AUTHORIZATION REQUIREMENTS
A. Prior authorization is required.
B. Retrospective authorization must be obtained when Medicaid eligibility is determined after
admission to, or discharge from, an inpatient bed.
C. Administrative day policy is consistent with the inpatient prior authorization and utilization
review policies.
204.3 PROVIDER RESPONSIBILITIES
A. Submit all pertinent discharge planning information to the QIO-like vendor with a prior
authorization request, when applicable, and obtain authorization for administrative days
within timeframes required by the QIO-like vendor.
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B. Notify the QIO-like vendor when there is a reduction in LOC to administrative days.
C. Maintain documentation of appropriate, comprehensive discharge planning in recipients’
medical records. This includes, but is not limited to:
1. All placement efforts, contacts and contact results;
2. Discharge planning notes from applicable social workers, case managers and/or
nurses;
3. Physicians’ orders and/or progress notes;
4. Modification to the discharge plan, whenever applicable; and
5. Acceptable reason and timeframes of unavoidable discharge planning delay.
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205 SWING-BED SERVICES POLICY
Reference Chapter 200, Attachment A, Policy #02-03, Hospital with Swing Beds.
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206 OUTPATIENT HOSPITAL SERVICES POLICY
General Medical/Surgical Hospitals commonly provide several outpatient services, included but
not limited to general, clinic, office, emergency department, ambulatory surgery center and
observation services.
206.1 COVERAGE AND LIMITATIONS
A. Outpatient hospital services provided by hospitals are subject to the same service
limitations as other outpatient service providers. Providers must refer to Medicaid/DHCFP
service manuals relevant to the specific services being provided. The following is a list of
some of the chapters a hospital should reference:
1. For physician, advanced practitioner of nursing, physician assistants, urgent care
sites and outpatient hospital clinic visits, refer to MSM Chapter 600.
2. For radiologic services, refer to MSM Chapter 300.
3. For pharmaceutical services, refer to MSM Chapter 1200.
4. For Partial Hospitalization Program (PHP) – Policy on an outpatient alternative to
an inpatient psychiatric care program with services furnished under a medical
model by a hospital or Federally Qualified Health Center (FQHC). Refer to MSM
Chapter 400 – Mental Health and Alcohol/Substance Abuse Services for PHP
policy.
This is not an all-inclusive list. The MSM in its entirety needs to be reviewed.
B. Emergency Department Services
Emergency department services are defined as a case in which delay in treatment of more
than 24 hours could result in severe pain, loss of life, limb, eyesight or hearing, injury to
self or bodily harm to others.
Non-emergent services provided in an emergency department are a covered service for
recipients with full Medicaid eligibility. Providers are expected to follow national coding
guidelines by billing at the most appropriate level for any services provided in an
emergency department setting.
Laboratory and radiological services ordered during the course of emergency department
services (when it is an emergency diagnosis and not a clinic diagnosis) are payable without
prior payment authorization.
Charges made for stat performance of laboratory or radiological procedures ordered during
a hospital’s normal operating hours in the applicable department are not a DHCFP benefit.
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Patients requiring mental health services while in the emergency department may receive
such services if medically appropriate but must first be stabilized. Every effort must be
made to transfer the patient to a psychiatric hospital or unit, accompanied by a physician’s
order. Authorization from the DHCFP’s QIO-like vendor is also required.
C. Outpatient Observation Services
Reference Chapter 200, Attachment A, Policy #02-04, Outpatient Observation Services.
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207 AMBULATORY SURGICAL CENTER SERVICES POLICY
Ambulatory Surgical Centers refers to freestanding or hospital based licensed ambulatory surgical
units that can administer general anesthesia, monitor the recipient, provide postoperative care and
provide resuscitation as necessary. These recipients receive care in a facility operated primarily
for performing surgical procedures on recipients expected to return safely home within 24 hours.
By contrast, physician office (MD Office) services refers to a setting limited to use of local
anesthesia, including private physician office, emergency department, urgent care centers and
clinic settings.
Observation/Medical short stay refers to the “ambulatory” recipient with a coexisting medical
condition or some unforeseen medical situation who may remain in a hospital environment for an
extended period. This extended stay, called observation or medical short stay can be used to assure
recipient stability without an inpatient admission. The recipient may occupy any hospital unit.
Observation recipients may be rolled over for inpatient admission any time the patient requires
acute care services. All rollovers to inpatient care require QIO-like vendor’s authorization within
24 hours of the admission/rollover. Observation stays which do not rollover to inpatient status are
limited to 48 hours.
207.1 COVERAGE AND LIMITATIONS
A. The DHCFP reimburses for services provided in a freestanding ambulatory surgical center
or an ambulatory surgical setting within a general hospital. Some ambulatory surgical
center services require QIO-like vendor authorization Reference MSM Chapter 200,
Ambulatory Surgical Services Policy, Authorization Process.
B. Ambulatory surgical services are not reimbursable when:
1. The recipient’s medical condition or treatment needs meet acute inpatient
guidelines and standards of care.
2. The recipient requires preoperative diagnostic testing that cannot be performed in
an outpatient setting.
3. The recipient requires therapeutic interventions (measures) that can only be
performed in an acute hospital setting.
4. The probability of significant, rapid onset of complications is exceptionally high.
Actual manifestation of such complications would require prompt
intervention/measures available only in an inpatient setting.
5. Complications occur during or following an outpatient procedure that requires
acute inpatient treatment and intervention.
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6. Services are not reasonable and medically necessary for diagnosis or treatment of
a recipient when provided for the convenience of the recipient, recipient’s family
or the physician.
7. Services are ordered as inpatient by the admitting physician.
8. Services can be provided in a less restrictive setting (e.g., physician office,
emergency department, clinic, urgent care setting).
C. Higher Setting of Service Delivery
When any listed procedure is planned in a higher setting, the physician or his/her office
staff must contact the QIO-like vendor for prior authorization of the setting. These
procedures are listed in the booklet entitled “Surgical Procedures Recommended for an
Ambulatory Setting (including inpatient prior authorization guidelines).”
D. Non-Covered Procedures
Reference MSM Chapter 600, Ambulatory Centers (ASC) Facility and Non-Facility Based.
E. Approval Process
The procedure approval process is designated to establish the medical necessity and
appropriateness for:
1. Procedures to be performed in a higher care setting;
2. Procedures that would not routinely be covered by the DHCFP; and
3. Procedures to be performed outside Nevada.
The requesting physician must provide the QIO-like vendor with the medical
documentation and justification to establish medical necessity and appropriateness.
207.2 PROVIDER RESPONSIBILITY
Please reference MSM Chapter 200, Inpatient Hospital Services Policy, Provider Responsibilities
for service provider responsibility.
207.3 AUTHORIZATION PROCESS
The provider must contact the QIO-like vendor 48 hours prior to the procedure date.
A. Provider must submit the required authorization form.
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B. A copy of Medicaid card to confirm that the physician’s office has verified the recipient’s
eligibility.
C. All supporting medical documentation the requesting physician would like considered.
D. Procedure pre-approval requests:
1. Cannot be accepted from the facility/hospital personnel.
2. Require up to two working days to process.
3. Date of Service (DOS) must be within 30 days from the Prior Authorization’s date
of issue.
E. Retroactive Eligible Recipients
For those recipients who applied for Medicaid eligibility after services were rendered, the
QIO-like vendor must be contacted for retro eligible authorization.
The QIO-like vendor reviews the information for medical necessity, appropriateness of the
procedure and compliance with Medicaid program benefits. Written notification of the
review determination is sent to the physician and facility within 30 days of receipt of all
required documentation.
F. Prior Authorization Is Required When:
1. A procedure indicated as “MD Office” is planned for a setting other than a
physician’s office, emergency department or clinic. This includes an ambulatory
surgery facility, a hospital-based outpatient surgery department or inpatient
treatment at an acute care hospital.
2. A procedure indicated as “Amb Surgical” is planned to be done on an inpatient
basis.
3. A procedure appearing on the list is planned for a recipient who is currently being
treated in an acute care hospital and the procedure is unrelated to the original reason
for admission. Authorization is not required if the procedure is for treatment related
to the admitting diagnosis.
4. The physician can provide compelling evidence that non-covered procedure is not
cosmetic but is medically necessary.
5. The Medicaid coverage is secondary to any other private, non-Medicare insurance
plans.
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6. A listed procedure(s) requiring prior authorization is to be performed in conjunction
with a procedure(s) exempt from authorization.
7. Any procedure is to be performed out-of-state that requires a prior authorization in-
state.
8. Any procedure that is to be performed on an inpatient basis.
9. A recipient is going to be rolled over from ambulatory or observation status to an
acute inpatient admission.
G. Prior Authorization is Not Required When:
1. A procedure is covered by Medicare Part B and Medicaid (QMB eligible) is only
required to pay coinsurance, up to the DHCFP allowable maximum.
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208 LONG TERM ACUTE CARE (LTAC) SPECIALTY HOSPITAL SERVICES POLICY
LTAC specialty hospitals meet Medicare inpatient hospital Conditions of Participation, maintain
an average length of stay greater than 25 days and provide comprehensive long-term acute care to
individuals with complex medical conditions and/or an acute illness, injury or exacerbation of a
disease process. Most commonly, specialty or LTAC hospitals treat patients who require
ventilator, wound care, or stroke-related services.
208.1 COVERAGE AND LIMITATIONS
A. COVERED SERVICES
1. The DHCFP reimburses medically necessary services meeting coverage
requirements, provided in either a freestanding long-term acute care hospital or a
long-term acute unit of a general hospital.
2. All of the following criteria must be met:
a. Frequent, specialized, therapeutic interventions are required on an inpatient
basis.
b. Services are ordered and supervised by a physician or another individual
authorized by State licensure law to prescribe treatment.
c. Services include skilled nursing services, with 24-hour, on-site, registered
nurse availability.
d. Services are provided in accordance with a multidisciplinary, coordinated
plan of care.
e. Services are authorized as medically necessary by the QIO-like vendor.
B. NON-COVERED SERVICES
Services are not covered in a long-term acute care hospital when:
1. A recipient does not meet eligibility requirements;
2. The services do not meet medical necessity requirements or are only for the
convenience of a recipient or a recipient’s family or physician; or
3. The services are limited to only rehabilitation, coma stimulation or pain
management interventions (e.g., relaxation techniques, stress management,
biofeedback).
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208.2 PRIOR AUTHORIZATION
A. Prior Authorization is required, except for Medicare and Medicaid dual eligible recipients
when Medicare benefits are not exhausted. Reference MSM Chapter 100, Authorization.
B. Authorization must be obtained on a retrospective basis when Medicaid eligibility is
determined after admission to or discharge from an LTAC specialty hospital.
C. LTAC specialty hospital’s policy is consistent with applicable inpatient prior authorization
and utilization review policies, MSM Chapter 200, Inpatient Hospital Services Policy,
Coverage and Limitations, Authorization Requirements.
208.3 PROVIDER RESPONSIBILITIES
Providers must:
A. Be in compliance with provider responsibilities specified in the MSM Chapter 200,
Inpatient Hospital Services Policy, Provider Responsibilities.
B. Maintain evidence of Medicare certification and state licensure as an LTAC.
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DIVISION OF HEALTH CARE FINANCING AND POLICY 209
Subject:
MEDICAID SERVICES MANUAL POLICY
209 INPATIENT REHABILITATION SPECIALTY HOSPITAL SERVICES POLICY
Inpatient rehabilitation specialty hospitals and distinct inpatient rehabilitation units in a general or
CAH provide intensive, multidisciplinary, coordinated rehabilitation services (e.g., physical,
occupational, speech or prosthetics/orthotics therapy) to restore optimal function following an
accident or illness, (e.g., spinal cord injury, brain injury, stroke, neurologic disorders, congenital
deformity, burns, amputation, major multiple trauma, fractures of the femur or hip, severe
advanced osteoarthritis, active polyarticular rheumatoid arthritis, systemic vasculitis with joint
inflammation, knee or hip replacement). Inpatient rehabilitation involves both retraining and
relearning to achieve the maximal level of function possible, based on a recipient’s abilities and
disabilities.
209.1 COVERAGE AND LIMITATIONS
A. COVERED SERVICES
1. The DHCFP reimburses medically necessary, intensive, inpatient rehabilitation
services meeting coverage requirements, provided in either a freestanding inpatient
rehabilitation hospital or an inpatient rehabilitation unit of a general or CAH.
2. All the following criteria must be met:
a. Services are ordered and provided under the direction of a physician with
specialized training or experience in rehabilitation.
b. Services are authorized as medically necessary by the QIO-like vendor.
c. The inpatient admission is from an acute hospital or NF and is within one
year from the initial injury or illness or most recent surgery/hospitalization
as a result of the initial illness or injury.
d. Active and ongoing therapeutic interventions from multiple therapy
disciplines are required on an inpatient basis.
e. Rehabilitative service is provided a minimum of either three hours per day,
five days per week, or 15 hours within each seven-consecutive day period,
beginning the date of admission.
f. Physical and/or occupational therapy must be a component of rehabilitative
services provided.
g. Inpatient rehabilitation is only ordered when a recipient is capable of
making significant, measurable, functional improvement in activities of
daily living within a specified period of time.
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DIVISION OF HEALTH CARE FINANCING AND POLICY 209
Subject:
MEDICAID SERVICES MANUAL POLICY
3. A brief exception to the intensity of service requirement, during which a recipient
is unable to participate in the intensive therapy program due to an unexpected
clinical event (e.g., severe flu symptoms, bed rest due to signs of deep vein
thrombosis, prolonged intravenous chemotherapy or blood transfusions), covered
when:
a. The exception is limited to once per admission and does not exceed three
consecutive days;
b. Comprehensive documentation of the unexpected clinical event is provided
to the QIO-like vendor; and
c. A preadmission screening, post admission physician evaluation and the plan
of care support that the recipient was initially able to actively participate in
the inpatient rehabilitation program.
4. In cases of brain injury, a recipient can be admitted on a trial basis lasting no longer
than seven days if a comprehensive preadmission assessment supports that the
recipient could reasonably be expected to benefit from an inpatient stay with an
interdisciplinary team approach to the delivery of rehabilitation services.
Additional days can be requested if assessments during the trial period demonstrate
the recipient will benefit from inpatient rehabilitation services.
5. A leave of absence not exceeding 32 hours for a therapeutic reason (e.g., preparing
for independent living) is covered when authorized by the QIO-like vendor and
when the following information is documented in a recipient’s medical record:
a. A physician’s order that specifies the number of hours for the leave;
b. The medically appropriate reason for the leave; and an evaluation of the
therapeutic effectiveness of the leave.
B. NON-COVERED SERVICES
Inpatient rehabilitation services are not covered when:
1. The services do not meet authorization or other policy coverage requirements (e.g.,
a preadmission screening demonstrates a recipient cannot participate with intensive
rehabilitation services);
2. The level of rehabilitative care required can be safely and effectively rendered in
an alternate, less intensive setting, such as an outpatient rehabilitation department
or a SNF; or
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 209
Subject:
MEDICAID SERVICES MANUAL POLICY
3. Treatment goals necessitating inpatient services are achieved or further progress
toward established rehabilitation goals is not occurring or is unlikely to occur.
209.2 PRIOR AUTHORIZATION
A. Prior Authorization is required, except for Medicare and Medicaid dual eligible recipients
when Medicare benefits are not exhausted. Refer to MSM Chapter 100, Authorization.
B. Prior Authorization is also required for a leave of absence expected to last longer than eight
hours or involving an overnight stay or a brief exception to the intensity of service rule.
C. Authorization must be obtained on a retrospective basis when Medicaid eligibility is
determined after admission to, or discharge from, an inpatient rehabilitation hospital.
D. Inpatient rehabilitation hospital policy is consistent with applicable inpatient prior
authorization and utilization review policies, MSM Chapter 200, Inpatient Hospital
Services Policy, Coverage and Limitations, Authorization Requirements,
209.3 PROVIDER RESPONSIBILITIES
A. Providers must be in compliance with Provider Responsibilities specified in the MSM
Chapter 200, Hospital Inpatient Services Policy, Provider Responsibilities.
B. Providers must ensure the following documentation is maintained in a recipient’s medical
record and submitted to the QIO-like vendor, as applicable:
1. A preadmission screen specifying the condition that caused the need for
rehabilitation, the recipient’s level of function, functional improvement goals and
the expected frequency and duration of treatments required to accomplish these
goals, any risk for clinical complications and the anticipated post discharge
destination.
2. A post-admission assessment performed by a rehabilitation physician documenting
a recipient’s status and any discrepancies between this assessment and the
preadmission screening.
3. Evidence of no less than 15 hours of therapy being provided per week, beginning
with the date of admission, unless comprehensive documentation is provided to the
QIO-vendor regarding an unexpected clinical event that meets the exception to
intensity of service criteria.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 209
Subject:
MEDICAID SERVICES MANUAL POLICY
C. Providers must ensure that the rehabilitation plan of care is:
1. Comprehensive, developed, and managed by a coordinated multidisciplinary team
that includes, but is not limited to, a physician and nurse with special training or
experience in the field of rehabilitation and a physical and/or occupational therapist;
2. Individualized and specify the intensity, frequency, and duration of therapies and
the anticipated, quantifiable treatment goals; and
3. Modified with changes in medical or functional status, as applicable.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 210
Subject:
MEDICAID SERVICES MANUAL POLICY
210 HEARINGS
Reference MSM Chapter 3100 – Hearings for the hearings process.
February 1, 2020 HOSPITAL SERVICES Section 210 Page 1
ATTACHMENT A
EFFECTIVE DATE:
POLICY #02-01 BIRTH CENTERS February 1, 2020
A. DESCRIPTION
Section 2301 of the Affordable Care Act (ACA) requires coverage of services furnished at freestanding
birth centers. A freestanding birth center is described as a health facility that is not a hospital or physician’s
office, where childbirth is planned to occur away from the pregnant woman’s residence. The birth center
must be in compliance with applicable state licensure and nationally recognized accreditation organization
requirements for the provision of prenatal care, labor, delivery, and postpartum care. “Obstetric Center”,
Nevada’s legal term for birth center, complies with Section 2301 of the ACA birth center requirements
related to the health and safety of recipients provided services by licensed birth centers.
B. POLICY
The DHCFP birth center coverage and reimbursement is limited to medically necessary childbirth services
which use natural childbirth procedures for labor, delivery, postpartum care, and immediate newborn care.
Birth center coverage and reimbursement are limited to women admitted to a birth center in accordance
with adequate prenatal care, prospect for a normal uncomplicated birth defined by criteria established by
the American College of Obstetricians and Gynecologists and by reasonable generally accepted clinical
standards for maternal and fetal health.
Refer to the Maternity Care section of MSM Chapter 600 – Physician Services, for comprehensive
maternity care coverage provided by physicians and/or nurse midwives.
C. PRIOR AUTHORIZATION IS NOT REQUIRED
D. COVERAGE AND LIMITATIONS
1. COVERED SERVICES
Birth center reimbursement includes childbirth services for labor, delivery, post-partum and
immediate newborn care when the following pregnancy criteria are met:
a. An uncomplicated low-risk prenatal course is reasonably expected to result in a normal and
uncomplicated vaginal birth in agreement with licensed birth center protocol;
b. Completion of at least 36 weeks gestation and not more than 42 weeks gestation.
Birth centers are not eligible for reimbursement if:
c. The pregnancy is high-risk.
d. There is history of major uterine wall surgery, cesarean section or other obstetrical
complications which are likely to recur.
e. The recipient is discharged prior to delivery.
2. NON-COVERED SERVICES
a. Emergency treatment as a separately billed service provided by the birth center. For
emergency treatment provided in a hospital – refer to policy in MSM Chapter 200 –
Hospital Services; and
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ATTACHMENT A
EFFECTIVE DATE:
POLICY #02-01 BIRTH CENTERS February 1, 2020
b. Emergency medical transportation as a separately billed service provided by the birth
center. For policy related to emergency transportation – refer to MSM Chapter 1900 –
Transportation Services.
E. PROVIDER REQUIREMENTS
Freestanding obstetric/birth center must meet the following criteria:
1. Have a provider contract with the DHCFP. Refer to MSM Chapter 100 – Medicaid Program,
Provider Enrollment.
2. Meet applicable state licensing and/or certification requirements in the state in which the center is
located.
3. Accreditation by one of the following nationally recognized accreditation organizations:
a. The Accreditation Association for Ambulatory Health Care, (AAAHC) Inc.;
b. The Commission for the Accreditation of Birth Centers, (CABC); or
c. The Joint Commission, for institution-affiliated outpatient maternity care programs which
principally provide a planned course of outpatient prenatal care and outpatient childbirth
service limited to low-risk pregnancies.
4. Informed consent: Each recipient admitted to the birth center will be informed in writing at the
time of admission of the nature and scope of the center’s program and of the possible risks
associated with maternity care and childbirth in the center.
5. The birth center must have a written MOU with a backup hospital (or physician with admitting
privileges) which will accept and treat any woman or newborn transferred from the center in need
of emergency obstetrical or neonatal medical care.
6. The birth center must have a written MOU with ambulance service which is routinely staffed by
qualified personnel to manage critical maternal and neonatal patients during transport to each
backup hospital.
For billing instructions and a list of covered procedure and diagnosis codes, please refer to the QIO-like
vendor’s Billing Manual.
February 1, 2020 HOSPITAL SERVICES Attachment A Page 2
ATTACHMENT A
EFFECTIVE DATE:
POLICY #02-02 FEDERAL EMERGENCY SERVICES PROGRAM February 1, 2020
A. INTRODUCTION
The Nevada State Plan provides that certain non-United States (U.S.) citizens, who otherwise meet the
requirements for Title XIX eligibility, are restricted to receive only emergency service as defined by 42
CFR 440.255, titled “Limited Services Available to Certain Aliens.” Provision of outpatient emergency
dialysis health care services through the Federal Emergency Services (FES) Program is also deemed an
emergent service for this eligibility group. The FES Program is also known as Emergency Medicaid Only
(EMO).
B. DEFINITIONS
For the purpose of this chapter, the following definitions apply:
1. Federal Emergency Service (FES) Program – The DHCFP will reimburse only for the alien’s care
and services which are necessary for the treatment after sudden onset of an emergency condition.
As defined in 42 CFR 440.255, an emergency condition means a medical condition (including
emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that the absence of immediate medical attention could reasonably be
expected to result in:
a. Placing the FES recipient’s health in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part.
2. FES recipient – Means a qualified or non-qualified alien as described by 42 CFR 435.406(c) and
42 CFR 436.406(c) who receives services pursuant to 42 CFR 440.255.
3. Acute – Means symptoms that have arisen quickly, and which are short-lived.
4. Chronic – Means a health-related state that is not acute persisting for a long period of time or
constantly recurring. The only chronic condition covered by the FES Program is ESRD.
5. End Stage Renal Disease (ESRD)/Dialysis Services – Means the method by which a dissolved
substance is removed from the body of a patient by diffusion, osmosis, and convection from one
fluid compartment to another fluid compartment across a semi permeable membrane (i.e.,
hemodialysis, peritoneal dialysis, and other miscellaneous dialysis procedures). This chronic
condition is covered.
6. Stabilized – With respect to an emergency medical situation, means that no material deterioration
of the condition is likely, within reasonable medical probability, to result from or occur during the
transfer of the individual from a facility.
C. COVERAGE AND LIMITATIONS
1. Any acute emergency medical condition that meets the definition of FES Program as identified
above in the definitions described and 42 CFR 440.255.
2. Outpatient dialysis services for a FES recipient with ESRD are covered as an emergency service
when the recipient’s treating physician signs and completes the certification stating that in his/her
February 1, 2020 HOSPITAL SERVICES Attachment A Page 3
ATTACHMENT A
EFFECTIVE DATE:
POLICY #02-02 FEDERAL EMERGENCY SERVICES PROGRAM February 1, 2020
medical opinion the absence of receiving dialysis at least three times per week, would reasonably
be expected to result in any one of the following:
a. Placing the FES Program recipient’s health in serious jeopardy;
b. Serious impairment of bodily functions; or
c. Serious dysfunction of a bodily organ or part.
D. PRIOR AUTHORIZATION
1. Authorization requirements for all emergency services under 42 CFR 440.255 must follow
authorization requirements as outlined in MSM Chapter 200.
2. Prior authorization is not required for ESRD services.
3. Refer to “Provider Requirements” Section for treating physician ESRD certification form
requirements.
E. NON-COVERED SERVICES
1. FES Program – dialysis for an eligibility group not qualified under 42 CFR 435.406(2)(i)(ii).
2. Services covered prior to the coverage date of this policy.
3. Services deemed non-covered when:
a. The “FA 100 – Initial Emergency Dialysis Case Certification” form is incomplete and/or
missing from the FES recipient’s medical record.
b. The “FA 101 – Monthly Emergency Dialysis Case Certification” form is incomplete and/or
missing from the FES recipient’s medical record.
F. ESRD PROVIDER REQUIREMENTS
1. Treating physicians must complete and sign the “FA 100 – Initial Emergency Dialysis Case
Certification” form and the “FA 101 – Monthly Emergency Dialysis Case Certification” form.
These forms must be maintained in the FES recipient’s medical record. These forms are found on
the QIO-like vendor website.
2. The DHCFP may audit FES Program recipient medical records to ensure compliance with the
initial and monthly requirement.
3. For billing instructions, please refer to the QIO-like vendor’s Billing Manual and/or PT45 and 81
Billing Guide.
February 1, 2020 HOSPITAL SERVICES Attachment A Page 4
ATTACHMENT A
EFFECTIVE DATE:
POLICY #02-03 HOSPITAL WITH SWING BEDS February 1, 2020
A. DESCRIPTION
A swing bed is a bed in a rural or CAH, certified as a swing bed by CMS, which can be used to provide
either acute care or post-acute skilled nursing services. A recipient admitted to a swing bed for post-acute
skilled nursing services following discharge from acute inpatient care, does not have to change beds or
locations in a facility, unless required by the facility.
B. POLICY
This policy is specific to an acute inpatient bed that provides post-acute NF services. The DHCFP
reimburses post-acute/NF swing bed days when: a recipient receiving acute inpatient hospital services for
at least three consecutive calendar days (not including the day of discharge) requires post-acute, skilled
nursing services seven days a week and no NF placement is available or the recipient or family refuses
NF placement outside the rural area. The three-day qualifying acute inpatient stay does not have to be
from the same facility as the swing-bed admission. Placement in a swing bed must be on a temporary (not
long term) basis.
C. PRIOR AUTHORIZATION
Prior authorization is required, except for Medicare and Medicaid dual eligible recipients when Medicare
benefits are not exhausted. Refer to MSM Chapter 100, Authorization.
Authorization must be obtained on a retrospective basis when Medicaid eligibility is determined after
admission to or discharge from a swing bed.
Services not included in the per diem rate may require prior authorization. Reference the MSM Chapter
applicable to the service type regarding authorization requirements.
D. COVERAGE AND LIMITATIONS
1. COVERED SERVICES
a. The DHCFP covers medically necessary, post-acute, NF LOC services provided on an
inpatient basis and reimbursed at a per diem rate. The per diem rate includes routine
services and supplies, including a regular room, dietary services, nursing services, social
services, activities, medical supplies, oxygen and the use of equipment and facilities
b. The following services are separately reimbursed when the service meets policy
requirements specific to that service:
1. Drugs available by prescription only, including compounded prescriptions and TPN
solution and additives.
2. Nutritional supplements in conjunction with tube feedings.
3. Personal appliances and devices, if recommended by a physician, such as
eyeglasses, hearing aids, braces, prostheses, etc.
4. Customized durable medical equipment.
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EFFECTIVE DATE:
POLICY #02-03 HOSPITAL WITH SWING BEDS February 1, 2020
5. Emergency transportation.
6. Physical, occupational and speech therapy services.
7. Physician services.
8. Laboratory, portable x-ray and other diagnostic services.
9. Repair of medical equipment and appliances which belong to the recipient.
2. NON-COVERED SERVICES
a. Swing bed placement when NF placement is available in the rural area where the hospital
is located or in another rural or urban area acceptable to the recipient or family.
b. Swing bed days not authorized by the QIO-like vendor.
E. PROVIDER RESPONSIBILITIES
1. Ensure compliance with Provider Responsibility requirements specified in Chapter 200, Section
203.2, federal and state swing bed requirements and the DHCFP coverage and authorization
requirements.
2. Utilize available NF beds prior to requesting swing bed placement, unless NF placement is outside
the rural area and there is documented evidence that a recipient or family objects to placement
outside the rural community.
3. Transfer a recipient to the first available NF bed.
4. Reference Chapter 500 for Pre-Admission Screening and Resident Review (PASRR) and NF LOC
screening requirements prior to a recipient being transferred from a swing bed to a NF bed within
the hospital or at another facility.
F. DOCUMENTATION
1. Notify and submit required documentation to the QIO-like vendor to initiate admission and
concurrent review authorizations when a recipient is retro eligible.
2. Submit the following documentation to the QIO-like vendor with the initial authorization request:
a. A history and physical or acute inpatient discharge summary indicating the need for skilled
nursing services;
b. A physician acute hospital discharge order and swing bed admission order;
c. NF placement efforts with documentation regarding NF bed unavailability or recipient or
family refusal of NF placement outside the rural area; and any additional documentation
requested by the QIO-like vendor.
February 1, 2020 HOSPITAL SERVICES Attachment A Page 6
ATTACHMENT A
EFFECTIVE DATE:
POLICY #02-03 HOSPITAL WITH SWING BEDS February 1, 2020
3. Submit the following documentation to the QIO-like vendor with a concurrent swing bed
authorization request no less frequently than monthly (when applicable):
a. Ongoing NF placement efforts and either the reasons NF bed placement is not available or
recipient or family refusal of NF placement outside the rural area;
b. A monthly nursing assessment summary indicating a recipient continues to meet a skilled
LOC; and
c. Any additional documentation requested by the QIO-like vendor.
February 1, 2020 HOSPITAL SERVICES Attachment A Page 7
ATTACHMENT A
EFFECTIVE DATE:
POLICY #02-04 OUTPATIENT OBSERVATION SERVICES February 1, 2020
A. DESCRIPTION
Outpatient observation services are physician ordered, clinically appropriate, short term hospital
outpatient services including diagnostic assessment and treatments provided when a recipient’s medical
needs do not meet acute inpatient care guidelines. A recipient’s condition is further evaluated to determine
if inpatient admission is required or the recipient can be safely discharged. Outpatient observation services
do not have to be provided in a designated hospital observation unit. Outpatient observation services can
be provided in any area of a hospital, such as on an obstetric unit or an intermediate/progressive coronary
care unit.
B. POLICY
Outpatient observation services are reimbursed when ordered by a physician or other clinician authorized
by State licensure law and hospital staff bylaws to order services and at an hourly basis up to 48 continuous
hours.
Medically necessary ancillary services (e.g. laboratory, radiology and other diagnostics, therapy and
pharmacy services) that meet the coverage and authorization requirements of the MSM applicable to the
service are separately reimbursed.
Observation and ancillary services provided at the same facility and on the same calendar date as an
inpatient admission, as part of one continuous episode of care, are included in the first inpatient day, per
diem rate (a rollover admission). Observation hours (not exceeding the observation 48-hour limit) and
ancillary services rendered on the calendar date(s) preceding the rollover inpatient admission date are
separately reimbursed.
C. PRIOR AUTHORIZATION IS NOT REQUIRED for hourly outpatient observation.
Medically necessary ancillary services may require prior authorization. Reference the MSM Chapter
applicable to the service type regarding authorization requirements.
D. COVERAGE AND LIMITATIONS
1. COVERED SERVICES
a. Observation begins the date and time specified on the physician’s observation order, not
when the recipient is placed in an observation bed. Observation ends when the 48-hour
policy limit is reached or at the date and time the physician writes an order for either
inpatient admission, transfer to another healthcare facility or discharge.
b. Observation days are covered when:
1. A recipient is clinically unstable for discharge from an outpatient setting due to
either:
a. A variance from generally accepted, safe laboratory values;
b. Clinical signs and symptoms above or below normal range requiring an
extension of monitoring and further evaluation;
February 1, 2020 HOSPITAL SERVICES Attachment A Page 8
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EFFECTIVE DATE:
POLICY #02-04 OUTPATIENT OBSERVATION SERVICES February 1, 2020
c. An unstable presentation with vague symptoms and no definitive diagnosis;
or
d. An uncertain severity of illness or condition in which a change in status
requiring medical intervention is anticipated.
e. A significant adverse reaction occurs subsequent to a therapeutic service
(e.g., blood or chemotherapy administration, dialysis);
f. The medically necessary services provided meet observation criteria, a
provider is notified that inpatient admission is denied because it does not
meet acute inpatient LOC criteria, a physician writes an order for
observation status and patient rights and utilization review federal
requirements are met pertaining to changing an inpatient admission to
outpatient observation status.
2. NON-COVERED SERVICES
a. Observation hours exceeding the 48-hour limit.
b. Services rendered without a signed, dated physician order or documentation in the medical
record that specifies the date and time observation services were initiated and discontinued.
c. Diagnostic testing or outpatient procedures prescribed for medically stable individual or
services deemed by the DHCFP, the DHCFP’s QIO-like vendor or other authorized agency
as not medically necessary or appropriate.
d. Observation status when either a recipient’s medical condition or treatment needs meet
acute inpatient guidelines/standards of care or the probability of a significant, rapid onset
complication is exceptionally high requiring prompt interventions available only in an
inpatient setting.
e. Services that can be safely and effectively provided in a less restrictive setting (e.g., a
physician’s office, emergency department, clinic, urgent care setting).
f. Services limited to a therapeutic procedure (e.g., outpatient blood transfusion, intravenous
fluids, chemotherapy administration, dialysis) when no other service is required or in the
absence of a documented adverse reaction.
g. Services that are routine preparation prior to or monitoring after a diagnostic test, treatment,
procedure or outpatient same-day surgery.
h. Services immediately preceding an inpatient admission for elective induction of labor
(EIOL) prior to 39 weeks’ gestation when the EIOL is not authorized as medically
necessary.
i. Services provided solely for the convenience of a recipient, recipient’s family or physician.
February 1, 2020 HOSPITAL SERVICES Attachment A Page 9
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j. Services provided to an individual not eligible (concurrently or retrospectively) for
Medicaid or NCU on the date of service or not covered by or performed in compliance
with this or any other MSM Chapter.
3. DOCUMENTATION REQUIREMENTS
Ensure the following information is maintained in a recipient’s medical record:
a. A physician’s order, clearly indicating the dates and times that observation begins and ends.
b. Comprehensive documentation that supports medical necessity and describes, when
applicable:
1. A significant complication or adverse reaction that requires services that would
normally be included in a recovery or post-procedure period; or
2. A high probability of a significant, rapid onset complication requiring prompt
interventions available in an observation setting.
February 1, 2020 HOSPITAL SERVICES Attachment A Page 10
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
August 27, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: TAMMY MOFFITT, CHIEF OF OPERATIONS
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 300 – RADIOLOGY SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 300 – Radiology Services are being
proposed to remove prior authorization requirements for medically necessary Magnetic Resonance
Imaging (MRI), Magnetic Resonance Angiography (MRA), Magnetic Resonance Spectroscopy
(MRS) and Positron Emission Tomography (PET) scans.
Entities Financially Affected: Outpatient Hospitals (PT 12), Physician, M.D., Osteopath (PT 20),
Advanced Practice Registered Nurse (PT 24), Radiology (PT 27) and Physician Assistant (PT 77).
Financial Impact on Local Government: Overall impact will be budget neutral.
These changes are effective September 1, 2019.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 17/19 MTL 16/18
MSM 300 – RADIOLOGY SERVICES MSM 300 – RADIOLOGY SERVICES
Background and Explanation of Policy
Manual Section Section Title Changes,
Clarifications and Updates
303.1A(1) COVERAGE AND Replaced Nurse Practitioner with Advanced Practice
LIMITATIONS Registered Nurse.
303.1A(5) COVERAGE AND Removed prior authorization requirements for
LIMITATIONS medically necessary Magnetic Resonance Imaging
(MRI), Magnetic Resonance Angiography (MRA),
Magnetic Resonance Spectroscopy (MRS) and
Positron Emission Tomography (PET) scans.
Page 1 of 1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
RADIOLOGY SERVICES
300 INTRODUCTION ...........................................................................................................................1
301 REGULATORY AUTHORITY ......................................................................................................1
302 RESERVED .....................................................................................................................................1
303 MEDICAID POLICY ......................................................................................................................1
303.1 RADIOLOGICAL STUDIES ..........................................................................................................1
303.1A COVERAGE AND LIMITATIONS ...............................................................................................1
303.1B PROVIDER RESPONSIBILITIES .................................................................................................2
303.1C RECIPIENT RESPONSIBILITY ....................................................................................................2
303.1D PRIOR AUTHORIZATION ............................................................................................................3
303.2 SCREENING MAMMOGRAPHY .................................................................................................3
303.2A COVERAGE AND LIMITATIONS ...............................................................................................3
303.3 ELECTRODIAGNOSTIC TESTING/NEUROPHYSIOLOGICAL STUDIES .............................3
303.3A COVERAGE AND LIMITATIONS ...............................................................................................4
303.4 ELECTROMYOGRAPHY (EMG), NERVE CONDUCTION STUDIES (NCS)
DESCRIPTION................................................................................................................................4
303.4A COVERAGE AND LIMITATIONS ...............................................................................................4
303.5 EVOKED POTENTIALS (EPS)
SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY (SSEP)
VISUAL EVOKED POTENTIAL (VEP)
AUDITORY EVOKED POTENTIALS (AEP) ...............................................................................5
303.5A COVERAGE AND LIMITATIONS ...............................................................................................6
303.6 MAGNETOENCEPHALOGRAPHY (MEG)
INTRAOPERATIVE NEUROPHYSIOLOGY MONITORING ....................................................6
303.6A COVERAGE AND LIMITATIONS ...............................................................................................7
303.7 SLEEP STUDY SERVICES............................................................................................................7
303.7A SLEEP STUDY DESCRIPTION ....................................................................................................7
303.7B PRIOR AUTHORIZATION ............................................................................................................8
303.7C COVERAGE AND LIMITATIONS ...............................................................................................8
303.7D UNATTENDED SLEEP STUDIES ................................................................................................9
303.7E NON-COVERED SLEEP STUDY SERVICES ............................................................................11
303.8 RADIOPHARMACEUTICALS AND CONTRAST AGENTS ...................................................11
303.8A RADIOPHARMACEUTICALS AND CONTRAST AGENTS DESCRIPTION ........................11
303.8B COVERAGE AND LIMITATIONS .............................................................................................11
304 HEARINGS .....................................................................................................................................1
Page 1 of 1
MTL 02/11
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 300
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
300 INTRODUCTION
Diagnostic testing and radiologic services are federally mandated Division of Health Care
Financing and Policy (DHCFP) Medicaid and Children’s Health Insurance Program (CHIP)
benefits. This chapter presents policy diagnostic services provided in outpatient hospitals,
diagnostic centers or mobile units.
The DHCFP reimbursement is based on the need to establish a diagnosis and to prescribe
treatment. Reimbursement is also provided for progressive follow-up or staging. Diagnostic
studies are rendered according to the written orders of the Physician, Physician’s Assistant or an
Advanced Practitioner of Nursing (APN) and must be directly related to the presenting symptoms.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), with the exception of the four areas where Medicaid and NCU policies differ
as documented in the NCU Manual Chapter 1000.
May 11, 2011 RADIOLOGY SERVICES Section 300 Page 1
MTL 19/03
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 301
Subject:
MEDICAID SERVICES MANUAL REGULATORY AUTHORITY
301 REGULATORY AUTHORITY
301.1 The citation denoting the amount, duration and scope of services are found in 42 Code of Federal
Regulations (CFR), Part 435 and Sections 1902 (a) (10) (A) (I) (IV) and (VI), 1902 (a) (10) (A) (ii)
(XI), 1902 (a) (10) (E), 1902 (1) and (m), 1905 (p), (q) and (s), 1920, and 1925 of the Act. Title
XVIII of the Social Security Act (SSA), 1862 (a) (1) (A), 411.15 et. seq. Title XVIII of the SSA,
1862 (a) (7), 405.1411-1416.
301.2 The State Legislature sets forth standards of practice for licensed professionals in the following
Nevada Revised Statutes (NRS):
Chapter 454 – Poisons; Dangerous Drugs and Hypodermics (Section 454.213);
Chapter 457 – Cancer;
Chapter 630 – Physicians and Assistant;
Chapter 639 – Pharmacists and Pharmacy (Sections 639.008, 639.0095, 639.0097, 639.0105,
639.0125 and 639.0143.)
301.3 Also cited, Title XXI State Plan Attachment 1.2-B, 101.9 E (Page 7) of Title XIX State Plan.
301.4 The Food and Drug Administration (FDA), Mammography Quality Standards Act (MQSA) of
1992.
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MEDICAID SERVICES MANUAL RESERVED
302 RESERVED
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 303
Subject:
MEDICAID SERVICES MANUAL POLICY
303 MEDICAID POLICY
303.1 RADIOLOGICAL STUDIES
The DHCFP medical assistance programs will reimburse for those covered services that are
considered to be medically necessary for the diagnosis and treatment of a specific illness, symptom,
complaint or injury or to improve the functioning of a malformed body part without prior payment
authorization. The investigational use for any radiological test is not a Medicaid covered benefit
303.1A COVERAGE AND LIMITATIONS
1. A licensed physician or other licensed persons working within the scope of their practice
must request radiology services (e.g., Advanced Practice Registered Nurse, Physician
Assistant, Podiatrist, etc.).
2. Payment for X-rays and other radiological examinations will only be allowed for those
services that are considered to be reasonable and necessary for the diagnosis and treatment
of a specific illness, symptom, complaint or injury or to improve the functioning of a
malformed body part.
3. An annual screening mammography is a covered benefit without prior authorization for
women age 40 and older and/or a woman between the ages of 35-39 considered a high risk
for breast cancer. High risk is defined as one or more of the following conditions:
a. Personal history of breast cancer;
b. Personal history of biopsy – proven beginning breast disease;
c. A mother, sister or daughter had breast cancer; and/or
d. A woman who has not given birth prior to age 30.
4. Diagnostic and/or treatment mammography’s are not restricted to age or sex and do not
require prior authorization.
5. The choice of the appropriate imaging modality or combination of imaging modalities
should be determined on an individual level. Prior authorization is not required for
medically necessary Magnetic Resonance Imaging (MRI), Magnetic Resonance
Angiography (MRA), Magnetic Resonance Spectroscopy (MRS) or Positron Emission
Tomography (PET) scans and the determination of medical necessity is based on nationally
recognized evidenced based clinical guidelines. Examples include but are not limited to:
MCG/McKesson/Interqual Criteria. Always use other modalities or less expensive tests
such as CT, ultrasound or standard X-ray, etc., when they will achieve the required results.
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Use of approved modalities for investigational/experimental reasons are not a Medicaid
benefit. Prior authorization will not be required for initial testing and tumor staging. Other
repeated testing will require prior authorization.
6. The DHCFP medical assistance programs cover certain types of X-rays and cover skeletal
films for arms, legs, pelvis, vertebral column, skull, chest and abdominal films that do not
involve the contrast material and electro cardiograms furnished by a portable X-ray supplier
in a residence used as a recipient’s home. These services must be performed under the
general supervision of a physician. All licensing conditions and health and safety conditions
must be met. Coverage of portable services are defined in 42 CFR 486.
7. Documentation must be available in the clinical record to support the reasonable and
necessary indications for all testing.
8. The following exception requires prior authorization:
All non-emergency services referred and/or provided out-of-state.
9. See Billing Manual for Diagnostic Test prior authorization schedule.
303.1B PROVIDER RESPONSIBILITY
Providers are responsible for the following:
1. Verify program eligibility each month (e.g., Qualified Medicaid Beneficiary (QMB),
Managed Care Organization (MCO), etc.) and comply with the program requirements.
Example: A QMB only recipient never requires a Medicaid payment authorization.
2. The provider must allow, upon the request of proper representatives of the DHCFP, access
to all records which pertain to Medicaid or CHIP recipients for regular review, audit or
utilization review.
3. Evidence to support medical necessity for the procedures must be clearly documented in the
clinical record. Duplicative testing when previous results are still pertinent is not a covered
benefit.
4. The ordering physician is responsible for forwarding appropriate clinical data to the
diagnostic facility.
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MEDICAID SERVICES MANUAL POLICY
303.1C RECIPIENT RESPONSIBILITY
The DHCFP medical assistance program recipient must:
1. present a current Medicaid card to service providers at each encounter.
2. notify providers immediately for any change in eligibility status, e.g. pending status to
eligible or Fee-for-Service to managed care.
303.1D PRIOR AUTHORIZATION
Providers must submit the following documentation to substantiate a prior authorization request:
the date, place and results of previous diagnostic tests performed. Fax or mail all information to the
Quality Improvement Organization (QIO)-like vendor.
303.2 SCREENING MAMMOGRAPHY
Screening mammograms are radiological procedures furnished to a woman without signs or
symptoms of breast disease, for the purpose of early detection of breast cancer, and include a
physician’s interpretation of the results. The service must be at a minimum, a two-view exposure
(that is, a cranio-caudal and medial lateral oblique view) of each breast.
The DHCFP pays for routine screening mammograms annually for women over age 40. For women
aged 35-39, a baseline mammogram is allowed once during this period of time. All facilities
providing mammography services are required to have a certificate issued by the FDA, assuring the
mammography provider meets national quality standards in accordance with the MQSA of 1992.
303.2A COVERAGE AND LIMITATIONS
A doctor’s prescription or referral is not necessary for the procedure to be covered. It is required
that there be 365 days from the date of the last mammogram until the next mammogram.
303.3 ELECTRODIAGNOSTIC TESTING/NEUROPHYSIOLOGICAL STUDIES
A neurological evaluation must proceed diagnostic testing.
a. ELECTROENCEPHALOGRAM (EEG)
Routine EEG tests measure and record the electrical impulses from the cortex of the brain.
A diagnosis can only be made with correlating clinical findings.
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MEDICAID SERVICES MANUAL POLICY
b. 24-HOUR ELECTROENCEPHALOGRAPHIC RECORDING
Intensive EEG recording (24-hours) is a safe and clinically effective method of diagnosis,
classification and localization for seizure disorders and other factors precipitating individual
seizures. Results can indicate which category of medication may be the most successful.
c. EEG BRAIN MAPPING
EEG brain mapping is a term commonly used for several quantitative EEG techniques.
These include:
1. EEG frequency analysis;
2. topographic display;
3. statistical comparisons to a normative database; and
4. other similar computer-based calculations based on EEG or evoked potentials.
Prior authorization requests must be reviewed by a Physician Advisor highly skilled in
clinical electroencephalographic testing for services which are provided by physician
specialists in clinical electroencephalography. A specific correlating diagnosis has not been
established.
303.3A COVERAGE AND LIMITATIONS:
EEG testing is covered when supported by sufficient information that its use was medically
appropriate considering the patient’s symptoms and preliminary diagnosis.
24-hour EEG recordings and EEG mapping require prior payment authorization.
303.4 ELECTROMYOGRAPHY (EMG), NERVE CONDUCTION STUDIES (NCS) DESCRIPTION:
Electromyoneurography is the combined use of electromyography (EMG) and
electroneurography/NCS. These studies are done to detect neuromuscular abnormalities by
measuring the nerve conduction and muscle potentials. F-wave studies assess motor nerve function
along each nerve. An impulse generated at the stimulating electrode travels up the motor nerves to
the motor neuron cell bodies in the spinal cord, on to the neuromuscular junction and the muscle.
H-reflex studies are entirely separate from F-wave studies. H-reflex studies assess sensory and
motor nerve function and their connections in the spinal cord. The EMG/NCS testing in
combination with evaluating the range of motion, motor power, sensory defects and reflexes can
differentiate between neuropathy and myopathy.
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DIVISION OF HEALTH CARE FINANCING AND POLICY 303
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MEDICAID SERVICES MANUAL POLICY
303.4A COVERAGE AND LIMITATIONS:
1. EMG measures the electrical activity of muscles at rest and during contractions.
2. NCS – Diagnostic nerve conduction studies include amplitude which differentiates nerve
conduction studies from screening studies performed with devices which only measure
latency.
3. F-wave studies are usually performed in conjunction with conventional motor nerve
conductions studies of the same nerve. F-wave studies assess motor nerve function along
the entire extent of each selected nerve.
4. Reflex Tests – H-reflex testing is unilateral and usually involves assessment of the tibial
motor nerve and the gastrocnemius-soleus muscle complex. They are not often performed
in conjunction with conventional nerve conduction studies of this nerve-muscle pair.
Typically, only one or two H-reflex studies are performed on a patient during a given
encounter.
5. Neuromuscular junction testing
COVERED DIAGNOSIS:
Carpal Tunnel Syndrome Neuritis
Diabetic Neuropathy Neuromuscular conditions
Disorders of the Peripheral Nervous System Pain in Limb
Disturbance of Skin Sensation Plexopathy
Fasciculation Joint Pain Radiculopathy
Muscle Weakness Spinal Cord Injury
Myopathy Swelling and Cramps
Myositis Trauma to Nerves
Nerve Root Compression Weakness
See Billing Manual for prior authorization requirements.
303.5 EVOKED POTENTIALS (EPS):
SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY (SSEP)
VISUAL EVOKED POTENTIAL (VEP)
AUDITORY EVOKED POTENTIALS (AEP)
DESCRIPTION: EPs are time-locked responses of the nervous system to external stimuli.
Somatosensory evoked potentials (SEPs) are one type of EP, which are generated by stimulation of
afferent peripheral nerve fibers elicited by electrical, tactile or other stimuli. “Short-latency” SEP
(SSEP) refers to that portion of the waveform of an SEP normally occurring within a specific time
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Subject:
MEDICAID SERVICES MANUAL POLICY
lapse variable after nerve stimulation. SEP abnormalities are not disease specific but can indicate
afferent conduction impairments associated with certain disorders.
303.5A COVERAGE AND LIMITATIONS
1. The SEP study is separated into upper and lower limbs to recognize that switching from the
upper to lower limbs requires an increase in work because many stimulating and recording
electrodes must be moved and the patient must be stimulated many more times to perform
the additional testing.
2. SEP studies performed on the trunk or head are completely separate tests from the upper
and lower limb studies.
3. The visual evoked potential codes are clinical neurophysiologic studies.
4. The auditory evoked potential procedure codes can be a clinical neurophysiologic study as
well as an audiology study.
COVERED DIAGNOSIS
SEP/SSEP: VER:
Spinal Cord Lesions Lesions of Optic Nerve/Optic Tracts
Stroke Multiple Sclerosis (MS)
Extremity numbness and weakness
ABR:
Lesions in the Brain Stem including Tumor Cerebellopontine Angle Lesions
Evaluate Hearing in Infants, Children, Adults Infarctions
Evaluation for peripheral Hearing Loss MS
See Billing Manual for prior authorization requirements.
303.6 MAGNETOENCEPHALOGRAPHY (MEG)
INTRAOPERATIVE NEUROPHYSIOLOGY MONITORING
DESCRIPTION: MEG is a highly refined noninvasive technique that measures the magnetic fields
generated by active groups of nerve cells in the brain which would obviate the need for depth
electrodes in the precise localization of epileptogenic foci. MEG Non-invasive use of MEG and
MEG - EEG have been able to help focus subdural electrodes for a chronic intracranial presurgical
evaluation in recipients with medically intractable epilepsy and comparison of epileptic activity
with normal evoked responses may help localize epileptic zones.
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Subject:
MEDICAID SERVICES MANUAL POLICY
Intraoperative neurophysiology/electrophysiologic monitoring of the nervous system is now widely
used to help prevent complications and to identify structures during neurosurgical and other
procedures. These techniques include EEG, evoked potentials, EMG and nerve conduction velocity
(NCV) testing and monitoring.
303.6A COVERAGE AND LIMITATIONS:
MEG – The procedure is limited to localization of the seizure zone in medically intractable partial
epilepsy for recipients being considered for surgical intervention.
Intraoperative electrophysiologic monitoring – EEG or SEP to monitor for cerebral ischemia;
electrocorticography (ECoG) and SEP sensory cortex identification to define the limits of cortical
resection; SEP spinal cord monitoring; Brainstem Auditory Evoke Potential (BAEP) and cranial
nerve EMG monitoring during posterior fossa procedures; functional localization of cortex with
direct cortical stimulation in expert hands; and EMG and compound muscle and nerve action
potential measurements of various peripheral nervous system structures.
1. COVERED DIAGNOSIS:
Partial intractable epilepsy, without mention of impairment of consciousness.
See Billing Manual for prior authorization requirements.
2. DOCUMENTATION REQUIREMENTS
Documentation supporting medical necessity for any of the above procedures must be
clearly documented in the recipient’s medical record and submitted when a prior
authorization is required.
303.7 SLEEP STUDY SERVICES
303.7A SLEEP STUDY DESCRIPTION
1. According to the U.S. Department of Health and Human Services, National Institutes of
Health (NIH), sleep studies are tests that measure how well someone sleeps and how the
body responds to sleep problems. Sleep studies are necessary because untreated sleep
disorders can raise risk for heart disease, high blood pressure, stroke and other medical
conditions. Sleep disorders have also been linked to an increased risk of injury, such as
falling in the elderly and automobile accidents.
a. The following sleep study tests are covered benefits: Polysomnography (PSG) is the
scientific evaluation of sleep that involves a physiologic recording of brain waves,
oxygen level in blood, heart rate and breathing and eye and leg movements.
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Subject:
MEDICAID SERVICES MANUAL POLICY
b. The multiple sleep latency test (MSLT) is performed to measure daytime sleepiness.
Also known as a daytime nap study, the MSLT is the standard tool used to diagnose
narcolepsy and idiopathic hypersomnia.
2. Sleep study services are performed with physician review, interpretation and report.
303.7B PRIOR AUTHORIZATION
1. The PSG and MSLT sleep study tests are limited to two services in a 12-month period
without prior authorization. If the services exceed limitations, a prior authorization is
required.
2. Prior authorization for MSLT includes authorization for a PSG performed on the preceding
night to be valid.
3. Documentation supporting medical necessity for sleep study services must be clearly
documented in the recipient’s medical record and submitted when a prior authorization is
requested.
303.7C COVERAGE AND LIMITATIONS
1. Sleep studies are covered services in the following settings:
a. a certified or accredited sleep disorder facility; or
b. an in-home (unattended) setting in conjunction with a comprehensive sleep
evaluation by a physician board certified in sleep medicine.
2. A licensed physician or other licensed professional working within the scope of their
practice must request the appropriate test.
3. The ordering provider is responsible for forwarding appropriate clinical data to the
diagnostic facility.
4. The need for diagnostic testing is confirmed by medical evidence, e.g. recipient history,
physician examination and other laboratory tests.
5. Reference Medicaid Services Manual (MSM) Chapter 1300, Durable Medical Equipment,
for coverage and limitation guidelines for the positive airway pressure device services.
6. Polysomnography (PSM) minimum requirements include the following:
a. EEG;
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b. Electro-oculography (EOG); and
c. EMG.
7. Additional parameters of sleep which may be monitored include:
a. EKG;
b. Airflow;
c. Ventilation and respiratory effort;
d. Gas exchange by oximetry, transcutaneous monitoring or end tidal gas analysis;
e. Extremity muscle activity, motor activity-movement;
f. Extended EEG monitoring;
g. Penile tumescence;
h. Gastroesophageal reflux;
i. Continuous blood pressure monitoring;
j. Snoring; and
k. Body positions, etc.
8. A PSG must be recorded and staged.
9. MSLT’s are covered only when symptoms suggest a diagnosis of narcolepsy.
303.7D UNATTENDED SLEEP STUDIES
1. Portable monitoring (PM) for the diagnosis of obstructive sleep apnea (OSA) should be
performed only in conjunction with a comprehensive sleep evaluation.
2. Clinical sleep evaluations following PM must be supervised and evaluated by a physician
board certified in sleep medicine.
3. PM may be used as an alternative to PSG for the diagnosis of OSA in recipients with a high
pretest probability to moderate to severe OSA.
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4. PM should not be used for the following recipients:
a. with significant comorbid medical conditions that may degrade the accuracy of PM,
including moderate to severe pulmonary disease, neuromuscular disorders, asthma,
stroke, severe hypertension or congestive heart failure.
b. suspect of having other sleep disorders, including central sleep apnea, periodic limb
movement disorder, insomnia, parasomnias, circadian rhythm disorders or
narcolepsy.
5. PM should not be used for general screening of asymptomatic recipients.
6. PM may be indicated for the diagnosis of OSA in recipients for whom in-laboratory PSG
is not possible by virtue of immobility, safety or critical illness.
7. At a minimum, the PM must record airflow, respiratory effort and blood oxygenation. The
type of biosensors used to monitor these parameters for in-laboratory PSG are
recommended for use in PM.
8. Unattended sleep studies are considered medically necessary using one of the following
diagnostic techniques for recipients with symptoms suggestive of OSA when the home
sleep study is used as part of a comprehensive sleep evaluation:
a. Sleep monitoring using a Type II device, minimum of seven channels (e.g. EEG,
EOG, EMG, ECG, airflow, respiratory effort, oxygen saturation);
b. Sleep monitoring using a Type III device, minimum of four monitored channels
including ventilation or airflow (at least two channels of respiratory movement or
airflow), heart rate or ECG and oxygen saturation; or
c. Sleep monitoring using a Type IV device, measuring at least three channels. Type
IV devices must allow channels that allow direct calculation of an apnea-hypopnea
index (AHI) or respiratory disturbance index (RDI) as the result of measuring
airflow or thoracoabdominal movement.
9. An experienced sleep technician, sleep technologist or appropriately trained healthcare
provider must perform the application of PM sensors or directly educate the recipient in
correct application of the sensors.
10. Due to the known rate of false negative PM tests, in-laboratory PSG should be performed
in cases where PM is technically inadequate or fails to establish the diagnosis of OSA in
recipients with a high pretest probability.
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MEDICAID SERVICES MANUAL POLICY
11. If a PM test is technically inadequate or does not provide the expected result, in-laboratory
PSG should be performed. Documentation supporting medical necessity for the repeat
services must be clearly documented in the recipient’s medical record.
303.7E NON-COVERED SLEEP STUDY SERVICES
1. Actigraphy and SleepStrip® are considered investigational/experimental and are not
covered benefits.
2. Repeat studies are not covered when documentation for a repeat study does not indicate
medical necessity (e.g. no new clinical documentation indicating the need for a repeat
study).
303.8 RADIOPHARMACEUTICALS AND CONTRAST AGENTS
303.8A RADIOPHARMACEUTICALS AND CONTRAST AGENTS DESCRIPTION
1. According to the FDA, radiopharmaceuticals and contrast agents are used in diagnostic
imaging procedures or for therapeutic purposes. Agents enhance the quality of MRI, MRA,
CT scans, PET, x-ray and other modalities. Agents are also used to monitor treatment effect.
Radiopharmaceuticals and contrast agents may be dispensed to the recipient in several
different ways, i.e. by mouth or injection or placed into the eye or bladder. They may also
be used for nuclear medicine.
303.8B COVERAGE AND LIMITATIONS
1. The DHCFP will reimburse covered, medically necessary radiopharmaceuticals and
contrast agents.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 304
Subject:
MEDICAID SERVICES MANUAL HEARINGS
304 HEARINGS
Please reference MSM, Chapter 3100, for Hearings process and policy.
May 11, 2011 RADIOLOGY SERVICES Section 304 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
June 29, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, HIPAA PRIVACY AND CIVIL RIGHTS
OFFICER /Jessica Kemmerer/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 400 – MENTAL HEALTH AND ALCOHOL/SUBSTANCE
ABUSE SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 400 – Mental Health and
Alcohol/Substance Abuse Services are being proposed to eliminate Biofeedback and Neurotherapy
services for the treatment of a mental health diagnosis. Neurotherapy is individual psychological
therapy incorporating biofeedback training combined with psychotherapy as a treatment for mental
health disorders. The elimination of these services is being made as a result of the approved
DHCFP budget during the 2021 Legislative session in effort to reduce current costs to the Medicaid
program and to address the Governor’s mandated budget cuts.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: This proposed change affects all Medicaid-enrolled providers
delivering biofeedback and neurotherapy type of services. Those provider types (PT) include, but
are not limited to; Hospital, Outpatient (PT 12); Behavioral Health Outpatient Treatment (PT 14);
Physician, M.D., Osteopath D.O. (PT 20); Advanced Practice Registered Nurse (PT 24);
Psychologist (PT 26); Physician’s Assistant (PT 77); Behavioral Health Rehabilitative Treatment
(PT 82), and Certified Community Behavioral Health Center (PT 17 Specialty 188).
Financial Impact on Local Government:
SFY 2022: $ 28,024,136
SFY 2023: $ 28,299,314
These changes are effective July 1, 2021.
Page 1 of 2
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 08/21 MTL 21/15, 21/20
MSM 400 - Mental Health and MSM 400 - Mental Health and
Alcohol/Substance Abuse Services Alcohol/Substance Abuse Services
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
403.4(C)(4) Outpatient Mental Removed entire section
Health Services --
Neurotherapy
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DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
MENTAL HEALTH AND ALCOHOL/SUBSTANCE ABUSE SERVICES
400 INTRODUCTION ...........................................................................................................................1
401 AUTHORITY ..................................................................................................................................1
402 RESERVED .....................................................................................................................................1
403 POLICY ...........................................................................................................................................1
403.1 OUTPATIENT SERVICE DELIVERY MODELS.........................................................................1
403.2 PROVIDER STANDARDS.............................................................................................................1
403.2A SUPERVISION STANDARDS ......................................................................................................5
403.2B DOCUMENTATION ......................................................................................................................7
403.3 PROVIDER QUALIFICATIONS - OUTPATIENT MENTAL HEALTH SERVICES ..............12
403.4 OUTPATIENT MENTAL HEALTH SERVICES ........................................................................14
403.5 OUTPATIENT MENTAL HEALTH (OMH) SERVICES-UTILIZATION MANAGEMENT...24
403.6 PROVIDER QUALIFICATIONS .................................................................................................31
403.6A REHABILITATION MENTAL HEALTH (RMH) SERVICES ...................................................31
403.6B REHABILITATIVE MENTAL HEALTH SERVICES ................................................................34
403.6C BASIC SKILLS TRAINING (BST) SERVICES ..........................................................................41
403.6D PROGRAM FOR ASSERTIVE COMMUNITY TREATMENT (PACT) ...................................44
403.6E RESERVED ..................................................................................................................................44
403.6F PEER-TO-PEER SERVICES ........................................................................................................44
403.6G PSYCHOSOCIAL REHABILITATION (PSR) SERVICES ........................................................46
403.6H CRISIS INTERVENTION (CI) SERVICES .................................................................................48
403.7 OUTPATIENT ALCOHOL AND SUBSTANCE ABUSE SERVICES POLICY .......................49
403.7A COVERAGE AND LIMITATIONS .............................................................................................49
403.7B PROVIDER RESPONSIBILITIES ...............................................................................................51
403.7C RECIPIENT RESPONSIBILITIES ...............................................................................................52
403.7D AUTHORIZATION PROCESS ....................................................................................................52
403.8 RESIDENTIAL TREATMENT CENTER (RTC) SERVICES ....................................................52
403.8A COVERAGE AND LIMITATIONS .............................................................................................53
403.8B PROVIDER RESPONSIBILITES .................................................................................................56
403.8C AUTHORIZATION PROCESS ....................................................................................................59
403.9 INPATIENT MENTAL HEALTH SERVICES POLICY .............................................................62
403.9A COVERAGE AND LIMITATIONS .............................................................................................63
403.9B PROVIDER RESPONSIBILITIES ...............................................................................................66
403.9C AUTHORIZATION PROCESS ....................................................................................................70
403.10 INPATIENT ALCOHOL/SUBSTANCE ABUSE DETOXIFICATION AND TREATMENT
SERVICES POLICY .....................................................................................................................72
403.10A COVERAGE AND LIMITATIONS .............................................................................................72
403.10B PROVIDER RESPONSIBILITES .................................................................................................74
403.10C RECIPIENT RESPONSIBILITIES ...............................................................................................75
403.10D AUTHORIZATION PROCESS ....................................................................................................75
403.11 ADMINISTRATIVE DAYS POLICY ..........................................................................................77
403.11A COVERAGE AND LIMITATIONS .............................................................................................77
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DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
403.11B PROVIDER RESPONSIBILITIES ...............................................................................................79
403.11C RECIPIENT RESPONSIBILITIES ...............................................................................................79
403.11D AUTHORIZATION PROCESS ....................................................................................................79
403.12 ELECTROCONVULSIVE THERAPY (ECT) .............................................................................80
403.12A COVERAGE AND LIMITATIONS .............................................................................................80
404 HEARINGS .....................................................................................................................................1
ATTACHMENT A ..................................................................................................................................................1
ATTACHMENT B ..................................................................................................................................................1
ATTACHMENT C ..................................................................................................................................................1
ATTACHMENT D .................................................................................................................................................1
Page 2 of 2
MTL 01/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 400
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
MENTAL HEALTH AND ALCOHOL/SUBSTANCE ABUSE SERVICES
400 INTRODUCTION
Nevada Medicaid reimburses for community-based and inpatient mental health services to both
children and adults under a combination of mental health rehabilitation, medical/clinical and
institutional authority. The services must be recommended by a physician or other licensed
practitioner of the healing arts, within their scope of practice under State law for the maximum
reduction of a physical or mental disability and to restore the individual to the best possible
functioning level. The services are to be provided in the least restrictive, most normative setting
possible and may be delivered in a medical professional clinic/office, within a community
environment, while in transit and/or in the recipient’s home. All services must be documented as
medically necessary and appropriate and must be prescribed on an individualized Treatment Plan.
Mental health rehabilitation assists individuals to develop, enhance and/or retain psychiatric
stability, social integration skills, personal adjustment and/or independent living competencies in
order to experience success and satisfaction in environments of their choice and to function as
independently as possible. Interventions occur concurrently with clinical treatment and begin as
soon as clinically possible.
Alcohol and substance abuse treatment and services are aimed to achieve the mental and physical
restoration of alcohol and drug abusers. To be Medicaid reimbursable, while services may be
delivered in inpatient or outpatient settings (inpatient substance abuse hospital, general hospital
with a substance abuse unit, mental health clinic, or by an individual psychiatrist or psychologist),
they must constitute a medical-model service delivery system.
All Medicaid policies and requirements (such as prior authorization, etc.) except for those listed
in the Nevada Check Up (NCU) Chapter 1000, are the same for NCU. Medicaid Services Manual
(MSM) Chapter 400 specifically covers behavioral health services and for other Medicaid services
coverage, limitations and provider responsibilities, the specific MSM needs to be referenced.
Nevada Medicaid’s philosophy assumes that behavioral health services shall be person-centered
and/or family driven. All services shall be culturally competent, community supportive, and
strength based. The services shall address multiple domains, be in the least restrictive environment,
and involve family members, caregivers and informal supports when considered appropriate per
the recipient or legal guardian. Service providers shall collaborate and facilitate full participation
from team members including the individual and their family to address the quality and progress
of the individualized care plan and tailor services to meet the recipient’s needs. In the case of child
recipients, providers shall deliver youth guided effective/comprehensive, evidence-based
treatments and interventions, monitor child/family outcomes through utilization of Child & Family
Team meetings and continuously work to improve services in order to ensure overall fidelity of
recipient care. (Reference Addendum – MSM Definitions).
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401 AUTHORITY
In 1965, the 89th Congress added Title XIX of the Social Security Act (SSA) authorizing varying
percentages of federal financial participation (FFP) for states that elected to offer medical
programs. States must offer the 11 basic required medical services. Two of these are inpatient
hospital services (42 Code of Federal Regulations (CFR) 440.10) and outpatient hospital services
(42 CFR 440.20). All other mental health and substance abuse services provided in a setting other
than an inpatient or outpatient hospital are covered by Medicaid as optional services. Additionally,
state Medicaid programs are required to correct or ameliorate defects and physical and mental
illnesses and conditions discovered as the result of an Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) screening for children 21 years or younger, whether or not such services are
covered under the state plan (Section 1905(a)).
Other authorities include:
• Section 1902(a)(20) of the SSA (State Provisions for Mental Institution Patients 65 and
Older)
• Section 1905(a)(13) of the SSA (Other Diagnostic Screening, Preventative and
Rehabilitative Services)
• Section 1905(h) of the SSA (Inpatient Psychiatric Services to Individuals Under Age 21)
• Section 1905(i) of the SSA (Definition of an Institution for Mental Diseases)
• Section 1905(r)(5) of the SSA (Mental Health Services for Children as it relates to EPSDT)
• 42 CFR 435.1009 (2) (Definition of Institution for Mental Diseases (IMD))
• 42 CFR 435.1010 (Definitions Relating to Institutional Status)
• 42 CFR 440.160 (Inpatient Psychiatric Services to Individuals Under Age 21)
• 42 CFR 441.150 to 441.156 (Inpatient Psychiatric Services for Individuals under age 21 in
Psychiatric Facilities or Programs)
• 42 CFR, Part 482 (Conditions of Participation for Hospitals)
• 42 CFR, Part 483 (Requirements for States and Long-Term Care Facilities)
• 42 CFR, PART 435 (Eligibility in the States, District of Columbia, the Northern Mariana
Islands and American Samoa), 440.130 (Definitions relating to institutional status)
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• 42 CFR, PART 440 (Services: General Provisions), 440.130 (Diagnostic, screening,
preventive and rehabilitative services)
• CMS 2261-P, Centers for Medicare and Medicaid Services (CMS) (Medicaid Program;
Coverage for Rehabilitative Services)
• CMS State Medicaid Manual, Chapter 4, Section 4390 (Requirements and Limits
applicable to Specific Services (IMD))
• Nevada Revised Statute (NRS), Chapter 629 (Healing Arts Generally)
• NRS 432.B (Protection of Children from Abuse and Neglect)
• NRS, Chapter 630 (Physicians, Physician Assistants and Practitioners of Respiratory Care)
• NRS Chapter 632 (Nursing)
• NRS 433.B.010 to 433.B.350 (Mental Health of Children)
• NRS 433.A.010 to 433.A.750 (Mental Health of Adults)
• NRS 449 (Medical and other Related Facilities)
• NRS 641 (Psychologists)
• NRS 641.A (Marriage and Family Therapists and Clinical Professional Counselors)
• NRS 641B (Social Workers)
• Nevada State Plan, Section 4.19-A, Page 4
• Nevada Medicaid Inpatient Psychiatric and Substance Abuse Policy, Procedures and
Requirements. The Joint Commission Restraint and Seclusion Standards for Behavioral
Health.
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402 RESERVED
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403 POLICY
403.1 OUTPATIENT SERVICE DELIVERY MODELS
Nevada Medicaid reimburses for outpatient mental health and/or mental health rehabilitative
services under the following service delivery models:
A. Behavioral Health Community Networks (BHCN)
Public or private entities that provides or contracts with an entity that provides:
1. Outpatient Mental Health (OMH) services, such as assessments, therapy, testing
and medication management, including specialized services for Nevada Medicaid
recipients who are experiencing symptoms relating to a covered, current
International Classification of Diseases (ICD) diagnosis or who are individuals with
a mental illness and residents of its mental health service area who have been
discharged from inpatient treatment;
2. 24-hour per day emergency response for recipients; and
3. Screening for recipients under consideration for admission to inpatient facilities.
BHCNs are a service delivery model and are not dependent on the physical structure of a
clinic. BHCNs can be reimbursed for all services covered in this chapter and may make
payment directly to the qualified provider of each service. BHCNs must coordinate care
with Rehabilitative Mental Health (RMH) rehabilitation providers.
B. Independent Professionals – State of Nevada licensed: psychiatrists, psychologists, clinical
social workers, marriage and family therapists and clinical professional counselors. These
providers are directly reimbursed for the professional services they deliver to Medicaid-
eligible recipients in accordance with their scope of practice, state licensure requirements
and expertise.
C. Individual Rehabilitative Mental Health (RMH) providers must meet the provider
qualifications for the specific service. If they cannot independently provide Clinical and
Direct Supervision, they must arrange for Clinical and Direct Supervision through a
contractual agreement with a BHCN or qualified Independent Professional. These
providers may directly bill Nevada Medicaid or may contract with a BHCN.
403.2 PROVIDER STANDARDS
A. All providers must:
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1. Provide medically necessary services;
2. Adhere to the regulations prescribed in this chapter and all applicable Division
chapters;
3. Provide only those services within the scope of their practice and expertise;
4. Ensure care coordination to recipients with higher intensity of needs;
5. Comply with recipient confidentiality laws and Health Insurance Portability and
Accountability Act (HIPAA);
6. Maintain required records and documentation;
7. Comply with requests from the Qualified Improvement Organization (QIO)-like
vendor;
8. Ensure client’s rights; and
9. Cooperate with the Division of Health Care Financing and Policy’s (DHCFP’s)
review process.
B. BHCN providers must also:
1. Have written policies and procedures to ensure the medical appropriateness of the
services provided;
2. Operate under Clinical supervision and ensure Clinical supervisors operate within
the scope of their license and expertise and have written policies and procedures to
document the prescribed process;
3. Ensure access to psychiatric services, when medically appropriate, through a
current written agreement, job description or similar type of binding document;
4. Utilize Clinical Supervision as prescribed in this chapter and have written policies
and procedures to document the process to ensure Clinical Supervision is performed
on a regular, routine basis at least monthly and the effectiveness of the mental health
treatment program is evaluated at least annually;
5. Work on behalf of recipient’s in their care to ensure effective care coordination
within the state system of care among other community mental health providers
and other agencies servicing a joint recipient;
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6. Implement and maintain a Quality Assurance (QA) program which continually
assesses quality measures and seeks to improve services on an ongoing basis. A
QA program description must be submitted upon enrollment and updated annually
on the anniversary of the BHCN enrollment month. The BHCN’s QA program
description and report must include the following:
a. A list of behavioral health services and evidence-based practices that the
BHCN provides to recipients.
1. Identify the goals and objectives of the services and methods which
will be used to restore recipient’s highest level of functioning.
b. An organization chart that outlines the BHCN’s supervisory structure and
the employees and positions within the agency. The organizational chart
must identify the Clinical Supervisor(s), Direct Supervisor(s), affiliated
mental health professional(s) and paraprofessionals names and National
Provider Identifier (NPI) numbers for each.
c. Document how clinical and supervisory trainings are conducted and how
they support standards to ensure compliance with regulations prescribed
within MSM Chapter 400. Provide a brief description of material covered,
date, frequency and duration of training, location, names of employees that
attended and the name of the instructor.
d. Demonstration of effectiveness of care, access/availability of care and
satisfaction of care. The BHCN must adhere to the QIO-like vendor’s
billing manual for further instructions concerning the required quality
measures below. The following quality measures are required:
1. Effectiveness of care:
a. Identify the percentage of recipients demonstrating stable or
improved functioning.
b. Develop assessment tool to review treatment and/or
rehabilitation plans and report results of assessment.
2. Access and availability to care:
a. Measure timeliness of appointment scheduling between
initial contact and rendered face to face services.
3. Satisfaction of care:
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a. Conduct a recipient and/or family satisfaction survey(s) and
provide results.
b. Submit a detail grievance policy and procedure.
e. The DHCFP may require the BHCN to submit a DHCFP approved
Corrective Action Plan (CAP) if the BHCN’s QA report has adverse
findings. The BHCN’s CAP shall contain the following and must be
provided within 30 days from the date of notice:
1. The type(s) of corrective action to be taken for improvement;
2. The goals of the corrective action;
3. The timetable for action;
4. The identified changes in processes, structure, internal/external
education;
5. The type of follow-up monitoring, evaluation and improvement.
f. QA Programs must be individualized to the BHCN delivery model and
services provided. Duplication of QA documentation between BHCNs may
be cause for rejection without review.
Failure to submit QA Program documentation or failure to meet standards of the QA Program
and/or Corrective Action Plan (CAP) as required in MSM 403.B.6 within designated
timeframes will result in the imposition of sanctions including, but not limited to, partial
suspension and/or termination of the BHCN provider contract. Further clarification of the
QA Program requirements may be found in the billing manual.
A BHCN that is accredited through the Joint Commission, Commission on Accreditation
of Rehabilitation Facilities (CARF) or Council of Accreditation (COA) may substitute a
copy of the documented QA program and report required for the certification in lieu of the
requirements of MSM 403.2B.6. Accreditation must be specific to a BHCN delivery
model.
C. Recipient and Family Participation and Responsibilities
1. Recipients or their legal guardians and their families (when applicable) must:
a. Participate in the development and implementation of their individualized
treatment plan;
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b. Keep all scheduled appointments; and
c. Inform their Medicaid providers of any changes to their Medicaid eligibility.
403.2A SUPERVISION STANDARDS
1. Clinical Supervision – The documented oversight by a Clinical Supervisor to assure the
mental and/or behavioral health services provided are medically necessary and clinically
appropriate. Clinical Supervision includes the on-going evaluation and monitoring of the
quality and effectiveness of the services provided, under ethical standards and professional
values set forth by state licensure, certification, and best practice. Clinical Supervision is
intended to be rendered on-site. Clinical Supervisors are accountable for all services
delivered and must be available to consult with all clinical staff related to delivery of
service, at the time the service is delivered. Licensed Clinical Social Workers (LCSW),
Licensed Marriage and Family Therapists (LMFT), Clinical Professional Counselors
(CPC) and Qualified Mental Health Professionals (QMHP), excluding Interns, operating
within the scope of their practice under state law, may function as Clinical Supervisors.
Clinical Supervisors must have the specific education, experience, training, credentials and
licensure to coordinate and oversee an array of mental and behavioral health services.
Clinical Supervisors assume professional responsibility for the mental and/or behavioral
health services provided by clinical staff, including Independent Professionals, QMHPs,
and Individual RMH providers, including Qualified Mental Health Associates (QMHA)
and Qualified Behavioral Aides (QBA). Clinical Supervisors can supervise other LCSWs,
LMFTs, CPCs, QMHPs, QMHAs and QBAs. Clinical Supervisors may also function as
Direct Supervisors.
Individual RMH providers, who are LCSWs, LMFTs, CPCs, and QMHPs, excluding
Interns, may function as Clinical Supervisors over RMH services. However, Individual
RMH providers, who are QMHPs, including interns, may not function as Clinical
Supervisors over OMH services, such as assessments, therapy, testing and medication
management. Clinical Supervisors must assure the following:
a. An up to date (within 30 days) case record is maintained on the recipient; and
b. A comprehensive mental and/or behavioral health assessment and diagnosis is
accomplished prior to providing mental and/or behavioral health services (with the
exception of Crisis Intervention services); and
c. A comprehensive and progressive treatment plan is developed and approved by the
Clinical Supervisor and/or a Direct Supervisor, who is a QMHP, LCSW, LMFT or
CPC; and
d. Goals and objectives are time specific, measurable (observable), achievable,
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realistic, time-limited, outcome driven, individualized, progressive and age and
developmentally appropriate; and
e. The recipient and their family/legal guardian (in the case of legal minors)
participate in all aspects of care planning, the recipient and their family/legal
guardian (in the case of legal minors) sign the treatment plan and the recipient and
their family/legal guardian (in the case of legal minors) receive a copy of the
treatment plan(s); and
f. The recipient and their family/legal guardian (in the case of legal minors)
acknowledge in writing that they understand their right to select a qualified provider
of their choosing; and
g. Only qualified providers provide prescribed services within scope of their practice
under state law; and
h. Recipients receive mental and/or behavioral health services in a safe and efficient
manner.
2. Direct Supervision – Independent Professionals, QMHPs and/or QMHAs may function as
Direct Supervisors within the scope of their practice. Direct Supervisors must have the
practice-specific education, experience, training, credentials, and/or licensure to coordinate
an array of OMH and/or RMH services. Direct Supervisors assure servicing providers
provide services in compliance with the established treatment plan(s). Direct Supervision is
limited to the delivery of services and does not include treatment and plan(s) modification
and/or approval. If qualified, Direct Supervisors may also function as Clinical Supervisors.
Direct Supervisors must document the following activities:
a. Their face-to-face and/or telephonic meetings with Clinical Supervisors.
1. These meetings must occur before treatment begins and periodically
thereafter;
2. The documentation regarding this supervision must reflect the content of
the training and/or clinical guidance; and
3. This supervision may occur in a group and/or individual settings.
b. Their face-to-face and/or telephonic meetings with the servicing provider(s).
1. These meetings must occur before treatment/rehabilitation begins and, at a
minimum, every 30 days thereafter;
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2. The documentation regarding this supervision must reflect the content of
the training and/or clinical guidance; and
3. This supervision may occur in group and/or individual settings;
c. Assist the Clinical Supervisor with Treatment Plan reviews and evaluations.
403.2B DOCUMENTATION
1. Individualized Treatment Plan
a. A written individualized treatment plan, referred to as Treatment Plan, is a
comprehensive, progressive, personalized plan that includes all prescribed
Behavioral Health (BH) services, to include Rehabilitative Mental Health (RMH)
and Outpatient Mental Health (OMH) services. A Treatment Plan is person-
centered, rehabilitative and recovery oriented. The treatment plan addresses
individualized goals and objectives. The objective is to reduce the duration and
intensity of BH services to the least intrusive level possible while sustaining overall
health. BH services are designed to improve the recipient’s functional level based
on achievable goals and objectives as determined in the Treatment Plan that
identifies the amount and duration of services. The Treatment Plan must consist of
services designed to achieve the maximum reduction of the BH services required
to restore the recipient to a functional level of independence.
b. Each prescribed BH service within the Treatment Plan must meet medical necessity
criteria, be clinically appropriate and must utilize evidence-based practices.
c. The prescribed services within the plan must support the recipient’s restoration of
functioning consistent with the individualized goals and objectives.
d. A Treatment Plan must be integrated and coordinated with other components of
overall health care.
e. The person-centered treatment plan must establish strength-based goals and
objectives to support the recipient’s individualized rehabilitative process. The BH
services are to accomplish specific, observable changes in skills and behaviors that
directly relate to the recipient’s individual diagnosed condition(s). BH services
must be rehabilitative and meet medically necessity for all services prescribed.
2. Treatment Plan Development
a. The Treatment Plan must be developed jointly with a QMHP and:
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1. The recipient or the recipient’s legal representative (in the case of legal
minors and when appropriate for an adult);
2. The recipient's parent, family member, guardian or legal representative with
given consent from the recipient if determined necessary by the recipient;
b. All BH services requested must ensure that the goal of restoring a recipient’s
functional levels is consistent with the therapeutic design of the services to be
provided under the Treatment Plan.
c. All requested BH services must ensure that all involved health professionals
incorporate a coherent and cohesive developed treatment plan that best serves the
recipient’s needs.
d. Services should be developed with a goal that promotes collaboration between other
health providers of the recipient, community supports including, but not limited to,
community resources, friends, family or other supporters of the recipient and
recipient identified stakeholders to ensure the recipient can receive care
coordination and continuity of care.
e. The requested services are to be specific, measurable and relevant in meeting the
goals and objectives identified in the Treatment Plan. The QMHP must identify
within the Treatment Plan the scope of services to be delivered and are not
duplicative or redundant of other prescribed BH services.
3. Required information contained in the Treatment Plan
a. Treatment Plans are required to include, but are not limited to, the following
information:
1. Recipient’s full name;
2. Recipient’s Medicaid/Nevada Check Up billing number;
3. Intensity of Needs determination;
4. Severe Emotional Disturbance (SED) or Serious Mental Illness (SMI)
determination;
5. Date of determination for SED or SMI;
6. The name and credentials of the provider who completed the determination.
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b. Goals and Objectives of the Treatment Plan
1. The individualized treatment plan must demonstrate an improvement of the
recipient’s medical, behavioral, social and emotional well-being of the
effectiveness of all requested BH services that are recommended in meeting
the plan's stated rehabilitative goals and objectives documenting the
effectiveness at each reevaluation determined by the QMHP.
c. Requested Services:
1. Services: Identify the specific behavioral health service(s) (i.e., family
therapy, individual therapy, medication management, basic skills training,
day treatment, etc.) to be provided;
2. Scope of Services and Duration: Identify the daily amount, service duration
and therapeutic scope for each service to be provided;
3. Providers: Identify the provider or providers who are responsible for
implementation of each of the plan's goals, interventions and services;
4. Rehabilitative Services: Document that the services have been determined
to be rehabilitative services consistent with the regulatory definition;
5. Care Coordination: When multiple providers are involved, the plan must
identify and designate a primary care coordinator. The primary care
coordinator develops the care coordination plan between the identified BH
services and integration of other supportive services involved with a
recipient’s services;
6. Strength-Based Care: Collaboratively develop a treatment plan of care
involving the strengths of the recipient and family (when applicable);
7. Declined Services: If the recipient declines recommended service(s), this
act must be documented within the treatment plan.
d. Discharge Plan – A Treatment Plan must include a discharge plan that identifies:
1. The planned duration of the overall services to be provided under the
Treatment Plan;
2. Discharge criteria;
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3. Recommended aftercare services for goals that were both achieved and not
achieved during duration of the Treatment Plan;
4. Identify available agency(ies) and independent provider(s) to provide
aftercare services (i.e. community-based services, community
organizations, nonprofit agencies, county organization(s) and other
institutions) and the purpose of each for the recipient’s identified needs
under the Treatment Plan to ensure the recipient has access to supportive
aftercare.
4. Required Signatures and Identified Credentials
a. Signatures, along with the identified credentials, are required on all treatment plans,
modifications to treatment plans and reevaluations of treatment plans include:
1. The clinical supervisor and their credentials;
2. The recipient, recipient’s family or their legal representative (in the case of
legal minors and when appropriate for an adult);
3. The individual QMHP and their credentials responsible for developing and
prescribing the plan within the scope of their licensure.
5. Treatment Plan Reevaluation: A QMHP must evaluate and reevaluate the Treatment Plan
at a minimum of every 90 days or a shorter period as determined by the QMHP. Every
reevaluated Treatment Plan must include a brief analysis that addresses the services
recommended, the services actually provided pursuant to the recommendations, a
determination of whether the provided services met the developed goals and objectives of
those services and whether or not the recipient would continue to benefit from future
services and be signed by the QMHP.
a. If it is determined that there has been no measurable restoration of functioning, a
new recipient-centered treatment plan must be developed by the QMHP.
b. All recommendations and changes to the treatment goals, objectives, strategies,
interventions, frequency or duration; any change of individual providers, or any
recommendation to change individual providers; and the expected duration of the
medical necessity for the recommended changes must be identified in the new plan.
c. The new treatment plan must adhere to what is identified in Sections 403.2B(1) and
403.2B(2) under Individualized Treatment Plan and Treatment Plan Development.
6. Progress Notes: Progress notes for all BH services including RMH and OMH services are
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the written documentation of treatment services, or services coordination provided to the
recipient pursuant to the Treatment Plan, which describes the progress, or lack of progress
towards the goals and objectives of the Treatment Plan.
a. All progress notes documented with the intent of submitting a billable Medicaid
behavioral health service claim must be documented in a manner that is sufficient
to support the claim and billing of the services provided and must further document
the amount, scope and duration of the service(s) provided as well as identify the
provider of the service(s).
b. A Progress Note is required for each day the service was delivered, must be legible
and must include the following information:
1. The name of the individual receiving the service(s). If the services are in a
group setting, it must be indicated;
2. The place of service;
3. The date the service was delivered;
4. The actual beginning and ending times the service was delivered;
5. The name of the provider who delivered the service;
6. The credentials of the person who delivered the service;
7. The signature of the provider who delivered the service;
8. The goals and objectives that were discussed and provided during the time
the services were provided; and
9. A statement assessing the recipient's progress towards attaining the
identified treatment goals and objectives requested by the QMHP.
c. Temporary, but clinically necessary, services do not require an alteration of the
treatment plan; however, these types of services, and why they are required, must
be identified in a progress note. The note must follow all requirements for progress
notes as stated within this section.
7. Discharge Summary: Written documentation of the last service contact with the recipient,
the diagnosis at admission and termination, and a summary statement describing the
effectiveness of the treatment modalities and progress, or lack of progress, toward
treatment goals and objectives as documented in the Treatment Plan. The discharge
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summary documentation must include the reason for discharge, current intensity of needs
level and recommendations for further treatment.
a. Discharge summaries are to be completed no later than 30 calendar days following
a planned discharge and 45 calendar days following an unplanned discharge.
b. In the case of a recipient’s transfer to another program, a verbal summary must be
given by the current health professional at the time of transition and followed with
a written summary within seven calendar days of the transfer. This summary will
be provided with the consent from the recipient or the recipient’s legal
representative.
403.3 PROVIDER QUALIFICATIONS – OUTPATIENT MENTAL HEALTH SERVICES
A. QMHA - A person who meets the following documented minimum qualifications:
1. Licensure as a RN in the State of Nevada or holds a bachelor’s degree from an
accredited college or university in a human, social services or behavioral field with
additional understanding of RMH treatment services and case file documentation
requirements; or
2. Holds an associate degree from an accredited college or university in a human,
social services or behavioral field with additional understanding of RMH treatment
services, and case file documentation and has four years of relevant professional
experience of providing direct services to individuals with mental health disorders;
or
3. An equivalent combination of education and experience as listed in Section
403.3.A.1-2 above; and
4. Whose education and experience demonstrate the competency under clinical
supervision to:
a. Direct and provide professional therapeutic interventions within the scope
of their practice and limits of their expertise;
b. Identify presenting problem(s);
c. Participate in treatment plan development and implementation;
d. Coordinate treatment;
e. Provide parenting skills training;
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f. Facilitate discharge plans; and
g. Effectively provide verbal and written communication on behalf of the
recipient to all involved parties.
5. Has a Federal Bureau of Investigation (FBI) background check in accordance with
the Qualified Behavioral Aides (QBA) provider qualifications listed under Section
403.6A.
B. Qualified Mental Health Professional (QMHP) - A Physician, Physician’s Assistant or a
person who meets the definition of a QMHA and also meets the following documented
minimum qualifications:
1. Holds any of the following educational degrees and licensure:
a. Doctorate degree in psychology and license;
b. Bachelor's degree in nursing and Advanced Practitioners of Nursing (APN)
(psychiatry);
c. Independent Nurse Practitioner; Graduate degree in social work and clinical
license;
d. Graduate degree in counseling and licensed as a marriage and family
therapist or clinical professional counselor; or
2. Who is employed and determined by a state mental health agency to meet
established class specification qualifications of a Mental Health Counselor; and
3. Whose education and experience demonstrate the competency to: identify
precipitating events, conduct a comprehensive mental health assessment, diagnose
a mental or emotional disorder and document a current ICD diagnosis, determine
intensity of service’s needs, establish measurable goals, objectives and discharge
criteria, write and supervise a treatment plan and provide direct therapeutic
treatment within the scope and limits of their expertise.
4. Interns
Reimbursement for Interns/Psychological Assistants is based upon the rate of a QMHP,
which includes the clinical and direct supervision of services by a licensed supervisor.
Interns are excluded from functioning as a clinical supervisor.
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The following are also considered QMHPs:
a. LCSW Interns meet the requirements under a program of internship and are
licensed as an intern pursuant to the State of Nevada, Board of Examiners
for Social Workers (Nevada Administrative Code (NAC) 641B).
b. LMFT and Licensed Clinical Professional Counselor Interns who meet the
requirements under a program of internship and are licensed as an intern
pursuant to the State of Nevada Board of Examiners for Marriage and
Family Therapists and Clinical Professional Counselors.
C. Licensed Psychologists – A person licensed through the Nevada Board of Psychological
Examiners.
1. Psychologists licensed in Nevada through the Board of Psychological Examiners
may supervise Psychological Assistants, Psychological Interns and Psychological
Trainees pursuant to NRS and NAC 461. A Supervising Psychologist, as defined
by NRS and NAC 461, may bill on behalf of services rendered by those they are
supervising within the scope of their practice and under the guidelines outlined by
the Psychological Board of Examiners. Assistants, Interns and Trainees must be
linked to their designated Supervisor.
2. Psychological Assistants registered through the Nevada Board of Psychological
Examiners and has a designated licensed Psychologist through the Board of
Psychological Examiners may render and their supervisor may bill for their services
pursuant to NRS and NAC 461.
3. Psychological Interns registered through the Nevada Board of Psychological
Examiners and has a designated licensed Psychologist through the Board of
Psychological Examiners may render and their supervisor may bill for their services
pursuant to NRS and NAC 461.
4. Psychological Trainees registered through the Nevada Board of Psychological
Examiners and has a designated licensed Psychologist through the Board of
Psychological Examiners may render and their supervisor may bill for their services
pursuant to NRS and NAC 461.
403.4 OUTPATIENT MENTAL HEALTH SERVICES
These services include assessment and diagnosis, testing, basic medical and therapeutic services,
crisis intervention, therapy, partial and intensive outpatient hospitalization, medication
management and case management services. For case management services, refer to MSM Chapter
2500 for Non-SED and Non-SMI definitions, service requirements, service limitations, provider
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qualifications and documentation requirements.
A. Assessments are covered for problem identification (diagnosis) and to establish measurable
treatment goals and objectives by a QMHP or designated QMHA in the case of a Mental
Health Screen.
1. Mental Health Screen – A behavioral health screen to determine eligibility for
admission to treatment program.
2. Comprehensive Assessment – A comprehensive, evaluation of a recipient’s history
and functioning which, combined with clinical judgment, is to include a covered,
current ICD diagnosis and a summary of identified rehabilitative treatment needs.
Health and Behavior Assessment – Used to identify the psychological, behavioral,
emotional, cognitive and social factors important to the prevention, treatment or
management of physical health needs. The focus of the assessment is not on the
mental health needs, but on the biopsychosocial factors important to physical health
needs and treatments. The focus of the intervention is to improve the recipient’s
health and well-being utilizing cognitive, behavioral, social and/or psycho-
physiological procedures designed to ameliorate specific disease related needs.
This type of assessment is covered on an individual basis, family with the recipient
present or family without the recipient present.
3. Psychiatric Diagnostic Interview – Covered once per calendar year without prior
authorization. If there is a substantial change in condition, subsequent assessments
may be requested through a prior-authorization from the QIO-like vendor for
Nevada Medicaid. A psychiatric diagnostic interview may consist of a clinical
interview, a medical and mental history, a mental status examination, behavioral
observations, medication evaluation and/or prescription by a licensed psychiatrist.
The psychiatric diagnostic interview is to conclude with a written report which
contains a current ICD diagnosis and treatment recommendations.
4. Psychological Assessment – Covered once per calendar year without prior
authorization. If there is a substantial change in condition, subsequent assessments
may be requested through a prior-authorization from the QIO-like vendor for
Nevada Medicaid. A psychological assessment may consist of a clinical interview,
a biopsychosocial history, a mental status examination and behavioral observations.
The psychological assessment is to conclude with a written report which contains
a current ICD diagnosis and treatment recommendations.
5. Functional Assessment – Used to comprehensively evaluate the recipient’s skills,
strengths and needs in relation to the skill demands and supports required in the
particular environment in which the recipient wants or needs to function; as such,
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environment is consistent with the goals listed in the recipient’s individualized
treatment plan. A functional assessment is used to assess the presence of functional
strengths and needs in the following domains: vocational, education, self-
maintenance, managing illness and wellness, relationships and social.
A person-centered conference is covered as part of the functional assessment to
collaboratively develop and communicate the goals and objectives of the
individualized treatment plan. The conference must include the recipient, a QMHP,
family or legal representative, significant others and case manager(s). The case
manager(s) or lead case manager, if there are multiple case managers, shall provide
advocacy for the recipient’s goals and independence, supporting the recipient’s
participation in the meeting and affirming the recipient’s dignity and rights in the
service planning process.
6. Intensity of Needs Determination - A standardized mechanism to determine the
intensity of services needed based upon the severity of the recipient’s condition.
The intensity of needs determination is to be utilized in conjunction with the clinical
judgment of the QMHP and/or trained QMHA. This assessment was previously
known as a level of care assessment. Currently, the DHCFP recognizes the Level
of Care Utilization System (LOCUS) for adults and the Child and Adolescent
Screening Intensity Instrument (CASII) for children and adolescents. There is no
level of care assessment tool recognized by the DHCFP for children below age six,
however, providers must utilize a tool comparable to the CASII and recognized as
a standard of practice in determining the intensity of needs for this age group.
7. Severe Emotional Disturbance (SED) Assessment - Covered annually or if there is
a significant change in functioning. The SED assessment is a tool utilized to
determine a recipient’s eligibility for higher levels of care and Medicaid service
categories.
8. Serious Mental Illness (SMI) Assessment - Covered annually or if there is a
significant change in functioning. The SMI assessment is a tool utilized to
determine a recipient’s eligibility for higher levels of care and Medicaid service
categories.
B. Neuro-Cognitive, Psychological and Mental Status Testing
1. Neuropsychological testing with interpretation and report involves assessment and
evaluation of brain behavioral relationships by a neuropsychologist. The evaluation
consists of qualitative and quantitative measurement that consider factors such as
the interaction of psychosocial, personality/emotional, intellectual, environmental,
neurocognitive, biogenetic and neurochemical aspects of behaviors in an effort to
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understand more fully the relationship between physiological and psychological
systems. This service requires prior authorization from the QIO-like vendor.
2. Neurobehavioral testing with interpretation and report involves the clinical
assessment of thinking, reasoning and judgment, acquired knowledge, attention,
memory, visual spatial abilities, language functions and planning. This service
requires prior authorization.
3. Psychological testing with interpretation and report is the administration,
evaluation and scoring of standardized tests which may include the evaluation of
intellectual functioning, clinical strengths and needs, psychodynamics, insight,
motivation and other factors influencing treatment outcomes.
C. Mental Health Therapies
Mental health therapy is covered for individual, group and/or family therapy with the
recipient present and for family therapy without the recipient present and described as
follows:
1. Family Therapy
Mental health treatment service provided to a specific recipient by a QMHP using
the natural or substitute family as the means to facilitate positive family interactions
among individuals. The recipient does not need to be present for family therapy
services; however, the services must deal with issues relating to the constructive
integration/reintegration of the recipient into the family.
2. Group Therapy
Mental health treatment service facilitated by a QMHP within their scope of
licensure or practice, which utilizes the interactions of more than one individual
and the focus of the group to address behavioral health needs and interpersonal
relationships. The therapy must be prescribed on the treatment plan and must have
measurable goals and objectives. Group therapy may focus on skill development
for learning new coping skills, such as stress reduction, or changing maladaptive
behavior, such as anger management. Participation in group therapy must be
documented on the clinical record. Minimum group size is three and maximum
therapist to participant ratio is one to ten. Group therapy can be less than three but
more than one based on unforeseen circumstances such as a no-show or
cancellation but cannot be billed as individual therapy. Group therapy may also
include a family without the recipient present and/or multi-family groups.
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3. Individual Therapy Services
Mental health treatment service provided to a specific recipient for a presenting
need by an individual therapist for a specified period of time. The amount, scope
and duration of individual therapy services may vary depending on the stage of the
presenting mental health need, treatment program and recipient’s response to the
treatment approach. Individual is one recipient. Each direct one-on-one episode
must be of a sufficient length of time to provide the appropriate skilled treatment
in accordance with each patient’s treatment/rehabilitative plan.
D. Mental Health Therapeutic Interventions
1. Partial Hospitalization Program (PHP) – A restorative program encompassing
mental and behavioral health services and psychiatric treatment services designed
for recipients who require a higher intensity of coordinated, comprehensive and
multidisciplinary treatment for mental or substance use disorders. These services
are furnished under a medical model by a hospital in an outpatient setting or by a
Federally Qualified Health Center (FQHC) that assumes clinical liability and meets
the criteria of a Certified Mental Health Clinic (CMHC). A hospital or an FQHC
may choose to offer PHP through an enrolled SAPTA-certified clinic or an enrolled
BHCN agency/entity/group, and the hospital or FQHC must enter into a contract
with this provider which specifically outlines the roles and responsibilities of both
parties in providing this program. The contract must be submitted to the DHCFP
and reported to its fiscal agent prior to the delivery of these services to the recipient.
These services are intended to be an alternative to inpatient psychiatric care and are
generally provided to recipients experiencing an exacerbation of a severe and
persistent mental illness and/or substance use disorder. PHP services include active
therapeutic treatment and must be targeted to meet the goals of alleviating
impairments and maintaining or improving functioning to prevent relapse or
hospitalization. PHP is provided to individuals who are determined as Severely
Emotionally Disturbed (SED) or Seriously Mentally Ill (SMI), or as medically
necessary under the American Society of Addiction Medicine (ASAM) criteria.
a. Scope of Services: PHP services may include:
1. Individual Therapy
2. Group Therapy
3. Family Therapy
4. Medication Management
5. Medication Assisted Treatment
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6. Drug Testing
7. Occupational Therapy
8. Behavioral Health Assessment
9. Basic Skills Training
10. Psychosocial Rehabilitation
11. Peer-to-Peer Support Services
12. Crisis Services
PHP requires around-the-clock availability of 24/7 psychiatric and
psychological services. These services may not be billed separately as PHP
is an all-inclusive rate.
b. Service Limitations: PHP services are direct services provided in a
mental/behavioral health setting for at least three days per week and no
more than five days per week; each day must include at least four hours of
direct services as clinically indicated based on a patient-centered approach.
If more/fewer hours and/or more/fewer days are indicated, the recipient
should be reevaluated. PHP delivered through a BHCN will always require
prior authorization and must be reauthorized every three weeks.
c. PHP Utilization Management: Evaluation of the patient’s response to
treatment interventions and progress monitoring toward treatment plan
goals must include ongoing patient assessments, including intensity of
needs determinations using ASAM/LOCUS/CASII at regularly scheduled
intervals and whenever clinically indicated.
d. Provider Qualifications: Direct services are face-to-face interactive services
led by licensed staff and components of this service can be performed by
qualified, enrolled health care workers practicing within their scope under
the Direct Supervision of a QMHP-level professional, including Interns.
Interns can provide PHP services under Clinical Supervision. Direct
Supervision requires that a licensed professional practicing within the scope
of their Nevada licensure be onsite where services are rendered. Each
component of the PHP must be provided by enrolled and qualified
individuals within the scope of their practice.
e. Documentation: Patient assessments must document the individual patient
response to the treatment plan, progress toward goals, changes in identified
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goals and objective based on progress and substantiate continued stay at the
current intensity/frequency of services. Resolution of issues necessitates
transfer to a higher or lower intensity/frequency of services or discharge
from treatment as no longer meeting medical necessity at any level. Transfer
and discharge planning must be evidence-based and reflect best practices
recognized by professional and advocacy organizations and ensure
coordination of needed services, follow-up care and recovery supports. The
direct provider of each service component must complete documentation
for that component. Further information on documentation standards is
located within the section “Documentation” within this chapter.
f. Non-Covered Services in PHP include, but are not limited to:
1. Non-evidence-based models;
2. Transportation or services delivered in transit;
3. Club house, recreational, vocational, after-school or mentorship
program;
4. Routine supervision, monitoring or respite;
5. Participation in community-based, social-based support groups
(e.g., Alcoholics Anonymous, Narcotics Anonymous);
6. Watching films or videos;
7. Doing assigned readings; and
8. Completing inventories or questionnaires.
2. Intensive Outpatient Program (IOP) – A comprehensive interdisciplinary program
of direct mental/behavioral health services which are expected to improve or
maintain an individual’s condition and functioning level for prevention of relapse
or hospitalization. IOP is provided to individuals who are determined as Severely
Emotionally Disturbed (SED) or Seriously Mentally Ill (SMI), or as medically
necessary under the ASAM criteria. IOP group sizes are required to be four to 15
recipients.
a. Scope of Services: IOP may include the following direct services:
1. Individual Therapy
2. Group Therapy
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3. Family Therapy
4. Medication Management
5. Medication Assisted Treatment
6. Drug Testing
7. Occupational Therapy
8. Behavioral Health Assessment
9. Basic Skills Training
10. Psychosocial Rehabilitation
11. Peer-to-Peer Support Services
12. Crisis Services
IOP requires around-the-clock availability of 24/7 psychiatric and
psychological services. These services may not be billed separately as IOP
is an all-inclusive rate.
b. Service Limitations: IOP services delivered in a mental/behavioral health
setting are direct services provided three days per week, each day must
include at least three hours and no more than six hours of direct service
delivery as clinically indicated based on a patient-centered approach. If
more/fewer hours and/or more/fewer days are indicated, the recipient
should be reevaluated. IOP delivered through a BHCN will always require
prior authorization and must be reauthorized every three weeks.
c. IOP Curriculum and Utilization Management: A curriculum and a schedule
for the program delivered through a BHCN must be submitted with each
prior authorization request; this information may also be provided with
enrollment and the description of IOP services. The curriculum must outline
the service array being delivered including evidence-based practice(s), best
practice(s), program goals, schedule of program and times for service
delivery, staff delivering services, and population served in the program.
IOP program recipients must receive on-going patient assessments, at
regularly scheduled intervals and whenever clinically indicated, including
intensity of needs determinations using ASAM/LOCUS/CASII to evaluate
the recipient’s response to treatment interventions and to monitor progress
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toward treatment plan goals. Recipient assessments must document the
individual’s response to the treatment plan, identify progress toward
individual and program goals, reflect changes in identified goals and
objectives, and substantiate continued stay at the current
intensity/frequency of services. An updated treatment plan must be
completed to justify a transfer to a higher or lower intensity/frequency of
services or discharge from treatment as no longer meeting medical necessity
at any level.
d. Provider Qualifications: Direct services are face-to-face interactive services
provided by qualified, enrolled providers, including both licensed staff. and
other health care workers practicing within their scope under the Direct
Supervision of a QMHP-level professional, including Interns. Interns can
provide IOP services under Clinical Supervision. Direct Supervision
requires that a licensed professional practicing within the scope of their
Nevada licensure be onsite where services are rendered. Each component
of the IOP must be provided by enrolled and qualified individuals within
the scope of their practice.
e. Documentation: Patient assessments must document the individual patient
response to the treatment plan, progress toward goals, changes in identified
goals and objective based on progress and substantiate continued stay at the
current intensity/frequency of services. Resolution of issues necessitates
transfer to a higher or lower intensity/frequency of services or discharge
from treatment as no longer meeting medical necessity at any level.
Transfer and discharge planning must be evidence-based and reflect best
practices recognized by professional and advocacy organizations and
ensure coordination of needed services, follow-up care, and recovery
supports. The direct provider of each service component must complete
documentation for that component. Further information on documentation
standards is located within the section “Documentation” within this chapter.
f. Non-Covered services in IOP include, but are not limited to:
1. Non-evidence-based models;
2. Transportation or services delivered in transit;
3. Club house, recreational, vocational, after-school or mentorship
program;
4. Routine supervision, monitoring or respite;
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5. Participating in community based, social based support groups (i.e.
Alcoholics Anonymous, Narcotics Anonymous);
6. Watching films or videos;
7. Doing assigned readings; and
8. Completing inventories or questionnaires.
3. Medication Management – A medical treatment service using psychotropic
medications for the purpose of rapid symptom reduction, to maintain improvement
in a chronic recurrent disorder or to prevent or reduce the chances of relapse or
reoccurrence. Medication management must be provided by a psychiatrist or
physician licensed to practice in the State of Nevada and may include, through
consultation, the use of a physician’s assistant or a certified nurse practitioner
licensed to practice in the State of Nevada within their scope of practice.
Medication management may be used by a physician who is prescribing
pharmacologic therapy for a recipient with an organic brain syndrome or whose
diagnosis is in the current ICD section of Mental, Behavioral and
Neurodevelopmental Disorders and is being managed primarily by psychotropic
drugs. It may also be used for the recipient whose psychotherapy is being managed
by another mental health professional and the billing physician is managing the
psychotropic medication. The service includes prescribing, monitoring the effect of
the medication and adjusting the dosage. Any psychotherapy provided is minimal
and is usually supportive only. If the recipient received psychotherapy and drug
management at the same visit, the drug management is included as part of that
service by definition and medication management should not be billed in addition.
4. Medication Training and Support – This service must be provided by a professional
other than a physician and is covered for monitoring of compliance, side effects,
recipient education and coordination of requests to a physician for changes in
medication(s). To be reimbursed for this service, the provider must be enrolled as:
A QMHP, a LCSW, a LMFT or a CPC. A Registered Nurse (RN) enrolled as a
QMHA may also provide this service if billed with the appropriate modifier.
Medication Training and Support is a face-to-face documented review and
educational session by a qualified professional, focusing on a member's response
to medication and compliance with the medication regimen. The review must
include an assessment of medication compliance and medication side effects. Vital
signs must be taken including pulse, blood pressure and respiration and documented
within the medical or clinical record. A physician is not required to be present but
must be available for consult. Medication Training and Support is designed to
maintain the member on the appropriate level of the least intrusive medications,
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encourage normalization and prevent hospitalization. Medication Training and
Support may not be billed for members who reside in ICF/IID facilities.
a. Service Limitations: Cannot exceed two units per month (30 minutes), per
recipient without a prior authorization.
b. Documentation Requirements: Documentation must include a description
of the intervention provided and must include:
1. If recipient was present or not;
2. Recipient’s response to the medication;
3. Recipient’s compliance with the medication regimen;
4. Medication benefits and side effects;
5. Vital signs, which include pulse, blood pressure and respiration; and
6. Documented within the progress notes/medication record.
a. Non-covered services in Medication Training and Support include, but are
not limited to:
1. Medication Training and Support is not allowed to be billed the
same day as an evaluation and management (E/M) service provided
by a psychiatrist.
2. If medication management, counseling or psychotherapy is
provided as an outpatient behavioral health service, and medication
management is a component, Medication Training and Support may
not be billed separately for the same visit by the same provider.
3. Coaching and instruction regarding recipient self-administration of
medications is not reimbursable under this service.
4. Medication Training and Support may not be provided for
professional caregivers.
403.5 OUTPATIENT MENTAL HEALTH (OMH) SERVICES - UTILIZATION MANAGEMENT
A. INTENSITY OF NEEDS DETERMINATION
The assessed level of needs and the amount, scope and duration of RMH services required
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to improve or retain a recipient’s level of functioning or prevent relapse. The determination
cannot be based upon the habilitative needs of the recipient. Intensity of needs
determination is completed by a trained QMHP or QMHA. Intensity of needs
determinations are based on several components consistent with person and family
centered treatment/rehabilitation planning. Intensity of Needs redeterminations must be
completed every 90 days or anytime there is a substantial change in the recipient’s clinical
status.
These components include:
1. A comprehensive assessment of the recipient’s level of functioning; The clinical
judgment of the QMHP; and
2. A proposed treatment and/or rehabilitation plan.
B. INTENSITY OF NEEDS GRID
1. The intensity of needs grid is an approved Level of Care (LOC) utilization system,
which bases the intensity of services on the assessed needs of a recipient. The
determined level on the grid guides the interdisciplinary team in planning treatment
to improve or retain a recipient’s level of functioning or prevent relapse. Each
Medicaid recipient must have an intensity of needs determination completed prior
to approval to transition to more intensive services (except in the case of a physician
or psychologist practicing as independent providers). The intensity of needs grid
was previously referred to as level of services grid.
2. Intensity of Need for Children:
Child and Adolescent Service Service Criteria
Intensity Instrument (CASII)
Levels I • Significant Life Stressors and/or current ICD Codes, Z55-Z65,
Basic Services: Recovery R45.850 and R45.821 that does not meet SED criteria (excluding
Maintenance and Health dementia, intellectual disabilities and related conditions or a
Management primary diagnosis of a substance abuse disorder, unless these
conditions co-occur with a mental illness).
Level II • Current ICD diagnosis in Mental, Behavioral and
Outpatient Services Neurodevelopmental Disorders that does not meet SED criteria
(excluding Z55-Z65, R45.850 and R45.821 Codes, dementia,
intellectual disabilities and related conditions, or a primary
diagnosis of a substance abuse disorder, unless these conditions
co-occur with a mental illness).
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Level III • Current ICD diagnosis in Mental, Behavioral and
Intensive Outpatient Services Neurodevelopmental Disorders (excluding Z55-Z65, R45.850 and
R45.821 Codes, dementia, intellectual disabilities and related
conditions, or a primary diagnosis of a substance abuse disorder,
unless these conditions co-occur with a mental illness); and
• SED Determination.
Levels IV • Current ICD diagnosis in Mental, Behavioral and
Intensive Integrated Services Neurodevelopmental Disorders (excluding Z55-Z65, R45.850 and
R45.821 Codes, dementia, intellectual disabilities and related
conditions, or a primary diagnosis of a substance abuse disorder,
unless these conditions co-occur with a mental illness); and SED
Determination.
Level V • Current ICD diagnosis in Mental, Behavioral and
Non-secure, 24-hour Services Neurodevelopmental Disorders (excluding Z55-Z65, R45.850 and
with Psychiatric Monitoring R45.821 Codes, dementia, intellectual disabilities and related
conditions, or a primary diagnosis of a substance abuse disorder,
unless these conditions co-occur with a mental illness); and
• SED Determination; and
• Requires specialized treatment (e.g., sex offender treatment, etc.).
Level VI • Current ICD diagnosis in Mental, Behavioral and
Secure, 24-hour Services with Neurodevelopmental Disorders (excluding Z55-Z65, R45.850 and
Psychiatric Management R45.821 Codes, dementia, intellectual disabilities and related
conditions, or a primary diagnosis of a substance abuse disorder,
unless these conditions co-occur with a mental illness); and
• SED Determination; and
• Requires inpatient/secured LOC.
3. Intensity of Needs for Adults:
Level of Care Utilization Service Criteria
System for Adults (LOCUS)
Levels I • Current ICD diagnosis in Mental, Behavioral and
Basic Services: Recovery Neurodevelopmental Disorders, including Z55-Z65, R45.850 and
Maintenance and Health R45.821 Codes, that do not meet SMI criteria (excluding
Management dementia, intellectual disabilities and related conditions, or a
primary diagnosis of a substance abuse disorder, unless these
conditions co-occur with a mental illness).
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Level II • Current ICD diagnosis in Mental, Behavioral and
Low Intensity Community Neurodevelopmental Disorders, including Z55-Z65, R45.850 and
Based Services R45.821 Codes that do not meet SMI criteria (excluding dementia,
intellectual disabilities and related conditions, or a primary
diagnosis of a substance abuse disorder, unless these conditions
co-occur with a mental illness).
Level III • Current ICD diagnosis in Mental, Behavioral and
High Intensity Community Neurodevelopmental Disorders (excluding Z55-Z65, R45.850 and
Based Services (HCBS) R45.821 Codes, dementia, intellectual disabilities and related
conditions, or a primary diagnosis of a substance abuse disorder,
unless these conditions co-occur with a mental illness); and
• SMI determination.
Levels IV • Current ICD diagnosis in Mental, Behavioral and
Medically Monitored Neurodevelopmental Disorders (excluding Z55-Z65, R45.850 and
Non-Residential Services R45.821 Codes, dementia, intellectual disabilities and related
conditions, or a primary diagnosis of a substance abuse disorder,
unless these conditions co-occur with a mental illness); and
• SMI determination.
Level V • Current ICD diagnosis in Mental, Behavioral and
Medically Monitored Neurodevelopmental Disorders (excluding Z55-Z65, R45.850 and
Residential Services R45.821 Codes, dementia, intellectual disabilities and related
conditions, or a primary diagnosis of a substance abuse disorder,
unless these conditions co-occur with a mental illness); and
• SMI determination; and
• Requires specialized treatment (e.g. sex offender treatment, etc.).
Level VI • Current ICD diagnosis in Mental, Behavioral and
Medically Managed Neurodevelopmental Disorders (excluding Z55-Z65, R45.850 and
Residential Services R45.821 Codes, dementia, intellectual disabilities and related
conditions, or a primary diagnosis of a substance abuse disorder,
unless these conditions co-occur with a mental illness); and
• SMI determination; and
• Requires inpatient/secured LOC.
C. Utilization Management for outpatient mental health services is provided by the DHCFP
QIO-like vendor as follows:
1. For BHCN, all service limitations are based upon the Intensity of Needs Grid in the
definitions. The recipient must have an Intensity of Needs determination to
supplement clinical judgment and to determine the appropriate service utilization.
The provider must document in the case notes the level that is determined from the
Intensity of Needs grid;
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2. Independent psychologists are not subject to the service limitations in the Intensity
of Needs Grid. The following service limitations are for psychologists:
a. Assessments – two per calendar year, additional services require prior
authorization from the QIO-like vendor; and
b. Therapy (group, individual, family) – Up to 26 visits per calendar year are
allowed without prior authorization. Additional services require prior
authorization demonstrating medical necessity from the QIO-like vendor.
3. Independent psychiatrists are not subject to the service limitations in the Intensity
of Needs grid. No prior authorization is required for this particular provider.
4. Medicaid Behavioral Health Intensity of Needs for Children and Adolescents.
Child and Adolescent Service Intensity of Services
Intensity Instrument (CASII) (Per Calendar Year1)
Levels I • Assessment two total sessions (does not include Mental Health
Basic Services: Recovery Maintenance Screen)
and Health Management • Individual, Group or Family Therapy 10 total sessions;
• Medication Management six total sessions
Level II • Assessments: four total sessions (does not include Mental
Outpatient Services Health Screen)
• Individual, Group or Family Therapy: 26 total sessions
• Medication Management: eight total sessions
Level III All Level Two Services Plus:
Intensive Outpatient Services • Assessments: four total sessions (does not include Mental
Health Screen)
• Individual, Group or Family Therapy: 26 total sessions
• Medication Management: eight total sessions Intensive
Outpatient Program (IOP)
Levels IV All Level Three Services
Intensive Integrated Services • Assessments: four total sessions (does not include Mental
Health Screen)
• Individual, Group or Family Therapy: 26 total sessions
• Medication Management: eight total sessions
• Partial Hospitalization Program (PHP)
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Level V All Level Four Services
Non-secure, 24-Hour Services with • Assessments: four total sessions (does not include Mental
Psychiatric Monitoring Health Screen)
• Individual, Group or Family Therapy: 26 total sessions
• Medication Management: eight total sessions
• PHP
Level VI All level Five services
Secure, 24-Hour, Services with
Psychiatric Management
A PA demonstrating medical necessity will be required and may be requested from
the QIO-like vendor for additional services above the service limitations for all
levels.
a. Service provision is based on the calendar year beginning on January 1.
b. Sessions indicates billable codes for this service may include occurrence-
based codes, time-based or a combination of both. Session = each time this
service occurs regardless of the duration of the service.
5. Medicaid Behavioral Health Intensity of Needs for Adults.
Medicaid Behavioral Health Intensity Intensity of Service
of Needs for Adults. Level of Care (Per Calendar Year1)
Utilization System for Adults
(LOCUS)
Levels I • Assessment: two total sessions (does not include Mental Health
Basic Services - Screen)
Recovery Maintenance and Health • Individual, Group or Family Therapy: six total sessions
Management • Medication Management: six total sessions
Level II • Assessment: (two assessments; does not include Mental Health
Low Intensity Community Based Screen)
Services • Individual, Group or Family Therapy: 12 total sessions
• Medication Management: eight total sessions
Level III • Assessment (two assessments; does not include Mental Health
High Intensity Community Based Screen)
Services • Individual, Group and Family therapy: 12 total sessions
• Medication Management: 12 total sessions
• IOP
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Level IV • Assessment (two assessments; does not include Mental Health
Medically Monitored Non-Residential Screen)
Services • Individual, Group and Family Therapy: 16 total sessions
• Medication Management (12 sessions)
• PHP
Level V • Assessment (two assessments; does not include Mental Health
Medically Monitored Residential Screen)
Services • Individual, Group and Family therapy: 18 total sessions
• Medication Management (12 sessions)
• PHP
Level VI All Level Five Services
Medically Managed Residential
Services
A PA demonstrating medical necessity will be required and may be requested from
the QIO-like vendor for additional services above the service limitations for all
levels.
a. Service provision is based on the calendar year beginning on January 1.
b. Sessions indicates billable codes for this service may include occurrence-
based codes, time-based or a combination of both. Session = each time this
service occurs regardless of the duration of the service.
D. Non-Covered OMH Services
The following services are not covered under the OMH program for Nevada Medicaid and
NCU:
1. Services under this chapter for a recipient who does not have a covered, current ICD
diagnosis;
2. Therapy for marital problems without a covered, current ICD diagnosis;
3. Therapy for parenting skills without a covered, current ICD diagnosis;
4. Therapy for gambling disorders without a covered, current ICD diagnosis;
5. Custodial services, including room and board;
6. Support group services other than Peer Support Services;
7. More than one provider seeing the recipient in the same therapy session;
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8. Services not authorized by the QIO-like vendor if an authorization is required
according to policy; and
9. Respite.
403.6 PROVIDER QUALIFICATIONS
403.6A REHABILITATION MENTAL HEALTH (RMH) SERVICES
RMH services may be provided by specific providers who meet the following qualifications for
an authorized service:
1. QBA – Is a person who has an educational background of a high-school diploma or General
Education Development (GED) equivalent and has been determined competent by the
overseeing Clinical Supervisor, to provide RMH services. These services must be provided
under direct contract with a BHCN or Independent RMH provider. A QBA must have the
documented competencies to assist in the provision of individual and group rehabilitative
services under the Clinical Supervision of a QMHP and the Direct Supervision of a QMHP
or QMHA.
a. QBAs must also have experience and/or training in service provision to people
diagnosed with mental and/or behavioral health disorders and the ability to:
1. read, write and follow written and oral instructions;
2. perform RMH services as prescribed on the rehabilitation plan;
3. identify emergency situations and respond accordingly;
4. communicate effectively;
5. document services provided; and
6. maintain recipient confidentiality.
b. Competency and In-services Training
1. Before QBAs can enroll as Medicaid providers, they are required to
successfully complete an initial 16-hour training program. This training must
be interactive, not solely based on self-study guides or videotapes and should
ensure that a QBA will be able to interact appropriately with individuals with
mental health disorders. At a minimum, this training must include the
following core competencies:
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a. Case file documentation;
b. Recipient's rights;
c. Client confidentiality pursuant to state and federal regulations;
d. Communication skills;
e. Problem solving and conflict resolution skills;
f. Communication techniques for individuals with communication or
sensory impairments;
g. Cardiopulmonary Resuscitation (CPR) certification (certification
may be obtained outside the agency); and
h. Understanding the components of a Rehabilitation Plan.
2. QBAs must also receive, at a minimum, two hours of quarterly in-service
training. At a minimum, this training must include any combination (or
single competency) of the following competencies:
a. Basic living and self-care skills: The ability to help recipients learn
how to manage their daily lives, recipients learn safe and appropriate
behaviors;
b. Social skills: The ability to help recipients learn how to identify and
comprehend the physical, emotional and interpersonal needs of
others – recipients learn how to interact with others;
c. Communication skills: The ability to help recipients learn how to
communicate their physical, emotional and interpersonal needs to
others – recipients learn how to listen and identify the needs of others;
d. Parental training: The ability to facilitate parents’ abilities to continue
the recipient’s (child’s) RMH care in home and community-based
settings.
e. Organization and time management skills: The ability to help
recipients learn how to manage and prioritize their daily activities;
and/or
f. Transitional living skills: The ability to help recipients learn
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necessary skills to begin partial-independent and/or fully
independent lives.
3. For QBAs whom will also function as peer-to-peer supporters, their quarterly
in-service training must also include, at a minimum, any combination (or
single competency) of the following competencies:
a. The ability to help stabilize the recipient;
b. The ability to help the recipient access community based mental
and/or behavioral health services;
c. The ability to assist during crisis situations and interventions;
d. The ability to provide preventative care assistance; and/or
e. The ability to provide personal encouragement, self-advocacy,
self- direction training and peer mentoring.
c. Applicants must have an FBI criminal background check before they can enroll with
Nevada Medicaid as QBAs. Applicants must submit the results of their criminal
background checks to the overseeing BHCN and/or the Individual RMH provider
(who must also be a Clinical Supervisor). The BHCN and/or the individual RMH
provider must maintain both the requests and the results with the applicant’s
personnel records. Upon request, the BHCN and/or the individual RMH provider
must make the criminal background request and results available to Nevada
Medicaid (DHCFP) for review.
d. Refer to MSM Chapter 100, Medicaid Program, under Conditions of Participation
for all Providers. In addition, the following criteria will exclude applicants from
becoming an eligible provider:
1. Conduct or practice detrimental to the health or safety of the occupants or
employees of the facility or agency;
2. Any other offense determined by the DHCFP to be inconsistent with the best
interest of all recipients.
The BHCN or independent RMH provider upon receiving information resulting
from the FBI criminal background check, or from any other source, may not continue
to employ a person who has been convicted of an offense as listed above, and as
cited within MSM Chapter 100. If an applicant believes that the information
provided as a result of the FBI criminal background check is incorrect, he or she
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must immediately inform the BHCN or independent RMH provider or the DHCFP
(respectively) in writing. The BHCN or independent RMH provider or the DHCFP,
that is so informed within five days, may give the employee or independent
contractor a reasonable amount of time, but not more than 60 days, to provide
corrected information before denying an application, or terminating the employment
or contract of the person pursuant to this section.
e. Have had tuberculosis (TB) tests with negative results documented or medical
clearance as outlined in NAC 441.A375 prior to the initiation of service delivery.
Documentation of TB testing and results must be maintained in the BHCN or
independent RMH provider personnel record. TB testing must be completed initially
and annually thereafter. Testing and surveillance shall be followed as outlined in
NAC 441A.375.3.
f. The purpose of the annual training is to facilitate the development of specialized
skills or knowledge not included in the basic training and/or to review or expand
skills or knowledge included in the basic training. Consideration must be given to
topics suggested by recipients. Documentation of the completed training and
achieved competencies meeting this requirement must be maintained by the BHCN
or independent RMH provider. Training requirements may be waived if the QBA
can provide written verification of comparable education and training. The BHCN
or independent RMH provider must document the comparability of the written
verification to the QBA training requirements.
2. QMHA, refer to Section 403.3A.
3. QMHP, refer to Section 403.3B.
403.6B REHABILITATIVE MENTAL HEALTH (RMH) SERVICES
1. Scope of Service: RMH services must be recommended by a QMHP within the scope of
their practice under state law. RMH services are goal-oriented outpatient interventions that
target the maximum reduction of mental and/or behavioral health impairments and strive to
restore the recipients to their best possible mental and/or behavioral health functioning.
RMH services must be coordinated in a manner that is in the best interest of the recipient.
RMH services may be provided in a variety of community and/or professional settings. The
objective is to reduce the duration and scope of care to the least intrusive level of mental
and/or behavioral health care possible while sustaining the recipient’s overall health. All
RMH services must be directly and medically necessary. RMH services cannot be
reimbursed on the same day as Applied Behavior Analysis (ABA) services, refer to MSM
Chapter 1500.
Prior to providing RMH services, a QMHP must conduct a comprehensive assessment of
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an individual’s rehabilitation needs including the presence of a functional impairment in
daily living and a mental and/or behavioral health diagnosis. This assessment must be based
on accepted standards of practice and include a covered, current ICD diagnosis. The
assessing QMHP must approve a written Rehabilitation Plan. The rehabilitation strategy, as
documented in the Rehabilitation Plan, must be sufficient in the amount, duration and scope
to achieve established rehabilitation goals and objectives. Simultaneously, RMH services
cannot be duplicative (redundant) of each other. Providers must assure that the RMH
services they provide are coordinated with other servicing providers. Case records must be
maintained on recipients receiving RMH services. These case records must include and/or
indicate:
a. the recipient’s name;
b. progress notes must reflect the date and time of day that RMS services were
provided; the recipient’s progress toward functional improvement and the
attainment of established rehabilitation goals and objectives; the nature, content and
number of RMH service units provided; the name, credential(s) and signature of the
person who provided the RMH service(s). Progress notes must be completed after
each session and/or daily; progress notes are not required on days when RMH
services are not provided; a single progress note may include any/all the RMH
services provided during that day;
c. the recipients and their families/legal guardians (in the case of legal minors)
acknowledgement of their freedom to select a qualified Medicaid provider of their
choosing;
d. indications that the recipients and their families/legal guardians (in the case of legal
minors) were involved in all aspects care planning;
e. indications that the recipients and their families/legal guardians (in the case of legal
minors) are aware of the scope, goals and objectives of the RMH services made
available; and
f. the recipients and their families/legal guardians (in the case of legal minors)
acknowledgement that RMH services are designed to reduce the duration and
intensity of care to the least intrusive level of care possible while sustaining the
recipient’s overall health.
2. Inclusive Services: RMH services include Basic Skills Training (BST), Program for
Assertive Community Treatment (PACT), Day Treatment, Peer-to-Peer Support,
Psychosocial Rehabilitation (PSR) and Crisis Intervention (CI).
3. Provider Qualifications:
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a. QMHP: QMHPs may provide BST, PACT, Day Treatment, Peer-to-Peer Support,
PSR and CI services.
b. QMHA: QMHAs may provide BST, PACT, Day Treatment, Peer-to-Peer Support,
PSR services under the Clinical Supervision of a QMHP.
c. QBA: QBAs may provide BST services under the Clinical Supervision of QMHP
and the Direct Supervision of a QMHP/QMHA. QBAs may provide Peer-to-Peer
Support services under the Clinical/Direct Supervision of a QMHP.
4. Therapeutic Design: RMH services are adjunct (enhancing) interventions designed to
complement more intensive mental health therapies and interventions. While some
rehabilitative models predominately utilize RMH services, these programs must
demonstrate the comprehensiveness and clinical appropriateness of their programs prior to
receiving prior authorization to provide RMH services. RMH services are time-limited
services, designed to be provided over the briefest and most effective period possible.
Service limitations are designed to help prevent rehabilitation diminishing return by
remaining within reasonable age and developmentally appropriate daily limits. Also taken
into consideration are other social, educational and intensive mental health obligations and
activities. RMH services are planned and coordinated services.
5. Non-Covered Services: RMH services do not include (from CMS 2261-P):
a. RMH services are not custodial care benefits for individuals with chronic conditions
but should result in a change in status;
b. custodial care and/or routine supervision: Age and developmentally appropriate
custodial care and/or routine supervision including monitoring for safety, teaching
or supervising hygiene skills, age appropriate social and self-care training and/or
other intrinsic parenting and/or care giver responsibilities;
c. maintaining level of functioning: Services provided primarily to maintain a level of
functioning in the absence of RMH goals and objectives, impromptu non-crisis
interventions and routine daily therapeutic milieus;
d. case management: Conducting and/or providing assessments, care planning/
coordination, referral and linkage and monitoring and follow-up;
e. habilitative services;
f. services provided to individuals with a primary diagnosis of intellectual disabilities
and related conditions (unless these conditions co-occur with a mental illness) and
which are not focused on rehabilitative mental and/or behavioral health;
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g. cognitive/intellectual functioning: Recipients with sub-average intellectual
functioning who would distinctly not therapeutically benefit from RMH services;
h. transportation: Transporting recipients to and from medical and other
appointments/services;
i. educational, vocational or academic services: General and advanced private, public
and compulsory educational programs; personal education not related to the
reduction of mental and/or behavioral health problem; and services intrinsically
provided through the Individuals with Disabilities Education Improvement Act
(IDEA);
j. inmates of public institutions: To include detention facilities, forestry camps,
training schools or any other facility operated primarily for the detention of children
who are determined to be delinquent;
k. room and board: Includes housing, food, non-medical transportation and other
miscellaneous expenses, as defined below:
1. Housing expenses include shelter (mortgage payments, rent, maintenance
and repairs and insurance), utilities (gas, electricity, fuel, telephone and
water) and housing furnishings and equipment (furniture, floor coverings,
major appliances and small appliances);
2. Food expenses include food and nonalcoholic beverages purchased at
grocery, convenience and specialty store;
3. Transportation expenses include the net outlay on purchase of new and used
vehicles, gasoline and motor oil, maintenance and repairs and insurance;
4. Miscellaneous expenses include clothing, personal care items, entertainment
and reading materials;
5. Administrative costs associated with room and board;
l. non-medical programs: Intrinsic benefits and/or administrative elements of non-
medical programs, such as foster care, therapeutic foster care, child welfare,
education, childcare, vocational and prevocational training, housing, parole and
probation and juvenile justice;
m. services under this chapter for a recipient who does not have a covered, current ICD
diagnosis;
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n. therapy for marital problems without a covered, current ICD diagnosis;
o. therapy for parenting skills without a covered, current ICD diagnosis;
p. therapy for gambling disorders without a covered, current ICD diagnosis;
q. support group services other than Peer Support services;
r. more than one provider seeing the recipient in the same RMH intervention with the
exception of CI services;
s. respite care;
t. recreational activities: Recreational activities not focused on rehabilitative
outcomes;
u. personal care: Personal care services intrinsic to other social services and not related
to RMH goals and objectives; and/or
v. services not authorized by the QIO-like vendor if an authorization is required
according to policy.
6. Service Limitations: All RMH services require prior authorization by Medicaid’s QIO-Like
vendor. RMH services may be prior authorized up to 90-days.
a. Intensity of Need Levels I & II: Recipients may receive BST and/or Peer-to-Peer
services provided:
1. a covered, current ICD and CASII/LOCUS Levels I or II; and clinical
judgment; and
2. the overall combination does not exceed a maximum of two hours per day;
and
3. the services provided in combination may not exceed the maximum
individual daily limits established for each RMH service.
b. Intensity of Need Level III: Recipients may receive any combination of BST, PSR,
Day Treatment and/or Peer-to-Peer services provided:
1. a covered, current ICD and CASII/LOCUS Level III; and
2. SED or SMI determination; and
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3. clinical judgment; and
4. the overall combination does not exceed a maximum of four hours per day;
and
5. the services provided in combination may not exceed the maximum
individual daily limits established for each RMH service.
c. Intensity of Need Level IV: Recipients may receive any combination of BST, PSR,
Day Treatment and/or Peer-to-Peer services provided:
1. a covered, current ICD and CASII/LOCUS Level IV; and
2. SED or SMI determination; and
3. clinical judgment; and
4. the overall combination does not exceed a maximum of six hours per day;
and
5. the services provided in combination may not exceed the maximum
individual daily limits established for each RMH service.
d. Intensity of Need Levels V & VI: Recipients may receive any combination of BST,
PSR, day treatment and/or peer-to-peer services provided:
1. a covered, current ICD and CASII/LOCUS Levels V or VI; and
2. SED or SMI determination; and
3. clinical judgment; and
4. the overall combination does not exceed a maximum of eight hours per day;
and
5. the services provided in combination may not exceed the maximum
individual daily limits established for each RMH service.
e. Additional RMH Service Authorizations: Recipients may receive any combination
of additional medically necessary RMH services beyond established daily
maximums. Additional RMH services must be prescribed on the recipient’s
rehabilitation plan and must be prior authorized by Medicaid’s QIO-like vendor.
Additional RMH services authorizations may only be authorized for 30-day periods.
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These requests must include:
1. a lifetime history of the recipient’s inpatient psychiatric admissions; and
2. a 90-day history of the recipient’s most recent outpatient psychiatric
services; and
3. progress notes for RMH services provided over the most current two-week period.
7. Each authorization is for an independent period of time as indicated by the start and end
date of the service period. If a provider believes it is medically necessary for services to be
rendered beyond the scope (units, time period or both), of the current authorization, the
provider is responsible for the submittal of a new prior authorization request. It is
recommended that the new request be submitted 15 days prior to the end date of the existing
service period, so an interruption in services may be avoided for the recipient. In order to
receive authorization for RMH services all of the following must be demonstrated in the
rehabilitation plan and progress notes (if applicable).
a. The recipient will reasonably benefit from the RMH service or services requested;
b. The recipient meets the specific RMH service admission criteria;
c. The recipient possesses the ability to achieve established treatment goals and
objectives;
d. The recipient and/or their family/legal guardian (in the case of legal minors) desire
to continue the service;
e. The recipient’s condition and/or level of impairment does not require a more or less
intensive level of service;
f. The recipient does not require a level of structure, intensity and/or supervision
beyond the scope of the RMH service or services requested; and
g. The retention of the RMH service or services will reasonably help prevent the
discomposure of the recipient’s mental and/or behavioral health and overall well-
being.
8. Exclusion and Discharge Criteria: Prior authorization will not be given for RMH services
if any of the following apply:
a. The recipient will not reasonably benefit from the RMH service or services
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requested;
b. The recipient does not continue to meet the specific RMH service admission criteria;
c. The recipient does not possess the ability to achieve established rehabilitation goals
and objectives;
d. The recipient demonstrates changes in condition, which warrants a more or less
intensive level of services;
e. The recipient and/or their family/legal guardian (in the case of legal minors) do not
desire to continue the service;
f. The recipient presents a clear and imminent threat of serious harm to self and/or
others (recipient presents the intent, capability and opportunity to harm themselves
and others); The recipient’s condition and/or level of impairment requires a more
intensive level of service; and
g. The retention of the RMH service or services will not reasonably help prevent the
discomposure of the recipient’s mental and/or behavioral health and overall
wellbeing.
403.6C BASIC SKILLS TRAINING (BST) SERVICES
1. Scope of Service: BST services are RMH interventions designed to reduce cognitive and
behavioral impairments and restore recipients to their highest level of functioning. BST
services are provided to recipients with age and developmentally inappropriate cognitive
and behavioral skills. BST services help recipients acquire (relearn) constructive cognitive
and behavioral skills through positive reinforcement, modeling, operant conditioning and
other training techniques. BST services reteach recipients a variety of life skills. BST
services may include the following interventions:
a. Basic living and self-care skills: Recipients learn how to manage their daily lives,
recipients learn safe and appropriate behaviors;
b. Social skills: Recipients learn how to identify and comprehend the physical,
emotional and interpersonal needs of others-recipients learn how to interact with
others;
c. Communication skills: Recipients learn how to communicate their physical,
emotional and interpersonal needs to others. Recipients learn how to listen and
identify the needs of others;
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d. Parental training: Parental training teaches the recipient’s parent(s) and/or legal
guardian(s) BST techniques. The objective is to help parents continue the recipient’s
RMH care in home and community-based settings. Parental training must target the
restoration of recipient’s cognitive and behavioral mental health impairment needs.
Parental training must be recipient centered;
e. Organization and time management skills: Recipients learn how to manage and
prioritize their daily activities; and/or
f. Transitional living skills: Recipients learn necessary skills to begin partial-
independent and/or fully independent lives.
2. Provider Qualifications:
a. QMHP: QMHPs may provide BST services. QMHA: QMHAs may provide BST
services under the clinical supervision of a QMHP.
b. QBA: QBAs may provide BST services under the clinical supervision of QMHP and
the direct supervision of a QMHP or QMHA.
3. Service Limitations: All BST services must be prior authorized. Up to two hours of BST
services per day for the first 90 consecutive days, one hour per day for the next 90
consecutive days and anything exceeding current service limitations above 180 consecutive
days would require a prior authorization meeting medical necessity. Any service limitations
may be exceeded with a prior authorization demonstrating medical necessity. Services are
based on a calendar year. Prior authorizations may not exceed 90-day intervals.
If a recipient has been receiving BST services for six consecutive months, the provider
must validate that continued services are reasonable and necessary. To be considered
reasonable and necessary, the following conditions must be met:
a. Expectation that the patient’s condition will improve significantly in a reasonable
and predictable period of time, or the services must be necessary for the
establishment of a safe and effective rehabilitative therapeutic design required in
connection with a specific disease state.
b. The amount, frequency and duration of BST must be reasonable under accepted
standards of practice.
c. If the rehabilitation plan goals have not been met, the re-evaluation of the
rehabilitation/treatment plan must reflect a change in the goal, objectives, services
and methods and reflect the incorporation of other medically appropriate services
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such as outpatient mental health services.
d. Documentation demonstrates a therapeutic benefit to the recipient by reflecting the
downward titration in units of service. The reduction in services should demonstrate
the reduction in symptoms/behavioral impairment.
BST services are based on the below daily maximums:
Service Limitations Children: CASII Adults: LOCUS
Levels I, II, III, IV, V Maximum of two hours per day Maximum of two hours per day
for the first 90 days. This service for the first 90 days. This service
limitation may be exceeded with a limitation may be exceeded with a
prior authorization demonstrating prior authorization demonstrating
medical necessity. medical necessity.
Levels I, II, III, IV, V Maximum of one hour per day for Maximum of one hour per day for
the next 90 days. This service the next 90 days. This service
limitation may be exceeded with a limitation may be exceeded with a
prior authorization demonstrating prior authorization demonstrating
medical necessity. medical necessity.
Levels I, II, III, IV, V Service limits exceeding two 90- Service limits exceeding two 90-
day intervals may be overridden day intervals may be overridden
with a prior authorization meeting with a prior authorization meeting
medical necessity. medical necessity.
4. Admission Criteria: The recipient and at least one parent and/or legal guardian (in the case
of legal minors) with whom the recipient is living must be willing to participate in home
and community based services; and assessment documentation must indicate that the
recipient has substantial impairments in any combination of the following areas:
a. Basic living and self-care skills: Recipients are experiencing age inappropriate
deficits in managing their daily lives and are engaging in unsafe and inappropriate
behaviors;
b. Social skills: Recipients are experiencing inappropriate deficits in identifying and
comprehending the physical, emotional and interpersonal needs of others;
c. Communication skills: Recipients are experiencing inappropriate deficits in
communicating their physical, emotional and interpersonal needs to others;
d. Organization and time management skills: Recipients are experiencing
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inappropriate deficits managing and prioritizing their daily activities; and/or
e. Transitional living skills: Recipients lack the skills to begin partial-independent
and/or fully independent lives.
403.6D PROGRAM FOR ASSERTIVE COMMUNITY TREATMENT (PACT)
1. A multi-disciplinary team-based approach of the direct delivering of comprehensive and
flexible treatment, support and services within the community. The team must be
composed of at least one QMHP and one other QMHP, QMHA or peer supporter.
2. PACT is for individuals who have the most serious and intractable symptoms of a severe
mental illness and who, consequently, have the greatest difficulty with basic daily
activities, keeping themselves safe, caring for their basic physical needs or maintaining a
safe and affordable place to live and require interventions that have not been effectively
addressed by traditional, less intensive services.
3. Services are available 24 hours a day, seven days per week. Team members may interact
with a person with acute needs multiple times a day. As the individual stabilizes, contacts
decrease. This team approach is facilitated by daily team meetings in which the team is
briefly updated on each individual. Activities for the day are organized and team members
are available to one another throughout the day to provide consultation or assistance. This
close monitoring allows the team to quickly adjust the nature and intensity of services in
response to individuals’ changing needs. PACT is reimbursed as unbundled services.
403.6E RESERVED
403.6F PEER-TO-PEER SERVICES
1. Scope of Service: Peer-to-peer support services are RMH interventions designed to reduce
social and behavioral impairments and restore recipients to their highest level of
functioning. peer-to-peer supporters (e.g. peer supporters) help the recipient live, work,
learn and participate fully in their communities. Peer-to-peer services must be delivered
directly to recipients and must directly contribute to the restoration of recipient’s diagnosis
mental and/or behavioral health condition. Peer-to-peer services may include any
combination of the following:
a. Helping stabilize the recipient;
b. Helping the recipient access community based mental and/or behavioral health
services;
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c. Assisting during crisis situations and interventions;
d. Providing preventative care assistance; and/or
2. Providing personal encouragement, self-advocacy, self-direction training and peer
mentoring.
Provider Qualifications: A peer supporter is a qualified individual who is currently or was
previously diagnosed with a mental and/or behavioral health disorder and who possess the
skills and abilities to work collaboratively with and under the clinical and direct supervision
of a QMHP. The selection of the supporter is based on the best rehabilitation interest of the
recipient. A peer supporter cannot be the legal guardian or spouse of the recipient. At a
minimum, a peer supporter must meet the qualifications for a QBA. Peer supporters are
contractually affiliated with a BHCN, independent professional (Psychologists and
Psychiatrists), or individual RMH providers may provide services to any eligible Medicaid-
recipient, if determined appropriate in the treatment planning process.
3. Service Limitation: All peer-to-peer services require prior authorization by Medicaid’s
QIO-like vendor. Prior authorizations may not exceed 90-day intervals. Peer-to-peer
service limits are based on the below 30-day maximums.
Service Limitations Children: CASII Adults: LOCUS
Levels I to II Maximum of six hour per 90-day Maximum of six hour per 90-day
period period
Level III Maximum of nine hour per 90-day Maximum of nine hours per 90-
period day period
Levels IV to VI Maximum of 12 hours per 90-day Maximum of 12 hours per 90-day
period period
4. Admission Criteria: Clinical documentation must demonstrate that the recipient meets all
of the following:
a. The recipient would benefit from the peer supporter’s understanding of the skills
needed to manage their mental and/or behavioral health symptoms and for
utilization of community resources;
b. The recipient requires assistance to develop self-advocacy skills;
c. The recipient requires peer modeling in order to take increased responsibilities for
his/her own recovery; and
d. Peer-to-peer support services would be in the best interest of the recipient and
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would most likely improve recipient’s mental, behavioral and overall health.
403.6G PSYCHOSOCIAL REHABILITATION (PSR) SERVICES
1. Scope of Service: PSR services are RMH interventions designed to reduce psychosocial
dysfunction (i.e., interpersonal cognitive, behavioral development, etc.) and restore
recipients to their highest level of functioning. PSR services target psychological
functioning within a variety of social settings.
PSR services may include any combination of the following interventions:
a. Behavior management: Recipients learn how to manage their interpersonal,
emotional, cognitive and behavioral responses to various situations. They learn how
to positively reflect anger, manage conflicts and express their frustrations verbally.
They learn the dynamic relationship between actions and consequences;
b. Social competency: Recipients learn interpersonal-social boundaries and gain
confidence in their interpersonal-social skills;
c. Problem identification and resolution: Recipients learn problem resolution
techniques and gain confidence in their problems solving skills;
d. Effective communication: Recipients learn how to genuinely listen to others and
make their personal, interpersonal, emotional and physical needs known;
e. Moral reasoning: Recipients learn culturally relevant moral guidelines and
judgment;
f. Identity and emotional intimacy: Recipients learn personal and interpersonal
acceptance. They learn healthy (appropriate) strategies to become emotionally and
interpersonally intimate with others;
g. Self-sufficiency: Recipients learn to build self-trust, self-confidence and/or self-
reliance;
h. Life goals: Recipients learn how to set and achieve observable specific, measurable,
achievable, realistic and time-limited life goals; and/or
i. Sense of humor: Recipients develop humorous perspectives regarding life’s
challenges.
2. Provider Qualifications:
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a. QMHP: QMHPs may provide PSR services.
b. QMHA: QMHAs may provide PSR services under the Clinical Supervision of a
QMHP.
c. QBA: QBAs may not provide PSR services.
3. Service Limitations: All PSR services require prior authorization by Medicaid’s QIO-like
vendor. Prior authorizations may not exceed 90-day intervals. PSR services are based on
the below daily maximums.
Service Limitations Children: CASII Adults: LOCUS
Levels I & II No services authorized No services authorized
Level III Maximum of two hours per day Maximum of two hours per day
Levels IV & V Maximum of three hours per day Maximum of three hours per day
Level VI Maximum of four hours per day Maximum of four hours per day
4. Admission Criteria: At least one parent or a legal guardian (in the case of legal minors)
with whom the recipient is living must be willing to participate in home and community-
based services; and the recipient must have substantial deficiencies in any combination of
the following criteria:
a. Behavior management: Recipients are experiencing severe deficits managing their
responses (viz., interpersonal, emotional, cognitive and behavioral) to various
situations. Recipients cannot age appropriately manage conflicts, positively
channel anger or express frustration verbally. They do not understand the
relationship between actions and consequences;
b. Social competency: Recipients are experiencing severe deficits navigating
interpersonal-social boundaries. They lack confidence in their social skills;
c. Problem identification and resolution: Recipients are experiencing severe deficits
resolving personal and interpersonal problems;
d. Effective communication: Recipients need to learn how to listen to others and make
their needs known to others. They cannot effectively communicate their personal,
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interpersonal, emotional and physical needs;
e. Moral reasoning: Recipients are experiencing severe deficits in culturally relevant
moral judgment;
f. Identity and emotional intimacy: Recipients are experiencing severe deficits with
personal and interpersonal acceptance. They avoid and/or lack the ability to become
emotionally and interpersonally intimate with other people;
g. Self-sufficiency: Recipients are experiencing severe deficits with self-confidence,
self-esteem and self-reliance; recipients express feelings of hopelessness and
helplessness; dealing with anxiety: Recipients are experiencing severe deficits
managing and accepting anxiety, they are fearful of taking culturally normal and
healthy rehabilitative risks;
h. Establishing realistic life goals: Recipients are experiencing severe deficits setting
and achieving realistic life goals; and/or
i. Sense of humor: Recipients are experiencing severe deficits seeing or
understanding the various humorous perspectives regarding life’s challenges.
403.6H CRISIS INTERVENTION (CI) SERVICES
1. Scope of Services: CI services are RMH interventions that target urgent situations where
recipients are experiencing acute psychiatric and/or personal distress. The goal of CI
services is to assess and stabilize situations (through brief and intense interventions) and
provide appropriate mental and behavioral health service referrals. The objective of CI
services is to reduce psychiatric and personal distress, restore recipients to their highest
level of functioning and help prevent acute hospital admissions. CI interventions may be
provided in a variety of settings, including but not limited to psychiatric emergency
departments, emergency rooms, homes, foster homes, schools, homeless shelters, while in
transit and telephonically. CI services do not include care coordination, case management,
or targeted case management services (see MSM Chapter 2500, Targeted Case
Management).
CI services must include the following:
a. Immediate and intensive interventions designed to help stabilize the recipient and
prevent hospitalization;
b. Conduct situational risk-of-harm assessment;
c. Follow-up and de-briefing sessions to ensure stabilization, continuity of care and
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identification of referral resources for ongoing community mental and/or
behavioral health services.
2. Provider Qualifications: QMHPs may provide CI services. If a multidisciplinary team is
used, the team must be led by a QMHP. The team leader assumes professional liability
over the CI services rendered.
3. Service Limitations: Recipients may receive a maximum of four hours per day over a three-
day period (one occurrence) without prior authorization. Recipients may receive a
maximum of three occurrences over a 90-day period without prior authorization.
Service Limitations Children: CASII Adults: LOCUS
Levels I to VI • Maximum of four hours per day • Maximum of four hours per day
over a three-day period (one over a three-day period (one
occurrence) occurrence)
• Maximum of three occurrences • Maximum of three occurrences
over a 90-day period over a 90-day period
4. Admission Criteria: Clinical documentation must demonstrate that the recipient meets any
combination of the following:
a. Recipient’s behavior requires immediate and intensive interventions to help
stabilize the current situation and prevent hospitalization;
b. Recipient presents a moderate risk of danger to themselves and others (or to
deteriorate to this dysfunctional level);
c. Recipient’s immediate behavior is unmanageable by family and/or community
members; and/or
d. Recipient will benefit from the stabilization, continuity of care and the referrals for
ongoing community mental and/or behavioral health services.
403.7 OUTPATIENT ALCOHOL AND SUBSTANCE ABUSE SERVICES POLICY
Outpatient substance abuse services may be provided by a QHMP within the scope of their practice
under state law and expertise.
403.7A COVERAGE AND LIMITATIONS
1. Nevada Medicaid reimburses the following:
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a. Outpatient alcohol/substance abuse treatment services within the context of
services discussed in Section 403.4 of this Chapter (individual and family therapy
is limited to one hour per session. Group therapy is limited to two hours per
session).
b. Psychiatrist (MD) – Office and clinic visits provided by a psychiatrist are a
Medicaid benefit. There are no limitations to services and prior authorization is not
required.
c. Psychologist – Initial office and clinic visits for psychological evaluation and
testing require a signed referral from a physician, licensed QMHP or a signed
referral through a Healthy Kids (EPSDT) screening. All services (psychological
evaluation, testing and subsequent individual, group and family therapies) provided
by psychologists must be prior authorized using the PAR form. For children under
age 21 services beyond 26 sessions per calendar year may only be provided if:
1. prior authorized by the QIO-like vendor; or
2. resulted from an EPSDT referral.
Testing services may also include an initial psychological evaluation.
d. APN – Office and clinic visits provided by an APN are a Medicaid benefit. There
are no limitations to services and prior authorization is not required.
e. Psychiatric/Psychological Evaluations – This service is covered once, at the onsite
of an illness or suspected illness. It may be utilized for the same recipient but only
if a new episode or illness occurs after a hiatus, or admission or readmission to
inpatient status due to complications of an underlying condition. Individual therapy
services require prior authorization. The individual sessions are limited to a
maximum of one hour per session and 26 sessions per calendar year, unless it is the
result of a Healthy Kids (EPSDT) screening. When requesting the therapy, the
provider needs to submit a psychological evaluation or summary with a treatment
plan and requested frequency. Approval is usually given for three months at a time.
When requesting additional therapy, the provider needs to submit a progress report
and include the number of attended sessions. It is the responsibility of the provider
to keep track of the sessions.
f. Group Therapy Services – Group therapy services require prior authorization.
These sessions are limited to a maximum of two hours. Each session counts against
the 26 hours per calendar year unless there is a Healthy Kids (EPSDT) screening.
Group therapy sessions may be requested on an alternate schedule with individual
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therapy. The provider needs to document what the recipient did, how the focus of
the group applies to the diagnosis in their progress report and how the plan of
therapy is being met. The provider will need to include the number of attended
sessions.
g. Family Therapy Services – Family therapy services require prior authorization and
are a benefit only when the recipient is present during the therapy. These sessions
are limited to a maximum of one hour and count against the 26 sessions per calendar
year unless there is a Healthy Kids (EPSDT) screening. Family therapy may be
requested with individual therapy, but frequency must be included for each therapy.
If additional therapy is requested after the initial request and approval, the provider
needs to submit a progress report, number of attended sessions and plan of
treatment.
h. Individual Therapy Services – Individual therapy services require prior
authorization. The sessions are limited to a maximum of one hour and to 26 sessions
in a calendar year, unless it is the result of a Healthy Kids (EPSDT) screening.
When requesting the therapy, the provider needs to submit a psychological
evaluation or summary with a treatment plan and requested frequency. Approval is
usually given for three months at a time. When requesting additional therapy, the
provider needs to submit a progress report and include the number of attended
sessions. It is the responsibility of the provider to keep track of the sessions.
2. Other Covered Services
Please consult Section 403.10 of this chapter for other covered services.
3. Non-Covered Services
Please consult Section 403.5B of this chapter for all non-covered services.
4. Billing
For enrollment, prior authorization and billing instructions, please refer to the billing
manual for Provider Types 11 and 13, located on the QIO-like vendor website.
403.7B PROVIDER RESPONSIBILITIES
Providers are responsible for:
1. Verifying Medicaid eligibility.
2. Submitting PARs to Medicaid's QIO-like vendor for purposes of obtaining prior
authorization.
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3. Appropriate billing procedures and code usage.
403.7C RECIPIENT RESPONSIBILITIES
1. Medicaid recipients are required to provide their Medicaid card to their service providers.
2. Medicaid recipients are expected to comply with the service provider’s treatment, care and
service plans, including making and keeping medical appointment.
403.7D AUTHORIZATION PROCESS
Prior authorization for psychological services is secured through Medicaid's QIO-like vendor by
submitting a PA with substantiating documentation which must include the diagnosis, an
evaluation or problem summary denoting the severity of presenting problems or functional
disability. Specific, realistically attainable and measurable goals, and anticipated frequency and
duration of treatment must be documented. Authorizations may be granted for a period of 90 days
(i.e., once per week times 12 weeks). To continue the payment process necessitates a new payment
authorization request and approval, progress notes and number of sessions seen.
Psychiatrist/Psychologist led group therapy counts as an office visit and meets the same limitation
criteria. Reimbursement for individuals age 21 years and older are limited to 26 individual, group
and/or family sessions in a calendar year for psychiatrists and psychologists.
All other specific authorization requirements are addressed earlier in this chapter in Section
403.5A, Coverage and Limitations.
403.8 RESIDENTIAL TREATMENT CENTER (RTC) SERVICES
A. RTC services are delivered in psychiatric, medical-model facilities, in- or out-of-state, that
are accredited by the Joint Commission, the Commission on Accreditation of
Rehabilitation Facilities (CARF) or the Council on Accreditation of Services for Families
and Children (COA) and licensed as an RTC within their state. RTC services are for
recipients under age 21 and must be provided before the individual reaches age 21. If the
individual was receiving services in an RTC immediately before reaching age 21, these
must be provided before:
1. the date the individual no longer requires the services; or
2. the date the individual reaches 22; and
3. is certified in writing to be necessary in the setting in which it will be provided.
B. The objective of RTC services is to assist recipients who have behavioral, emotional,
psychiatric and/or psychological disorders, or conditions, who are no longer at or
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appropriate for an acute level of care, or who cannot effectively receive services in a less
restrictive setting and who meet medical necessity and admission criteria for RTC services.
RTCs are part of the mental health continuum of care and are an integral part of Nevada
Medicaid’s behavioral health system of care. Recipients who respond well to treatment in
an RTC are anticipated to be discharged to a lower level of care, such as intensive home
and community-based services, or to the care of a psychiatrist, psychologist or other
QMHP.
All Medicaid policies and requirements for RTC’s (such as prior authorization, etc.) are
the same for NCU, except where noted in the NCU Manual, Chapter 1000.
C. Medicaid Behavioral Health Intensity of Needs for Children and Adolescents:
Child and Adolescent Children: CASII Adults: LOCUS
Service Intensity
Instrument (CASII)
Levels I to V Not Authorized Not Authorized
Level VI Accredited Residential Not Authorized
Secure, 24 Hour, Treatment Center
Services with (RTC)
Psychiatric
Management
403.8A COVERAGE AND LIMITATIONS
1. Nevada Medicaid’s all-inclusive RTC daily rate includes room and board, active treatment,
psychiatric services, psychological services, therapeutic and behavioral modification
services, individual, group, family, recreation and milieu therapies, nursing services, all
medications, quarterly RTC-sponsored family visits, psycho-educational services and
supervised work projects.
2. The all-inclusive daily rate does not include general physician (non-psychiatrist) services,
neuropsychological, dental, optometry, durable medical equipment, radiology, lab and
therapies (physical, speech and occupational) or formal educational services. Services that
are Medicaid benefits must be billed separately by the particular service provider and may
require prior authorization.
3. The QIO-like vendor may authorize all RTC stays, both Fee-for-Service and Health
Maintenance Organization (HMO) (see MSM Chapter 3600) Medicaid in three-month (or
less) increments. For Medicaid recipients to remain in RTCs longer than three months, the
RTC must, prior to the expiration of each authorization, submit a Continuing Stay Request
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to the QIO-like vendor for authorization.
4. For recipients under the age of 21 in the custody of a public child welfare agency, Nevada
Medicaid will reimburse for prior authorized RTC services only when the public child
welfare agency has also approved the admission.
5. Criteria for Exclusion from RTC Admission
One or more of the following criteria must be met which prohibit the recipient from
benefiting rehabilitatively from RTC treatment or involve the RTC’s inability to provide a
necessary specialized service or program, clinical decisions will be made individually on a
case-by-case basis:
a. Psychiatric symptoms requiring acute hospitalization;
b. The following conditions which limits the recipient’s ability to fully participate in
RTC services and cannot be reasonably accommodated by the RTC;
1. Physical Disability;
2. Learning Capacity;
3. Traumatic Brain Injury (TBI);
4. Organic brain syndrome;
c. Pregnancy, unless the RTC can appropriately meet the needs of the adolescent,
including obtaining prenatal care while in the facility. In the case of the birth of the
infant while the recipient is in the RTC, planning for the infant’s care is included
in the discharge plan. (In such an instance the infant would be covered individually
by Medicaid for medically necessary costs associated with medical care);
d. Chronic unmanageable violent behavior incompatible with RTC services which
poses unacceptable and unsafe risks to other clients or staff for any reason (i.e., a
danger to self, others or property);
e. Medical illness which limits the recipient’s ability to fully participate in RTC
services and is beyond the RTC’s capacity for medical care;
f. Drug and/or alcohol detoxification is required as a primary treatment modality
before a recipient can benefit rehabilitatively from RTC services; or
g. A diagnosis of Oppositional Defiant Disorder (ODD) and/or Conduct Disorder,
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alone and apart from any other covered, current ICD diagnosis.
6. RTC Therapeutic Home Passes
RTC Therapeutic Home Passes are to be utilized to facilitate a recipient’s discharge back
to their home or less restrictive setting. RTC recipients are allowed to utilize Therapeutic
Home Passes based on individualized treatment planning needs and upon the
recommendations of the RTC clinical treatment team. A total of three Therapeutic Home
Passes are allowed per calendar year and Therapeutic Home Passes cannot be accumulated
beyond a calendar year period. Duration per pass is no greater than 72 hours unless there
is a documented medically necessary reason for a longer-term pass. The QIO-like vendor
must be notified by the RTC of all therapeutic home passes at least 14 days prior to the
pass being issued to the recipient. The notification form can be located on the QIO-like
vendor website. All passes which exceed 72 hours must be prior authorized by the QIO-
like vendor.
a. The following guidelines must be adhered to for reimbursement. Failure to follow
these guidelines will result in non-payment to RTCs during the time the recipient
was away on a Therapeutic Home Pass:
1. A physician’s order is required for all Therapeutic Home Passes. If it is
clinically appropriate for the recipient to travel alone, this must be specified
in the physician’s order.
2. A Therapeutic Home Pass will only occur within 90 days of the recipient’s
planned discharge and in coordination with their discharge plan. The
recipient must have demonstrated a series of successful incremental day
passes before the Therapeutic Home Pass occurs. The recipient must also
be in the final phase of treatment in the RTC program.
3. Therapeutic Home Pass information which verifies days used must be
documented in the recipient’s case file and must include: dates for each
pass, location of the pass, treatment objectives to be met by use of each pass
and the total number of days used per calendar year. A copy of the physician
order for each pass must also be maintained in the recipient’s clinical case
file.
4. The RTC must track the number of Therapeutic Home Passes used as the
QIO-like vendor will not reimburse RTCs for pass days for any recipient
exceeding a total of three passes per calendar year.
5. If the recipient leaves without issuance of a Therapeutic Home Pass the
recipient will be considered discharged and the QIO-like vendor must be
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notified of the discharge and date the recipient left the facility.
6. In the event a recipient unexpectedly does not return to the RTC from a
Therapeutic Home Pass or family emergency, and such an absence has been
properly documented by the RTC, the RTC may utilize the day the recipient
was expected to return from leave as the discharge date as long as the period
does not exceed 72 hours. In the case of a family emergency or an extended
pass which has been approved by the QIO-like vendor, this period cannot
exceed 120 hours.
7. Any recipient who is formally discharged from an RTC and is readmitted is
considered to be a new admission, regardless of the length of time away
from the facility. Prior authorization and a Certificate of Need (CON)
signed by a physician, is required for payment.
8. The three passes per calendar year Therapeutic Home Pass policy applies to
all RTC recipients, regardless of the recipient's custody status.
9. Therapeutic Home Passes include the day the pass begins and ends the day
before the recipient returns (prior to midnight).
7. Transportation
Nevada Medicaid may reimburse the following RTC travel related services for an eligible
recipient and attendant when determined to be medically necessary for:
a. initial travel to the RTC upon admission;
b. travel for an RTC Therapeutic Home Pass;
c. travel upon discharge from the RTC; and
d. travel for transfer from one RTC to another RTC or Acute Inpatient Services.
Transportation must be coordinated in accordance with Chapter 1900 of the MSM.
403.8B PROVIDER RESPONSIBILITIES
1. All RTCs must comply with the regulations in this MSM chapter and all other applicable
MSM chapters.
2. Critical Events Reporting Requirements RTCs are required to notify within 48 hours:
a. The QIO-like vendor of any critical event or interaction involving any Nevada
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Medicaid RTC recipient. Information which must be reported includes, but is not
limited to, deaths, injuries, assaults, suicide attempts, police or sheriff’s
investigations and physical, sexual or emotional abuse allegations.
b. The State Medicaid agency, State-designated client protection and advocacy
agency and the Nevada State Bureau of Health Care Quality and Compliance
(HCQC) of a resident’s death, serious injury or suicide attempt for an in-state
facility. If the facility is out-of-state, their own state licensing entity or appropriate
departments as well as the QIO-like vendor and Nevada State Medicaid;
c. Their local Centers for Medicare and Medicaid Services (CMS) office of the death
of any recipient, no later than the close of business the next business day after the
resident’s death per 42 CFR 483.374(c).
1. Upon notification of a critical event, Nevada Medicaid may make an
adverse decision against the RTC. In the event of a death, suicide attempt,
or very serious injury (injury requiring hospitalization) of a recipient,
Nevada Medicaid may make an administrative decision to impose a ban on
future Medicaid-eligible admissions and/or remove recipients currently at
the RTC, if they are believed to be in danger.
2. If a ban is imposed, Medicaid must receive and review HIPAA compliant
documents requested from the RTC, including but not limited to, police,
autopsy, state licensing, social services and internal death or serious injury
reports before a decision is made to remove or continue the imposed ban or
terminate the contractual relationship with the RTC.
3. RTC Regulatory and Compliance Requirements
The RTC must ensure on-going Joint Commission, COA or CARF accreditation and
comply with all accreditation requirements.
4. Letter of Attestation
The RTC must comply with 42 CFR Subpart G 483.374(a) and submit a Letter of
Attestation to Nevada State, by the individual having legal authority to do so (i.e., facility
director, CEO, or administrator), which confirms the facility is in compliance with CMS
standards governing the use of restraint and seclusion. The Letter of Attestation must be
submitted at the time of enrollment as a Medicaid provider and at any time there is a change
in the legal authority of the RTC. A copy of an example Letter of Attestation is available
upon request from Nevada Medicaid.
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5. QA/Quality Improvement
The RTC must have a QA/Quality Improvement program in place at the time of enrollment
and a process to submit an annual QA report to the DHCFP upon request.
6. Quarterly Family Visits
Quarterly family visits are based on clinical appropriateness and are utilized to support
person- and family- centered treatment planning. It is the responsibility of out-of-state and
in-state RTCs, as part of the all-inclusive daily rate, to bring up to two family members to
the facility on a quarterly basis when the family resides 200 miles or more from the RTC.
This includes the RTC providing travel, lodging and meals, to the family.
For Medicaid-eligible recipients in the custody of a public child welfare agency, prior to
arranging the visit, the RTC must consult with and obtain approval from the agency’s
clinical representative pertaining to the appropriateness of such a visit.
7. Discharge Accompaniments
RTCs must ensure the following is provided to the legal representative upon discharge of
a Medicaid-eligible recipient:
a. Supply or access to current prescribed medications;
b. The recipient’s Medicaid-eligibility status;
c. All pertinent medical records and post discharge plans to ensure coordination of and
continuity of care.
8. Clinical Requirements
a. The RTC must have a Medical Director who has overall medical responsibility for
the RTC program. The Medical Director must be a board-certified/board eligible
psychiatrist with specific experience in child and adolescent psychiatry.
b. Psychiatric/Medical Services
1. Medicaid-eligible children and adolescents must receive, at a minimum, two
monthly face-to-face/one-on-one sessions with a child and adolescent
psychiatrist and a psychiatrist must be available 24 hours a day.
2. The RTC must provide routine medical oversight to effectively coordinate
all treatment, manage medication trials and/or adjustments to minimize
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serious side effects and provide medical management of all psychiatric and
medical issues.
c. Clinical psychotherapy (individual, group or family therapy) must be provided by
a licensed QMHP. All RMH services may also be provided by a QMHP, a QMHA
or a QBA within the scope of their practice under state law and expertise.
Consultation by a licensed clinical psychologist must be available when determined
medically necessary.
d. RTC Interns/Psychological Assistant
1. RTC providers may be reimbursed for services provided by Interns/
Psychological Assistants within the all-inclusive daily rate if they meet the
requirements as prescribed in the Provider Qualifications – Outpatient
Mental Health Services section of this Chapter.
2. Approved out-of-state RTC providers must comply with the
Interns/Psychological Assistants requirements in their own state.
9. Patient Rights
RTCs must protect and promote patient’s rights in accordance with all applicable Federal
and State regulations.
10. Federal Requirements
RTCs must comply with all Federal and State Admission Requirements. Federal
regulations 42 CFR 441.151 to 441.156 address certification of need, individual plan of
care, active treatment and composition of the team developing the individual plan of care.
403.8C AUTHORIZATION PROCESS
1. Admission Criteria
All RTC admissions must be prior authorized by the QIO-like vendor. RTCs must submit
the following documentation to the QIO-like vendor:
a. RTC Prior Authorization Request Form which includes a comprehensive
psychiatric assessment current within six months of the request for RTC admission;
and
b. A CON signed by a physician which includes:
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1. The current functioning of the recipient;
2. The strengths of the recipient and their family;
3. Covered, current ICD diagnosis;
4. Psychiatric hospitalization history;
5. Medical history; and
6. Current medications.
c. An initial individualized treatment plan; and
d. A proposed discharge plan.
2. The QIO-like vendor must verify the medical necessity for all RTC services and verify:
a. The level of intensity of needs for RTC services;
b. The ability for the recipient to benefit rehabilitatively from RTC services;
c. The treatment plan includes active participation by the recipient and their family
(when applicable); and
d. The discharge plan is viable and includes coordinated case management services.
3. All RTCs must notify the QIO-like vendor of the transfer of a recipient to an acute
psychiatric hospital or unit. If the transfer is not emergent, the hospital must receive prior
authorization for the transfer. For transfers to an acute psychiatric hospital or unit, the QIO-
like vendor must verify the medical necessity for acute inpatient psychiatric services and
verify:
a. The Level of Intensity of Needs for acute inpatient psychiatric services;
b. The ability for the recipient to benefit rehabilitatively from acute inpatient
psychiatric services;
c. Effective care coordination is in place for pre- and post-transfer service; and
d. One of the following admission criteria has been met by the recipient:
1. Active suicidal ideation accompanied by a documented suicide attempt or
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documented history of a suicide attempt within the past 30 days; or
2. Active suicidal ideation within the past 30 days accompanied by physical
evidence (e.g. note) or means to carry out the suicide threat (e.g. gun, knife
or other deadly weapon); or
3. Documented aggression within the 72-hour period before admission which:
a. Resulted in harm to self, others or property;
b. Demonstrates that control cannot be maintained outside of inpatient
hospitalization; and
c. Is expected to continue if no treatment is provided.
4. The RTC must request prior authorization from the QIO-like vendor to return a recipient
to the RTC from acute psychiatric services. The prior authorization request must include a
Discharge Summary of the acute psychiatric inpatient services.
5. Prior authorization is required prior to transferring a recipient from one RTC to another for
unanticipated specialized treatment services not available at the initial RTC placement.
6. RTCs may request a retro-eligibility authorization review from the QIO-like vendor for
reimbursement for an RTC patient who was not Medicaid-eligible at the time of admission
and later becomes eligible for Medicaid for the period RTC services were provided.
a. If a client becomes Medicaid eligible after admission to an RTC, the facility must
submit an initial Prior Authorization request and all required information to the
QIO-like vendor in accordance with MSM Chapter 100.
b. The QIO-like vendor will process initial prior authorization requests for retro-
eligible recipients in accordance with MSM Chapter 100.
7. Continuing Stay Criteria
a. The RTC must submit a Continuing Stay Request to the QIO-like vendor prior to
the expiration of the current authorization period.
b. The QIO-like vendor will process Continuing Stay Requests for RTC services
within 14 days of receipt of all required information.
c. The RTC must notify the QIO-like vendor of all Medicaid recipient discharges
within 24 hours of the discharge and provide a Discharge Summary within 30 days
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for a planned discharge and within 45 days of an unplanned discharge. In the case
of a recipient’s transfer to another program, a verbal summary must be given at the
time of transition and followed with a written summary within seven calendar days
of the transfer.
d. Continued Stays Requests not authorized by the QIO-like vendor will not be
reimbursed by Medicaid. The RTC must submit a request for reconsideration to the
QIO-like vendor within the timelines as outlined in the QIO-like vendor’s billing
manual for RTC’s if the continuing stay request has been denied.
8. Discharge Criteria
The QIO-like vendor will issue a denial or partial denial for RTC services based on review
of medical necessity and admission or continuing stay criteria.
Denials may be issued for, but are not limited to:
a. RTC services are not shown to be medically necessary;
b. The service exceeds Medicaid program limitations;
c. Level 6 of Intensity of Needs is not met, and services may be provided in a less
restrictive setting;
d. Specialized RTC services are not required;
e. The legal guardian for the Medicaid recipient has requested the services be
withdrawn or terminated;
f. The services are not a Medicaid benefit; and/or
g. A change in federal or state law has occurred (the Medicaid recipient is not entitled
to a hearing in this case; see MSM Chapter 3100).
9. Reimbursement
RTC’s all-inclusive daily rates are negotiated by the provider through the DHCFP’s Rates
and Cost Containment Unit. Please see MSM Chapter 700 and the Nevada Medicaid State
Plan, Attachment 4.19-A, describing the methods and standards for reimbursement of
Residential Treatment Centers.
403.9 INPATIENT MENTAL HEALTH SERVICES POLICY
A. Inpatient mental health services are those services delivered in freestanding psychiatric
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hospitals or general hospitals with a specialized psychiatric unit which include a secure,
structured environment, 24-hour observation and supervision by mental health
professionals and provide a multidisciplinary clinical approach to treatment.
Inpatient mental health services include treatments or interventions provided to an
individual who has an acute, clinically identifiable covered, current ICD psychiatric
diagnosis to ameliorate or reduce symptoms for improved functioning and return to a less
restrictive setting.
B. Medicaid Behavioral Health Intensity of Needs for Children and Adolescents:
Child and Adolescent Children: CASII Adults: LOCUS
Service Intensity
Instrument (CASII)
Levels I to V Not Authorized Not Authorized
Level VI Inpatient Hospitalization Inpatient Hospitalization
Secure, 24-Hour, Authorized Authorized
Services with Psychiatric
Management
403.9A COVERAGE AND LIMITATIONS
1. Admissions
a. Certification Requirement:
1. A physician must issue a written order for admission or provide a verbal
order for admission, which is later countersigned by the same physician.
The order must be issued:
a. During the hospital stay;
b. At the time acute care services are rendered; or
c. The recipient has been transferred, or is awaiting transfer, to an acute
care bed from an emergency department, operating room, admitting
department or other hospital service.
2. The physician’s order must be based on:
a. The recipient meeting Level 6 criteria on the Intensity of Needs grid
and must include: The date and time of the order and the status of
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the recipient’s admission (i.e., inpatient, observation, same day
surgery, transfer from observation, etc.).
b. Admission Date and Time:
The admission date and time must be reflected on the certification as the date and
time the admission order was written prior to or during hospitalization. If the date
and time of the physician admission orders are not clear or available, the QIO-like
vendor applies the documentation most relevant to the admission determination
contingent upon provision of acute care services.
c. Transfers and Planned Admissions:
For those instances in which a physician’s admission order was issued for a planned
admission and before the recipient arrives at the hospital, the order must be signed
by the physician and indicate the anticipated date of admission. A physician’s order
must also be issued for transfers from another acute care hospital.
Responsibilities:
1. The admission must be certified by the QIO-like vendor based on:
a. Medical necessity;
b. Clear evidence of a physician’s admission order; and the
c. Recipient meeting Level 6 on the intensity of needs grid.
2. The hospital must submit all required documentation including:
a. The physician’s order which is signed by a physician and reflects
the admission date and time; and
b. All other pertinent information requested by the QIO-like vendor.
d. Observation:
1. Observation status cannot exceed a maximum of 48 hours.
2. Observation begins when the physician issues an observation status order
and ends when the recipient is discharged from the hospital.
3. A new admissions order must be issued and signed by a physician when a recipient is
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admitted to inpatient status post discharge from an observation stay. Nevada Medicaid
reimburses for admissions certified by the QIO-like vendor to a:
a. Psychiatric unit of a general hospital, regardless of age; or
b. Psychiatric hospital (Institution for Mental Diseases) for recipients under age 21 or
65 or older.
For recipients under age 21 in the custody of the public child welfare agency, Nevada
Medicaid reimburses for inpatient mental health services only when:
a. The child welfare agency also approves the admission/placement (this does not
apply to placements at State-owned and operated facilities); and the admission is
certified by the QIO-like vendor.
4. Reimbursement
a. Nevada Medicaid reimburses for services for recipients admitted with a mental
health or psychiatric condition to a general hospital without a psychiatric unit only
under one of the following conditions:
1. The admission is an emergency and is certified by the QIO-like vendor. The
hospital must submit clinical documentation to the QIO-like vendor within
five business days of the admission and make all efforts to stabilize the
recipient's condition and discharge the recipient to a psychiatric hospital or
general hospital with a psychiatric unit in as expeditiously as possible; or
2. The recipient has been dually diagnosed as having both medical and mental
diagnoses which warrant inpatient general hospital services, as determined
by the QIO-like vendor.
b. Nevada Medicaid does not reimburse for services not authorized by the QIO-like
vendor.
c. If a recipient is initially admitted to a hospital for acute care and is then authorized
by the QIO-like vendor to receive mental health services, the acute care is paid at
the medical/surgical rate.
5. Authorized substance abuse services are paid at the substance abuse service rate.
6. Absences
a. In special circumstances, Nevada Medicaid may allow up to an eight-hour pass
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from the acute hospital without denial of payment. Absences may include, but are
not limited to, a trial home visit, a respite visit with parents (in the case of a child),
a death in the immediate family, etc. The hospital must request prior authorization
from the QIO-like vendor for an absence if the absence is expected to last longer
than eight hours.
b. There must be a physician's order that a recipient is medically appropriate to leave
on pass and the therapeutic reason for the pass must be clearly documented in the
chart prior to the issuance of the pass. Upon the recipient's return, the pass must be
evaluated for therapeutic effect and the results clearly documented in the recipient’s
chart.
7. Non-Covered Services Reference Section 403.9A.
403.9B PROVIDER RESPONSIBILITIES
1. Authorization by the QIO-like vendor must be obtained prior to admission. A tentative
treatment plan will be required for the QIO-like vendor’s authorization. The only exception
is in the event of an emergency admission, in which the recipient may be admitted, and the
QIO-like vendor must be notified of the admission within five business days.
In the event authorization is not obtained, the admission will not be authorized and/or
certified by the QIO-like vendor for payment.
2. Medical Records
A medical record shall be maintained for each recipient and shall contain the following
items:
a. An initial assessment of the recipient's clinically identifiable psychiatric disorder,
which should include a chief complaint or equivalent, a history of the disorder, a
statement of the circumstances which led to the request for services, a mental status
examination and observations, a diagnosis or differential diagnosis and a statement
of treatment goals and objectives and method of treatment.
b. A written, individualized treatment plan (ITP) to address the problems documented
during the intake evaluation. The plan shall include the frequency, modality and the
goals of treatment interventions planned. It also shall include the type of personnel
that will furnish the service.
c. Dated progress notes are required for each treatment encounter to include the
amount of time services were rendered, the type of service rendered, the progress
of the recipient with respect to resolution of the presenting symptoms or problems,
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any side effects or necessary changes in treatment and the interval to the next
treatment encounter.
The provider shall make available to Nevada Medicaid or Medicaid's QIO-like
vendor copies of the medical record, progress notes or summary documents which
reflect the ongoing need for treatment and support any additional services
requested.
For inpatient and outpatient services, the provider is responsible to meet Healthy
Kids (EPSDT) and QIO-like vendor authorization guidelines, as discussed
previously in this chapter.
d. Patient Self-Determination Act (Advance Directives) Compliance Pursuant to the
Omnibus Budget Reconciliation Act of 1990 (OBRA 90), and federal regulations at
42 CFR 489.100, hospitals which participate in and receive funding from Medicare
and/or Medicaid must comply with The Patient Self-Determination Act (PSDA) of
1990, including Advance Directives. Specifically, the PSDA requires all Medicare
and Medicaid hospital providers to do the following: Provide written information
to all adult (age 18 and older) patients upon admission concerning:
1. The individual’s rights under state law to make decisions concerning their
medical care, including the right to accept or refuse medical or surgical
treatment, and the right to formulate advance directives (declarations and
durable powers of attorney for health care decisions).
2. The written policies of the provider or organization respecting
implementation of such rights, including a clear and precise statement of
limitation if the provider cannot implement an advance directive on the
basis of conscience.
At a minimum, a provider’s or organization’s statement of limitation must:
a. Clarify any differences between institution-wide conscience
objections and those that may be raised by individual physicians;
b. identify the state legal authority permitting such objections (which
in Nevada is NRS 449.628); and
c. describe the range of medical conditions or procedures affected by
the conscience objection.
e. Document in the individual's medical record whether the individual has an advance
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directive.
f. Not to condition the provision of care or otherwise discriminate against an
individual based on whether the individual has executed an advance directive.
g. Ensure compliance with the requirements of state law respecting advance
directives. The hospital must inform individuals any complaints concerning the
advance directives requirements may be filed with the state survey and certification
agency (which in Nevada is the Nevada State Health Division, HCQC).Provide
education of staff concerning its policies and procedures on advance directives (at
least annually).
h. Provide for community education regarding issues concerning advance directives (at least
annually). At a minimum, education presented should define what constitutes an advance
directive, emphasizing that an advance directive is designed to enhance an incapacitated
individual’s control over medical treatment, and describe applicable state law concerning
advance directives. A provider must be able to document and verify its community
education efforts.
Nevada Medicaid is responsible for monitoring/reviewing hospitals periodically to
determine whether they are complying with federal and state Advance Directive
requirements.
4. QA Medical Care Evaluation Studies
The purpose of medical care evaluation studies is to promote the most effective and
efficient use of available health facilities and services consistent with patient needs and
professionally recognized standards of care (42 CFR 456.141 to 456.145). As part of the
conditions of participation in the Medicaid Title XIX program, a minimum of one Medical
Care Evaluation Study must be in progress at any time. Additionally, one study must be
completed each year. The completed study must be submitted to the QIO-like vendor at
the end of each calendar year along with the study in progress topic. (A report summarizing
the study topics will be submitted to Nevada Medicaid, by the QIO-like vendor). Hospitals
may design and choose their own study topic, or at the request of Medicaid perform a topic
designated by Medicaid and forward a copy of the completed study to the QIO-like vendor
office within the specified time frames.
5. Medicaid Form NMO-3058 (Admit/Discharge/Death Notice)
All hospitals are required to submit Form NMO-3058 to their local Welfare District Office
whenever a hospital admission, discharge or death occurs. Failure to submit this form could
result in payment delay or denial. To obtain copies of Form NMO-3058, please contact
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Medicaid's fiscal agent.
6. Patient Rights
Pertaining to the acute psychiatric hospital's responsibilities of protecting and promoting
each patient's rights, please consult the following authorities:
a. 42 CFR 482.13.
b. NRS 449.730.
c. Joint Commission "Restraint and Seclusion Standards for Behavioral Health."
(Available at the following website: www.jointcommission.org).
7. Non-Emergency Admissions
Non-emergency admissions for Medicaid eligible recipients must be prior authorized by
the QIO-like vendor within one business day of the admission. Physicians may call them
during normal business hours. (Non-emergency admissions not prior authorized by the
QIO-like vendor will not be reimbursed by Nevada Medicaid.)
8. Claims for Denied Admissions
Hospitals are not permitted, after having an inpatient service denied by the QIO-like
vendor, to submit the claim to Medicaid's fiscal agent as an outpatient service. The only
exception to this is if an outpatient or non-inpatient related service was truly rendered prior
to the inpatient admission order by the physician but the inpatient stay was denied by the
QIO-like vendor (i.e., admit from ER or rollover from observation days).
9. Hospital Responsibilities for Outside Services
Any hospital receiving authorization from the QIO-like vendor to admit and provide
services for a recipient is responsible for that recipient service and treatment needs. If a
hospital does not have the proper or functional medical equipment or services, and must
transfer a recipient temporarily to another hospital or other medical service provider
(generally for only a portion of that day) for testing/evaluation/treatment, etc., it is the
transferring hospital's responsibility, not Medicaid's, to fund the particular services and, if
necessary, transportation.
10. Acute Psychiatric Admission Requirements
a. 42 CFR 441.152 addresses Certification of Need requirements.
b. 42 CFR 441.155 addresses Individual Plan of Care requirements.
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c. 42 CFR 441.156 addresses the requirements of the composition of the team
developing the individual plan of care.
11. Patient Liability
IMDs/freestanding psychiatric hospitals are exempt from Patient Liability (PL)
requirements.
403.9C AUTHORIZATION PROCESS
The QIO-like vendor contracts with Medicaid to provide utilization and quality control review
(UR) of Medicaid inpatient psychiatric hospital admissions. Within the range of the QIO-like
vendors UR responsibilities are admission and length of stay criteria development, prior
authorization, concurrent and retrospective review, certification and reconsideration decisions.
The QIO-like vendor must approve both emergency and non-emergency inpatient psychiatric
inpatient admissions. Any hospital which alters, modifies or changes any QIO-like vendor
certification in any way, will be denied payment.
1. For purposes of Medicaid mental health services, an emergency inpatient psychiatric
admission to either a general hospital with a psychiatric unit or freestanding psychiatric
hospital, is defined as meeting at least one of the following three criteria:
a. Active suicidal ideation accompanied by a documented suicide attempt or
documented history of a suicide attempt(s) within the past 30 days; or
b. Active suicidal ideation within the past 30 days accompanied by physical evidence
(e.g. note) or means to carry out the suicide threat (e.g., gun, knife or other deadly
weapon); or
c. Documented aggression within the 72-hour period before admission:
1. Which resulted in harm to self, others or property;
2. Which manifests that control cannot be maintained outside an inpatient
hospitalization; and
3. Which is expected to continue without treatment.
2. Concurrent Reviews
For non-emergency admissions, the prior authorization request form and Certificate of
Need (CON) must be submitted at least one business day prior to admission. For emergency
admissions, the prior authorization request form and CON must be submitted no later than
five business days following admission. Prior authorization requests, if medically and
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clinically appropriate, will be authorized up to seven days. If additional inpatient days are
required, a provider must submit a concurrent (continuing stay) authorization request
within five business days of the last day of the current/existing authorization period. The
request and information submitted must identify all pertinent written medical information
that supports a continued inpatient stay. The request and information submitted must be in
the format and within the timeframes required by the QIO-like vendor. Failure to provide
all pertinent medical information as required by the QIO-like vendor will result in
authorization denial. Inpatient days not authorized by the QIO-like vendor are not covered.
These concurrent review procedures also apply to inpatient substance abuse detoxification
and treatment services.
The psychiatric assessment, discharge plan and written treatment plan must be initiated,
with the attending physician's involvement, during the initial authorization period. In
addition, when a recipient remains hospitalized longer than seven days the attending
physician must document the medical necessity of each additional inpatient day.
3. Nevada Medicaid will reimburse for services for recipients admitted with a mental health
or psychiatric condition to a general hospital without a psychiatric unit only under one of
the following conditions:
a. The admission is an emergency admission and is certified by the QIO-like vendor
(who must be contacted within five business days after the admission). The hospital
must make all efforts to stabilize the recipient's condition and discharge the
recipient to a psychiatric hospital or general hospital with a psychiatric unit as
expeditiously as possible; or
b. The recipient has been dually diagnosed as having both medical and mental
conditions/diagnoses which warrant inpatient general hospital services, as
determined by the QIO-like vendor.
Also, if a recipient is initially admitted to a hospital for acute care and is then
authorized to receive mental health services, the acute care is paid at the
medical/surgical tiered rate. The substance abuse services are paid at the substance
abuse service rate. Hospitals are required to bill Medicaid separately for each of the
types of stays. The QIO-like vendor must certify the two types of stays separately.
4. Acute inpatient admissions authorized by the QIO-like vendor do not require an additional
authorization for physician ordered psychological evaluations and testing. The
psychologist must list the "Inpatient Authorization Number" on the claim form when
billing for services.
5. Prior Resources
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Pursuant to federal law, Medicaid is payer of last resort whenever any other resources may
be responsible for payment. Prior resources include but are not limited to: Medicare, labor
unions, Worker's Compensation Insurance carriers, private/group insurance and
CHAMPUS. Exceptions to this regulation are Bureau of Family Health Services, Indian
Health Services (IHS), Ryan White Act and Victims of Crime, when Medicaid is primary.
Benefits available free of charge to recipients from other sources must be provided free of
charge to Nevada Medicaid recipients.
6. Reimbursement
Inpatient freestanding psychiatric and/or alcohol/substance abuse hospitals and general
acute hospitals with a psychiatric and/or substance abuse unit are reimbursed a per diem,
all-inclusive prospective daily rate determined and developed by the Nevada DHCFP’s
Rate Development and Cost Containment Unit. (Days certified as administrative are paid
at the all-inclusive prospective administrative day rate.)
For claims involving Medicare crossover, Medicaid payment is the lower of the Medicare
deductible amount or the difference between the Medicare payment and the Medicaid per
diem prospective payment. (Medicare crossover claims involving recipient’s ages 21 to 64
in freestanding psychiatric hospitals are reimbursable only if the recipient is a QMB.) Also,
additional Medicaid reimbursement is not made when the Medicare payment exceeds the
Medicaid prospective rate. Service claims denied by Medicare are also denied by Medicaid.
403.10 INPATIENT ALCOHOL/SUBSTANCE ABUSE DETOXIFICATION AND TREATMENT
SERVICES POLICY
Inpatient substance abuse services are those services delivered in freestanding substance abuse
treatment hospitals or general hospitals with a specialized substance abuse treatment unit which
includes a secure, structured environment, 24-hour observation and supervision by mental health
substance abuse professionals and a structured multidisciplinary clinical approach to treatment.
These hospitals provide medical detoxification and treatment services for individuals suffering
from acute alcohol and substance abuse conditions.
403.10A COVERAGE AND LIMITATIONS
1. Hospital inpatient days may be considered a Medicaid benefit when detoxification and
treatment for acute alcohol and/or other substance abuse necessitates the constant
availability of physicians and/or medical services found in the acute hospital setting.
Medicaid reimburses for admissions to substance abuse units of general hospitals
(regardless of age), or freestanding psychiatric and substance abuse hospitals for recipients
age 65 and older, or those under age 21. The QIO-like vendor must prior authorize and
certify all hospital admissions for both detoxification and treatment services to verify
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Subject:
MEDICAID SERVICES MANUAL POLICY
appropriateness of placement and justify treatment and length of stay.
Prior authorization is required for all Medicaid and pending Medicaid recipients, and
Medicaid recipients covered through primary insurance, except Medicare Part A. If this is
the case, then authorization may need to be sent through Medicare.
Medicaid reimburses only for the following hospital alcohol/substance abuse
detoxification and treatment services:
a. Detoxification
1. Recipients (under age 21) – Medicaid reimburses for up to five hospital
inpatient detoxification days with unlimited lifetime admission services
(Medicaid covers stays beyond five days only if additional detoxification
services are deemed medically necessary by the QIO-like vendor).
2. Recipients age 21 years and older – Medicaid reimburses for up to five
hospital inpatient detoxification days with unlimited lifetime admission
services. (Medicaid covers stays beyond five days only if additional
detoxification services are deemed medically necessary by the QIO-like
vendor).
3. For recipients of all ages, results of a urine drug screen or blood alcohol test
must be provided at the time of the initial request for authorization.
b. Treatment
1. Recipients (under age 21) – Medicaid reimburses for up to 21 hospital
inpatient treatment days with unlimited lifetime admission services until the
recipient reaches age 21 (stays beyond 21 days are covered only if
additional treatment services are deemed medically necessary by the QIO-
like vendor).
2. Recipients age 21 years and older – Medicaid reimburses for up to 21
hospital treatment days with unlimited lifetime admissions only if the
recipient is deemed amenable for treatment, and has the potential to remain
sober, and as determined by the physician. (Stays beyond 21 days are
covered only if the additional treatment services are deemed medically
necessary by the QIO-like vendor).
To measure the recipient's ability to be amenable to treatment and the
potential to remain sober, he/she must:
a. Be currently attending, or willing to attend during treatment and
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upon discharge, and actively participate in Alcoholics Anonymous
(AA) and/or Narcotics Anonymous (NA) meetings.
b. Develop, over the duration of treatment, a support system to assist
sobriety efforts and a substance abuse-free lifestyle.
c. Seek employment, employment training or return to past
employment if still available or attend or remain in an educational
program (i.e., college, vocational training).
It is the hospital's responsibility to assist the recipient during hospitalization
to assure the above-mentioned post discharge resources will be utilized.
Prior to inpatient admission, the referring or admitting physician must
document discussing the above three “amenable to treatment” issues with
the recipient, including the recipient's response to each. This documentation
must be part of the recipient's inpatient hospital record. Prior to authorizing
the admission, the QIO-like vendor will:
d. per discussion with the physician, verify the physician-patient
communication did occur and the recipient accepts his/her
responsibility toward maintaining sobriety and/or a drug free
lifestyle after treatment; and
e. verify appropriateness of admission, treatment and length of stay.
A psychiatric screening must also be completed within 72 hours of any
inpatient detoxification or treatment admission.
c. Absences
Please consult Section 403.9A.5 of this chapter regarding absences.
1. All Other Inpatient Services Coverage and Limitations. Please consult
Section 403.9A of this chapter for all other Coverage and Limitations.
2. Non-Covered Services.
Please consult Section 403.9A for non-covered services.
403.10B PROVIDER RESPONSIBILITIES
1. The need for hospital alcohol/substance abuse detoxification and/or treatment services
must be prior authorized by the QIO-like vendor. The only exception is in the event of an
emergency, where a delay in treatment of more than 24 hours could result in severe pain,
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loss of life, limb, eyesight or hearing, injury to self or bodily harm to others. In this instance,
the recipient may be admitted, and the QIO-like vendor must be contacted for authorization
purpose within five business days of the admission.
2. Please consult Section 403.9B.1-11, of this chapter for additional provider responsibilities.
403.10C RECIPIENT RESPONSIBILITIES
1. Medicaid recipients are required to provide a valid monthly Medicaid eligibility card to
their service providers.
2. Medicaid recipients are expected to comply with the service provider’s treatment, care and
service plans, including making and keeping medical appointments.
403.10D AUTHORIZATION PROCESS
The QIO-like vendor must certify all inpatient substance abuse detoxification and treatment
admissions. Transfers to and from substance abuse detoxification/treatment services require prior
authorization by the QIO-like vendor.
1. For recipients under age 21 in the custody of the public agency, Nevada Medicaid
reimburses for alcohol/substance abuse detoxification and treatment services only when
the following criteria are met:
a. The Division of Child and Family Services (DCFS) Regional Resource Council
(RRC), Utilization Review Team (URT) or Family Programs Office (FPO) (entities
responsible for reviewing, recommending and authorizing appropriate placement
and treatment services) approves the admission/placement (does not apply to
placements at Desert Willow Treatment Center).
b. The admission is prior authorized and certified by the QIO-like vendor. For
recipients under age 21 not in the custody of the public agency, only “b” applies.
2. Nevada Medicaid reimburses for services for recipients admitted with an alcohol/substance
abuse condition/diagnosis to a general hospital without a specialized alcohol/substance
abuse unit only under one of the following conditions:
a. The admission is an emergency and is certified by the QIO-like vendor (who must
be contacted, for authorization purposes, within five business days of the
admission) and the hospital, as determined by the QIO-like vendor, makes all
efforts to stabilize the recipient's condition and discharge the recipient to a
substance abuse/psychiatric hospital or general hospital with a substance
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abuse/psychiatric unit as expeditiously as possible; or
b. The recipient is dually diagnosed as having both medical and substance abuse
conditions which warrant inpatient general hospital services, as determined by the
QIO-like vendor; or
The admission is certified by the QIO-like vendor for medical detoxification only.
Medicaid recipients between 21 and 64 years of age are covered for inpatient
alcohol/substance abuse detoxification and treatment services only in a general
hospital with a specialized alcohol/substance abuse unit. Those Medicaid recipients
age 20 and under and age 65 and older are covered for inpatient substance abuse
detoxification and treatment services in a freestanding psychiatric and/or
alcohol/substance abuse hospital, as well as a general hospital with a specialized
alcohol/substance abuse unit.
All transfers from detoxification to treatment require prior authorization. This
applies to all Medicaid recipients, regardless of age.
Also, if a recipient is initially admitted to a hospital for acute care and is then
authorized to receive alcohol/substance abuse services, the acute care is paid at the
appropriate medical/surgical tier rate. The alcohol/substance abuse services are
paid at the substance abuse service rate. Hospitals are required to bill Medicaid
separately for each of the types of stays. The QIO-like vendor must certify the two
types of stays separately.
3. Acute inpatient admissions authorized by the QIO-like vendor do not require an additional
PA for physician ordered psychological evaluations and testing. The psychologist must list
the QIO-like vendors “Inpatient’s authorization number" on the claim form when billing
for services.
4. Retrospective Reviews
The QIO-like vendor authorizes only Medicaid eligible clients, not pending eligible.
Should a client become Medicaid eligible while in the facility, a retrospective review must
be requested by the provider to the QIO-like vendor:
a. The medical record must be submitted to the QIO-like vendor within 30 days from
the date of the eligibility determination.
b. If the information submitted is not complete, a technical denial for service will be
issued.
c. The QIO-like vendor will complete the review and issue a final determination
within 30 days of receipt of all requested information.
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5. Determination Letters (Notices)
a. Approvals
The RTC provider is sent a “Notice of Medical Necessity Determination.”
b. Denials
The RTC provider is sent a “Notice of Medical Necessity Determination” and
“Request for Reconsideration” form. The Medicaid client is sent a “Notice of
Decision (NOD) for Authorization Form” and “Hearing Information and Hearing
Request Form.” Denials may be due to technical/administrative (e.g. the provider
did not obtain prior authorization) or clinical (e.g. client did not meet medical or
clinical necessity) reasons.
6. Reimbursement
Please consult Section 403.9C.6 of this chapter regarding reimbursement.
7. Patient Liability
Please consult Section 403.9B.11 of this chapter regarding patient liability.
403.11 ADMINISTRATIVE DAYS POLICY
The primary purpose and function of administrative days is to assist hospitals, which, through no
fault of their own, cannot discharge a recipient who no longer requires acute level services, due to
lack of, or a delay in, an alternative appropriate setting, which includes the adequate and
comprehensive documentation of discharge planning efforts. Administrative Days are reimbursed
on a retrospective, not cost settlement, basis.
403.11A COVERAGE AND LIMITATIONS
Administrative days are those inpatient days which have been certified for payment by the QIO-
like vendor, based on physician advisement, at the Skilled Nursing Level (SNL) or Intermediate
Care Level (ICL).
1. SNL is a unique payment benefit of the Nevada Medicaid program. These reimbursement
levels provide for ongoing hospital services for those recipients who do not require acute
care. Discharge to a nursing facility is not required. Issuance of this level is a reflection of
the hospital services required by and provided to the recipient.
SNL days may be authorized when one or more of the following apply, or as determined
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by physician review:
a. Recipient is awaiting placement, or evaluation for placement, at a nursing
facility/extended care facility, group home, or other treatment setting, for continuity
of medical services, e.g.:
1. Transfers to other facilities.
2. Rehabilitation or independent living.
3. Hospice, etc.
b. Recipient is to be discharged home and is awaiting home equipment set
up/availability, nursing services and/or other caretaker requirements, e.g.:
1. Home health nursing.
2. Public health nursing.
3. Durable medical equipment.
4. Family preparation.
5. Respite care.
c. Conditions which may prevent a non-acute recipient from leaving the hospital (e.g.,
recipient’s labs must be monitored, cultures taken for staph infection or any
treatment/work up that could not be safely and effectively accomplished in another
setting).
d. Recipient is awaiting placement at a residential treatment center, group home, or
psychiatric treatment center for continuity of psychiatric services., e.g.:
1. Partial hospitalization.
2. Therapeutic foster care.
3. Day treatment.
4. Rural mental health follow-up services.
5. Set up for wrap around services.
e. Recipient has mental disabilities that prevent nursing facility placement (e.g., failed
PASRR screening), and the recipient will eventually go to an institution of mental
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diseases.
2. ICL is a unique payment benefit of the Nevada Medicaid program, which provides
reimbursement for ongoing hospital services, for those recipients who cannot be discharged
due to social reasons.
ICL days are authorized when one or more of the following apply, or as determined by
physician review:
a. Stable child awaiting adoption or discharge home when the mother is discharged.
b. Ready for discharge and is awaiting transportation.
c. ICL at a nursing home or alternate setting.
d. Victim of crime in need of assessment and evaluation.
3. Administrative days are denied when:
a. A recipient, recipient’s family or physician refuses a Nursing Facility (NF)
placement.
b. A recipient, family or physician refuses a psychiatric RTC placement, group home
or psychiatric treatment center.
c. There is insufficient documentation (Monday through Friday contacts and results)
in the chart reflecting adequate discharge planning.
403.11B PROVIDER RESPONSIBILITIES
Please consult Section 403.10B of this chapter for provider responsibilities.
403.11C RECIPIENT RESPONSIBILITIES
1. Medicaid recipients are required to provide a valid monthly Medicaid eligibility card to
their service providers.
2. Medicaid recipients are expected to comply with the service provider’s treatment, care and
service plans, including making and keeping medical appointments.
403.11D AUTHORIZATION PROCESS
If appropriate, the QIO-like vendor certifies administrative days at either an SNL or ICL level of
care.
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403.12 ELECTROCONVULSIVE THERAPY (ECT)
Effective date March 1, 2004 ECT is a treatment for mental disorders, primarily depression, but
also acute psychotic episodes in Schizophrenia and Bipolar Disorder. A low voltage alternating
current is used to induce a generalized seizure that is monitored electrographically while under
general anesthesia and muscle relaxation.
Medicaid will reimburse medically necessary ECT treatments when administered by a Board-
Certified Psychiatrist in a qualified acute care general hospital, contracted acute care psychiatric
hospital, or in a hospital outpatient surgery center/ambulatory surgery center. Recipients receiving
outpatient ECT do not require a global treatment program provided in the inpatient setting prior to
outpatient services.
Prior Authorization is required.
403.12A COVERAGE AND LIMITATIONS
ECT is generally used for treatment of affective disorders unresponsive to other forms of treatment.
It has also been used in schizophrenia, primarily for acute schizophrenic episodes.
1. Prior authorization requires documentation of the following medically necessary
indicators:
a. Severe psychotic forms of affective disorders.
b. Failure to respond to other therapies.
c. Medical preclusion to use of drugs.
d. Need for rapid response.
e. Uncontrolled agitation or violence to self or others.
f. Medically deemed for probable preferential response to ECT.
2. Recipients under 16 years of age must have all of the above indicators and:
a. Two prior medication trials predetermined by a physician.
b. Two concurring opinions by a Board-Certified Psychiatrist.
c. Informed written consent by custodial parent(s)/legal guardian.
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3. Covered, current ICD Codes:
F20-F29 Schizophrenic disorders.
F30-F33.9 Affective psychoses and depressive type psychosis and other nonorganic
psychoses.
4. Covered CPT Codes:
90870 – Electroconvulsive therapy (includes necessary monitoring); single seizure.
5. Reasons for Denial
a. Continuing use of ECT without evidence of recipient improvement.
b. Diagnostic codes not encompassed in the foregoing list.
6. Coding Guidelines
a. Anesthesia administration for ECT is a payable service only if provided by a
physician other than the one administering ECT.
b. If billing is received for ECT and a visit on the same day, the latter will be denied
if rendered by the physician administering ECT.
7. Documentation Requirements
Medical records should include recipient symptoms, physical findings and diagnosis to
document the medical necessity of performing ECT.
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404 HEARINGS
Please reference MSM Chapter 3100 – Hearings, for hearings procedures.
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ATTACHMENT A
POLICY #4-01 DAY TREATMENT AGES 3-6
A. DESCRIPTION
Day treatment services are interventions performed in a therapeutic milieu designed to provide evidence-
based strategies to reduce emotional, cognitive, and behavioral problems. Day treatment services target
emotional, cognitive and behavioral functioning within a variety of actual and/or simulated social settings.
Day treatment services provide recipients the opportunity to implement and expand upon (trial and error)
what they previously learned/gained from other mental and/or behavioral health therapies and
interventions in a safe setting. The goal of day treatment services is to restore recipients to their highest
level of functioning while preparing them for reintegration back into home and community-based settings.
B. POLICY
Day treatment coverage is limited to medically necessary services and is reimbursed at an hourly rate. Day
treatment services must:
1. Have goals and objectives that are:
a. time specific;
b. measurable (observable);
c. achievable;
d. realistic;
e. time limited;
f. outcome driven;
g. individualized;
h. progressive; and
i. age/developmentally appropriate.
2. Provide for a process to involve the recipient, and family or other responsible individuals; and
3. Not be contingent on the living arrangements of the recipient.
Day treatment services are:
1. Facility based out of home services;
2. A fluid combination of Outpatient Mental Health and Rehabilitative Mental Health (RMH)
services; and
3. Provided under a Behavioral Health Community Network (BHCN) medical model.
C. PRIOR AUTHORIZATION IS REQUIRED
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ATTACHMENT A
POLICY #4-01 DAY TREATMENT AGES 3-6
D. COVERAGE AND LIMITATIONS
1. COVERED SERVICES
Clinical documentation must demonstrate the recipient meets all of the following criteria to be
considered a covered benefit:
a. Early Childhood Service Intensity Instrument (ECSII) level II or Child and Adolescent
Service Intensity Instrument (CASII) score of III or higher;
b. A primary covered, current ICD diagnosis;
c. Determined Severe Emotional Disturbance (SED);
d. Requires and will benefit from opportunities to test their acquired emotional, cognitive and
behavioral skills in settings that emulate their normal home and community-based
environments;
e. Clinical evidence that the recipient’s condition requires a structured program with
treatment that cannot be provided in a less intensive outpatient setting;
f. Adequate social support system available to provide the stability necessary for maintenance
in the program; and
g. Emotional, cognitive and behavioral health issues which:
1. are incapacitating, interfering with daily activities or places others in danger to the
point that it causes anguish or suffering;
2. require intensive, coordinated, multifaceted interventions within a therapeutic
milieu; and
3. cannot be appropriately addressed in a day care or school setting, as the issues are
impacting their ability to function in those settings and/or are contributing to
expulsion or near expulsion from day care, head start, school and/ or home
placements.
Service Limitations Ages 3-6: CASII
Levels I & II No Services Authorized
Level III Maximum of three hours per day
Level IV Maximum of three hours per day
Levels V & VI Maximum of three hours per day
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ATTACHMENT A
POLICY #4-01 DAY TREATMENT AGES 3-6
2. NON-COVERED SERVICES
a. Transportation or services delivered in transit.
b. Facilities licensed as a daycare.
c. Club house, recreational, vocational, afterschool or mentorship programs.
d. Services provided in the home or homelike setting including campus/institution
establishment that furnishes (in single or multiple facilities) food, shelter and some
treatment or services to four or more persons unrelated to the proprietor.
e. Routine supervision, monitoring or respite.
f. Non-evidenced based models.
g. Non milieu models.
h. Programs restricted or only provided to those recipients who reside at the same location.
E. PROVIDER REQUIREMENTS
To receive reimbursement day treatment programs must be separately enrolled with the DHCFP. Program
Criteria:
1. Services not to exceed three hours per day, five days per week;
2. Parental/caregiver involvement and participation in the day treatment program;
3. Ongoing participation in family counseling/therapy;
4. Minimum staff to recipient ratio is 1:3;
5. Maximum group size is six;
6. Therapeutic milieu design;
7. Services must be provided by a Qualified Mental Health Professional (QMHP) or by a Qualified
Mental Health Associates (QMHA) under the Direct Supervision of an onsite QMHP;
8. Evidence based programmatic model with established curriculum and schedule;
9. Program admission, service continuation and discharge criteria; and
10. Policies and procedures specific to the day treatment program which at a minimum address the
following:
a. Clinical and Direct Supervision;
b. Health Insurance Portability and Accountability Act (HIPAA) and client’s rights;
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ATTACHMENT A
POLICY #4-01 DAY TREATMENT AGES 3-6
c. Service provision and documentation; and
d. Admission and discharge criteria and process.
For individual provider requirements see MSM Chapter 400.
For enrollment, prior authorization and billing instructions please refer to the QIO-like vendor website.
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ATTACHMENT A
POLICY #4-02 DAY TREATMENT AGES 7-18
A. DESCRIPTION
Day treatment services are interventions performed in a therapeutic milieu designed to provide evidence-
based strategies to reduce emotional, cognitive and behavioral problems. Day treatment services target
emotional, cognitive and behavioral functioning within a variety of actual and/or simulated social settings.
Day treatment services provide recipients the opportunity to implement and expand upon (trial and error)
what they previously learned/gained from other mental and/or behavioral health therapies and
interventions in a safe setting. The goal of day treatment services is to restore recipients to their highest
level of functioning while preparing them for reintegration back into home and community-based settings.
B. POLICY
Day treatment coverage is limited to medically necessary services and is reimbursed at an hourly rate. Day
treatment services must:
1. Have goals and objectives that are:
a. time specific;
b. measurable (observable);
c. achievable;
d. realistic;
e. time limited;
f. outcome driven;
g. individualized;
h. progressive; and
i. age/developmentally appropriate.
2. Provide for a process to involve the recipient, and family or other responsible individuals; and
3. Not be contingent on the living arrangements of the recipient.
Day treatment services are:
1. Facility based out of home services;
2. A fluid combination of Outpatient Mental Health and RMH services; and
3. Provided under a BHCN medical model.
C. PRIOR AUTHORIZATION IS REQUIRED
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ATTACHMENT A
POLICY #4-02 DAY TREATMENT AGES 7-18
D. COVERAGE AND LIMITATIONS
1. COVERED SERVICES
Clinical documentation must demonstrate the recipient meets all of the following criteria to be
considered a covered benefit:
a. CASII score of III or higher;
b. A primary covered, current ICD diagnosis;
c. Determined SED;
d. Requires and will benefit from opportunities to test their acquired emotional, cognitive and
behavioral skills in settings that emulate their normal home and community-based
environments;
e. Clinical evidence that the recipient’s condition requires a structured program with
treatment that cannot be provided in a less intensive outpatient setting;
f. Adequate social support system available to provide the stability necessary for maintenance
in the program; and
g. Emotional, cognitive and behavioral health issues which:
1. are incapacitating, interfering with daily activities or places others in danger to the
point that it causes anguish or suffering;
2. require intensive, coordinated, multifaceted interventions within a therapeutic
milieu; and
3. cannot be appropriately addressed in a day care or school setting, as the issues are
impacting their ability to function in those settings and/or are contributing to
expulsion or near expulsion from day care, school and/ or home placements.
Service Limitations Ages 7-18: CASII
Levels I & II No Services Authorized
Level III Maximum of four hours per day
Level IV Maximum of five hours per day
Levels V & VI Maximum of six hours per day
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POLICY #4-02 DAY TREATMENT AGES 7-18
2. NON-COVERED SERVICES
a. Transportation or services delivered in transit.
b. Facilities licensed as a daycare.
c. Club house, recreational, vocational, afterschool or mentorship programs.
d. Services provided in the home or homelike setting including campus/institution
establishment that furnishes (in single or multiple facilities) food, shelter and some
treatment or services to four or more persons unrelated to the proprietor.
e. Routine supervision, monitoring or respite.
f. Non-evidenced based models.
g. Non milieu models.
h. Programs restricted or only provided to those recipients who reside at the same location.
E. PROVIDER REQUIREMENTS
To receive reimbursement day treatment programs must be separately enrolled with the DHCFP.
1. Program Criteria:
a. Services not to exceed six hours per day, five days per week;
b. Parental/caregiver involvement and participation in the day treatment program;
c. Ongoing participation in individual therapy (not reimbursed under day treatment model);
d. Minimum staff to recipient ratio is 1:5;
e. Maximum group size is 10;
f. Therapeutic milieu design;
g. Services must be provided by a QMHP or by a QMHA under the Direct Supervision of an
onsite QMHP;
h. Evidence based programmatic model with established curriculum and schedule;
i. Program admission, service continuation and discharge criteria; and
j. Policies and procedures specific to the day treatment program which at a minimum address
the following:
1. Clinical and Direct Supervision;
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POLICY #4-02 DAY TREATMENT AGES 7-18
2. HIPAA and client’s rights;
3. Service provision and documentation; and
4 Admission and discharge criteria and process.
For individual provider requirements see MSM Chapter 400.
For enrollment, prior authorization and billing instructions please refer to the QIO-like vendor
website.
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ATTACHMENT A
POLICY #4-03 DAY TREATMENT AGES 19 AND OLDER
A. DESCRIPTION
Day treatment services are RMH interventions performed in a therapeutic milieu to provide evidence-
based strategies to restore and/or retain psychiatric stability, social integration skills and/or independent
living competencies to function as independently as possible. Services provide recipients the opportunity
to implement and expand upon what was previously learned from other mental or behavioral health
therapies and interventions in a safe setting. The goal of day treatment services is to prepare recipients for
reintegration back into home and community-based settings, prevent hospitalizations and ensure stability.
B. POLICY
Day treatment coverage and reimbursement is limited to medically necessary services and are covered at
an hourly rate.
Day treatment services must:
1. Have goals and objective that are:
a. time specific;
b. measurable (observable);
c. achievable;
d. realistic;
e. time limited;
f. outcome driven;
g. individualized;
h. progressive; and
i. age/developmentally appropriate.
2. Must involve the recipient and family or other individuals, as appropriate, and
3. Not be contingent on the living arrangements of the recipient.
Day treatment services are:
1. Facility based, out of home services.
2. A fluid combination of all the RMH services.
3. Provided under a BHCN medical model.
C. PRIOR AUTHORIZATION IS REQUIRED
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ATTACHMENT A
POLICY #4-03 DAY TREATMENT AGES 19 AND OLDER
D. COVERAGE AND LIMITATIONS
1. COVERED SERVICES
Clinical documentation must demonstrate that the recipient meets all of the following criteria:
a. Must have Level of Care Utilization System for Adults (LOCUS) score of IV, V or VI;
b. A primary covered, current ICD diagnosis;
c. Determined as Serious Mental Illness (SMI);
d. Requires and benefits from opportunities to test their acquired emotional, cognitive and
behavioral skills in settings that emulate their normal home and community-based
environments;
e. The recipient’s condition requires a structured program with treatment that cannot be
provided in a less intensive outpatient setting;
f. An adequate social support system is available to provide the stability necessary for
maintenance in the program; and
g. Recipient’s emotional, cognitive and behavioral issues which:
1. require intensive, coordinated, multifaceted interventions within a therapeutic
milieu; and
2. are incapacitating, interfere with daily activities or place others in danger to the
point that it causes anguish or suffering.
Service Limitations Ages 19 and older: LOCUS
Levels I & II No Services Authorized
Level III No Services Authorized
Level IV Maximum of five hours per day
Levels V & VI Maximum of six hours per day
2. NON-COVERED SERVICES
a. Transportation or services in transit.
b. Facilities licensed as adult daycare may not provide day treatment services.
c. Recreational, mentorship or club house programs.
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ATTACHMENT A
POLICY #4-03 DAY TREATMENT AGES 19 AND OLDER
d. Services in a home based or home like settings, including campus/institutions that furnish
in single or multiple areas, food, shelter and some treatment/services to four or more
persons unrelated to the proprietor.
e. Non-evidenced based models.
f. Non milieu models.
g. Programs restricted to only those recipients residing at the same location.
E. PROVIDER REQUIREMENTS
1. Program Criteria:
a. Day Treatment services must be provided by a QMHP or by a QMHA under the Direct
Supervision of an onsite QMHP;
b. Services not to exceed a maximum of six hours a day, five days a week;
c. Must involve the recipient and family or other individuals, as appropriate in the day
treatment program and family counseling/therapy;
d. Minimum staff to recipient ratio is 1:5;
e. Maximum group size is 10;
f. Therapeutic milieu design;
g. Evidence based programmatic model with established curriculum and schedule;
h. Program admission, service continuation and discharge criteria in place; and
i. Policies and procedures specific to the day treatment program which as a minimum address
the following:
1. Clinical and Direct Supervision;
2. HIPAA and client’s rights;
3. Service provision and documentation; and
4. Admission and discharge criteria and process
Day treatment services will only be reimbursable to those programs which have been approved
and enrolled to serve as Day Treatment Program service providers
For individual provider requirements see MSM Chapter 400.
For enrollment, prior authorization and billing instructions please refer to the QIO-like vendor’s
Billing Manual and Guidelines.
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ATTACHMENT B
SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
A. DESCRIPTION/POLICY
B. SUBSTANCE ABUSE AGENCIES MODEL (SAAM)
The DHCFP covers services for prevention and treatment for recipients who have been diagnosed or at
risk of substance abuse disorders. The substance abuse policy is under the rehabilitative authority of the
State Plan for behavioral health services. Services must be recommended by a physician or other licensed
practitioner of the healing arts, within their scope of practice and prescribed on an individualized treatment
plan to achieve maximum reduction of a mental disability and restore the recipient to their optimal level
of functioning.
The below coverage policies are developed based upon the Treatment Improvement Protocols (TIPs),
developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental
Health Services Administration (SAMHSA) within the DHHS and are best-practice guidelines for the
treatment of substance abuse disorders.
In addition, the DHCFP utilizes American Society of Addiction Medicine (ASAM) patient placement
criteria to establish guidelines for level of care placements within the substance abuse continuum. For
mental health continuum the DHCFP utilizes the Level of Care Utilization System (LOCUS) for adults
and Child and Adolescent Screening Intensity Instrument (CASII) for children when assessing the mental
health level of care needs of recipients as described under Section 403.4(7).
The DHCFP encourages providers to utilize SAMHSA’s working definition, dimensions and guiding
principles of recovery from substance use disorders in their clinical decisions. The definition is continually
changing due to updates in the clinical field reference http://www.samhsa.gov/ for the latest best practices.
There are four major dimensions that support a life in recovery:
1. Health – Overcoming or managing one’s disease(s) or symptoms;
2. Home – A stable and safe place to live;
3. Purpose – Meaningful daily activities, such as a job, school, volunteerism, family caretaking or
creative endeavors, and the independence, income and resources to participate in society; and
4. Community – Relationships and social networks that provide support, friendships, love and hope.
The guiding principles of recovery are:
1. Recovery emerges from hope;
2. Recovery is person-driven;
3. Recovery occurs via many pathways;
4. Recovery is holistic;
5. Recovery is supported by peers and allies;
6. Recovery is supported through relationship and social networks; Recovery is culturally based and
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SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
7. influenced;
8. Recovery is supported by addressing trauma;
9. Recovery involves individual, family and community strengths and responsibility; and
10. Recovery is based on respect.
C. DEFINITIONS
1. Co-Occurring Capable (COC) programs – are those that “address co-occurring mental and
substance use disorders in their policies and procedures, assessment, treatment planning, program
content and discharge planning” (The ASAM Criteria 2013, P. 416).
2. Co-Occurring Enhanced (COE) programs – have a higher level of integration of substance abuse
and mental health treatment services. These programs are able to provide primary substance abuse
treatment to clients and “are designed to routinely (as opposed to occasionally) deal with patients
who have mental health or cognitive conditions that are more acute or associated with more serious
disabilities.”
(The ASAM Criteria, 2013, P. 29) Enhanced-level service “place their primary focus on the
integration of service for mental and substance use disorders in their staffing, services and program
content.” (The ASAM Criteria, 2013, P. 417).
3. Recovery - A process of change through which individuals improve their health and wellness, live
a self-directed life, and strive to reach their full potential.
4. Substance abuse – as defined in DSM-V (5th Edition, Text Revision; APA 2013) is a “cluster of
cognitive, behavioral and physiological symptoms indicating that the individual continues using
the substance despite significant substance-related problems” (APA 2013, P. 483).
5. Substance dependence – is more serious than abuse. This maladaptive pattern of substance abuse
includes such features as increased tolerance for the substance, resulting in the need for ever greater
amounts of the substance to achieve the intended effect; an obsession with securing the substance
and with its use; or persistence in using the substance in the face of serious physical or mental
health problems.
6. Integrated interventions – are specific treatment strategies or therapeutic techniques in which
interventions for both disorders are combined in a single session or integration, or in a series of
interactions or multiple sessions. Integrated interventions can include a wide range of techniques.
Some examples include:
a. Integrated screening and assessment process;
b. Dual recovery mutual self-help meetings;
c. Motivational enhancement interventions (individual or group) that address issues related
to both mental health and substance use disorder problems;
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ATTACHMENT B
SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
d. Group interventions for persons with the triple diagnosis of mental disorder, substance
abuse disorder and trauma, or which are designed to meet the needs of persons with co-
occurring disorder and another shared problem such as homelessness or criminality; and
e. Combined psychopharmacological interventions, in which an individual receives
medication designed to reduce cravings for substances as well as medication for a mental
disorder.
Integrated interventions can be part of a single program or can be used in multiple program
settings.
7. Quadrant of Care Model as developed by the National Association of State Mental Health Program
Directors (NASMHPD) and National Association of State Alcohol and Drug Abuse Directors
(NASADAD):
a. Category I: Less Severe mental disorder/less severe substance disorder.
b. Category II: More severe mental disorder/less severe substance disorder.
c. Category III: Less severe mental disorder/more severe substance disorder.
d. Category IV: More severe mental disorder/more severe substance disorder.
This assessment assists the provider in integrating care, defining and guiding treatment options for
recipients with co-occurring disorders.
D. PROVIDER REQUIREMENTS
1. In order to be recognized and reimbursed as a Prevention and Early Intervention Level 0.5 by the
DHCFP, the providers must be:
a. Recognized health care clinicians and systems by the U.S. Preventive Services Task Force
(USPSTF) within their scope of practice; and
b. Certified providers under the Nevada Administrative Code (NAC) 458.103 scope of
practice.
2. In order to be recognized and reimbursed as a Substance Abuse Treatment Clinic for Levels I-III
by the DHCFP, the provider must:
a. Be certified and receiving funding from the Division of Public and Behavioral Health
(DPBH) as an alcohol and drug abuse program under NAC 458.103; and
b. Provide Integrated Interventions; and
c. Be a Co-Occurring Capable Program; or
d. A Co-Occurring Enhanced Program.
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SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
3. In order to be recognized and reimbursed as a Substance Abuse Level 4 – WM Medically Managed
Intensive Inpatient Withdrawal Management Program by the DHCFP the provider must be
Licensed by the Nevada DPBH as:
a. An acute care general hospital with a psychiatric unit; or
b. A free-standing psychiatric hospital (patients ages 22 – 64 in an IMD are not covered).
c. A licensed chemical dependency specialty hospital with acute care medical and nursing
staff (patients ages 22 – 64 in an IMD are not covered).
d. Have Medicare certification.
E. QUALITY IMPROVEMENT
The DHCFP requires providers who are receiving funds from the DHCFP to be deemed compliant by the
DPBH, NRS and NAC. Qualification is based upon the DPBH’s Substance Abuse Prevention and
Treatment Agency (SAPTA) Certification tool. The certification tool reviews the program for areas such
as, but not limited to, compliance with federal and state regulations, quality improvement, applications of
policies and procedures, health and safety of the recipients, clinical documentation requirements, and
staff/training documentation. Non-compliance will result in the DHCFP provider termination and/or
suspension without cause depending on severity of infraction.
This does not apply to Level 4 providers or physicians providing Level 0.5 services. They are governed
by separate licensing boards.
F. DOCUMENTATION REQUIREMENTS
All program levels require individualized progress notes in the recipient’s medical records that clearly
reflect implementation of the treatment plan and the recipient’s response to the therapeutic interventions
for all disorders treated, as well as subsequent amendments to the plan. Treatment plan reviews are
conducted at specified times as documented on the treatment plan.
1. Treatment Plan – A written individualized plan that is developed jointly with the recipient, their
family (in the case of legal minors) and/or their legal representative and licensed professional
within the scope of their practice under state law. The treatment plan is based on a comprehensive
assessment and includes:
a. The strengths and needs of the recipients and their families (in the case of legal minors and
when appropriate for an adult);
b. Documentation supporting ASAM Criteria assessment dimensions and levels of care;
c. Specific, measurable (observable), achievable, realistic and time-limited goals and
objectives;
d. Discharge criteria specific to each goal; and for
e. High-risk recipients accessing multiple government-affiliated and/or private agencies/
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SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
evidence of care by those involved with the recipient’s care.
2. The recipient, or their legal representative, must be fully involved in the treatment planning
process, choice of providers and indicate an understanding of the need for services and the
elements of the treatment plan. Recipient’s, family’s (when appropriate) and/or representative’s
participation in treatment planning must be documented on the treatment plan.
3. Temporary, but clinically necessary, services do not require an alteration of the treatment plan,
however, must be identified in a progress note. The note must indicate the necessity, amount scope,
duration and provider of the service.
4. Progress Note – Reference section 403.2B(3).
5. Discharge Plan – Reference section 403.2B(4).
6. Discharge Summary – Reference Section 403.2B(5).
7. Required signatures for treatment plan:
a. Clinical supervisor;
b. Recipient and their family/legal guardian (in the case of legal minors); and
c. The individual responsible for developing the plan.
G. SUPERVISION REQUIREMENTS
Clinical Supervisor – A licensed professional operating within the scope of their practice under state law
may function as clinical supervisor. Clinical supervisor must have the specific education, experience,
training, credentials, and licensure to coordinate and oversee an array of services for behavioral health.
The clinical supervisor will have administrative and clinical oversight of the program and must ensure
that services provided are medically necessary, clinically appropriate and follow an evidence-based model
recognized by the Health Division. The designated supervisor must be approved by the program operator
of a SAPTA certified and funded network per NAC 458.103.
If the clinical supervisor will supervise interns, they are required to have the appropriate additional
licensure needed per the Board of Examiners in addition to their professional licensure. Supervision must
be within the scope of their practice and field.
H. COVERAGE AND LIMITATIONS
The DHCFP reimburses for integrated interventions in a substance abuse medical treatment delivery
model provided by qualified Medicaid providers. Patients are assessed as meeting diagnostic criteria for
substance-related disorders (including substance use disorder or substance-induced disorders) and/or
mental health disorders as defined in the current International Classification of Diseases (ICD).
1. Screening – A brief systematic process to determine the possibility of a co-occurring disorder.
MENTAL HEALTH AND ALCOHOL/SUBSTANCE
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ATTACHMENT B
SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
a. The following screens are covered within the DHCFP program. Screens must be a
nationally accepted screening instrument through SAMHSA/CSAT Treatment
Improvement Protocols or other Peer Supported Literature. Below is a list of recognized
tools:
1. Clinical Institute Withdrawal Assessment (CIWA)
2. Michigan Alcohol Drug Inventory Screen (MADIS)
3. Michigan Alcoholism Screening Test (MAST)
4. Modified Mini
5. Problem Behavior Inventory (PBI)
6. Substance Abuse Subtle Screening Inventory (SASSI)
7. Substance Use Disorder (SUDDS)
8. Recovery Attitude and Treatment Evaluator (RAATE)
9. Treatment Intervention Inventory (TII)
10. Western Personality Interview (WPI)
2. Assessment – A Comprehensive Co-occurring Assessment is an individualized examination which
establishes the presence or absence of mental health and substance abuse disorders, determines the
recipient’s readiness for change, and identifies the strengths or problem areas that may affect the
recipient’s treatment. The comprehensive assessment process includes an extensive recipient
history which may include: current medical conditions, past medical history, labs and diagnostics,
medication history, substance abuse history, legal history, family, educational and social history
and risk assessment. The information collected from this comprehensive assessment shall be used
to determine appropriate interventions and treatment planning.
3. Level of Care Determination and Authorization Requirements
a. The DHCFP utilizes the ASAM Criteria, for individuals presenting with substance use
disorder(s) to determine appropriate placement in a level of care. In addition, the DHCFP
utilizes medical necessity as defined in MSM Chapter 100, Section 103.1. The process
considers assessment and documentation of the following six dimensions:
1. Dimension 1: Acute Intoxication and/or Withdrawal Potential
2. Dimension 2: Biomedical Conditions and Complications
3. Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications
4. Dimension 4: Readiness to Change
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SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
5. Dimension 5: Relapse, Continued Use, or Continued Problem Potential
6. Dimension 6: Recovery/Living Environment
b. The DHCFP utilizes the Level of Care Utilization System (LOCUS) for adults and Child
and Adolescent Screening Intensity Instrument (CASII) for children when assessing the
mental health level of care needs of recipients.
c. Each authorization is for an independent period of time as indicated by the start and end
date of the service period. If a provider believes it is medically necessary for services to be
rendered beyond the scope (units, time period or both), of the current authorization, the
provider is responsible for the submittal of a new prior authorization request.
d. Reference Attachment C for authorization requirements for Substance Abuse Agency
Model.
4. Treatment Services – The DHCFP covers the below levels based upon the ASAM patient
placement criteria. Reference Attachment C for the coverage and utilization management
requirements.
a. Level 0.5 Early Intervention/Prevention
b. Level 1 Outpatient Services
c. Level 2.1 Intensive Outpatient Program
d. Level 2.5 Partial Hospitalization
e. Level 3 Outpatient Services provided in a Licensed Level 3 environment
f. Level 4 Medically Managed Intensive Inpatient Treatment
5. Pharmaceutical coverage – For coverage and limitations of Narcotic Withdrawal Therapy Agents
(Opioid Dependent Drugs) refer to Chapter 1200 of the MSM.
6. Opioid Use Treatment
a. Provided in a Nevada licensed entity through SAPTA as an Opioid Use Disorder Treatment
Program.
b. Coverage of the service:
1. Requires diagnosis of Opioid Use Disorder; and
2. Requires documentation as meeting the assessment criteria of all six dimensions of
opioid treatment program in The ASAM Criteria.
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ATTACHMENT B
SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
c. The following service is covered for Opioid Treatment Program:
1. Medication assessment, prescribing, administering, reassessing and regulating dose
levels appropriate to the individual, supervising withdrawal management from
opioids, opioid use disorder treatment, overseeing and facilitating access to
appropriate treatment, including medication for other physical and mental health
disorders;
d. Opioid use disorder treatment program is required to perform:
1. Linkage with or access to psychological, medical and psychiatric consultation;
2. Linkage with or access to emergency medical and psychiatric care through
affiliations with more intensive levels of care;
3. Linkage with or access to evaluation and ongoing primary medical care;
4. Ability to conduct or arrange for appropriate laboratory and toxicology tests;
a. Availability of physicians to evaluate, prescribe and monitor use of
methadone and levo-alpha-acetylmethadol (LAAM), and of nurses and
pharmacists to dispense and administer methadone or LAAM; and
b. Ability to assist in arrangements for transportation services for patients who
are unable to drive safely or who lack transportation.
7. Non-Covered Services – the following services are not covered under the substance abuse services
program for the DHCFP:
a. Services for recipients without an assessment documenting diagnostic criteria for
substance-related disorder (including substance use disorder or substance-induced
disorders) or mental health disorder as defined in the current ICD;
b. Services for marital problems without a covered, current ICD diagnosis;
c. Services for parenting skills without a covered, current ICD diagnosis;
d. Services for gambling disorders without a covered, current ICD diagnosis;
e. Custodial services, including room and board;
f. More than one provider seeing the recipient in the same therapy session;
g. Services not authorized by the QIO-like vendor if an authorization is required according to
policy;
h. Respite;
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ATTACHMENT B
SUBSTANCE ABUSE AGENCIES MODEL
POLICY #4-04 (SAAM)
i. Services for education;
j. Services for vocation training;
k. Habilitative services;
l. Phone consultation services;
m. Services for individual ages 22 – 64 in an Institution for Mental Disease (IMD);
n. Services provided by agencies not receiving funding by Nevada DPBH for Levels I-III
under NAC 458.103;
o. Services provided under Nevada State Certification Level 2WM – 3.7 Withdrawal
Management programs;
p. Counseling services for Opioid Treatment Programs; and
q. Care Coordination and treatment planning.
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ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care Covered Services Description of Treatment Level Utilization Management
Prevention
Level 0.5 1. Screening services recommended by the A. DEPRESSION SCREENING No prior authorization
Early U.S. Preventive Services Task Force: required.
Intervention/ Adults: Many formal screening tools are
Prevention a. Depression screening in adults and available, including instruments designed Limited to one screen per 90
adolescents. specifically for older adults. (See Policy, days per disorder.
Page 4) Asking two simple questions about
b. Alcohol screening in adults, including mood and anhedonia ("Over the past two
pregnant women. weeks, have you felt down, depressed or
hopeless?" and "Over the past two weeks,
c. Tobacco use, counseling and have you felt little interest or pleasure in
interventions for pregnant women. doing things?") may be as effective as
using more formal instruments (2). There
2. Must be direct visualization. Self-screens is little evidence to recommend one
and over the phone are non-covered. screening method over another; therefore,
clinicians may choose the method most
consistent with their personal preference,
the patient population being served and the
practice setting.
All positive screening tests should trigger
full diagnostic interviews that use standard
diagnostic criteria (that is, those from the
updated Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition) to
determine the presence or absence of
specific depressive disorders, such as
MDD or dysthymia. The severity of
depression and comorbid psychological
problems (for example, anxiety, panic
attacks or substance abuse) should be
addressed.
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE
October 1, 2015 SERVICES Attachment C Page 1
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care Covered Services Description of Treatment Level Utilization Management
Prevention
Level 0.5 Adolescents: Instruments developed for
Early primary care (Patient Health Questionnaire
Intervention/ for Adolescents [PHQ-A] and the Beck
Prevention Depression Inventory-Primary Care
(Continued) Version [BDI-PC]) have been used
successfully in adolescents. There are
limited data describing the accuracy of
using MDD screening instruments in
younger children (7-11 years of age).
B. ALCOHOL SCREENING
Adults/Pregnant Women: The USPSTF
considers three tools as the instruments of
choice for screening for alcohol misuse in
the primary care setting: the Alcohol Use
Disorders Identification Test (AUDIT), the
abbreviated AUDIT-consumption
(AUDIT-C) and single question screening
(for example, the NIAAA recommends
asking, “How many times in the past year
have you had five [for men] or four [for
women and all adults older than 65 years]
or more drinks in a day?”). Of available
screening tools, AUDIT is the most widely
studied for detecting alcohol misuse in
primary care settings; both AUDIT and the
abbreviated AUDIT-C have good
sensitivity and specificity for detecting the
full spectrum of alcohol misuse across
multiple populations.
BEHAVIORAL HEALTH AND SUBSTANCE
October 1, 2015 ABUSE SERVICES Attachment C Page 2
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care Covered Services Description of Treatment Level Utilization Management
Prevention
Level 0.5 AUDIT comprises 10 questions and requires
Early approximately two to five minutes to
Intervention/ administer. AUDIT-C comprises three
Prevention questions and takes one to two minutes to
(Continued) complete. Single-question screening also
has adequate sensitivity and specificity
across the alcohol-misuse spectrum and
requires less than one minute to administer.
C. TOBACCO
Pregnant Women
Various primary care clinicians may deliver
effective interventions. There is a dose-
response relationship between quit rates and
the intensity of counseling (that is, more or
longer sessions improve quit rates). Quit
rates seem to plateau after 90 minutes of
total counseling contact time. Helpful
components of counseling include problem-
solving guidance for smokers (to help them
develop a plan to quit and overcome
common barriers to quitting) and the
provision of social support as part of
treatment. Complementary practices that
improve cessation rates include
motivational interviewing, assessing
readiness to change, offering more intensive
counseling or referrals, and using telephone
"quit lines."
BEHAVIORAL HEALTH AND SUBSTANCE
October 1, 2015 ABUSE SERVICES Attachment C Page 3
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care Covered Services Description of Treatment Level Utilization Management
Outpatient Services
Level 1 1. Medication management A clinic model that meets the certification Prior authorization is required
Outpatient 2. 24-hour crisis intervention services face requirement NAC 458.103 for alcohol and drug on services after service
Services to face or telephonically available seven abuse programs. limitations have been
days per week exceeded.
3. Behavioral Health/Substance Abuse The entity will provide medical, psychiatric,
Covered Screens psychological services, which are available Post authorization is not
4. Comprehensive biopsychosocial onsite or through consultation or referral. required for substance use
assessment Medical and psychiatric consultations are only crisis intervention.
5. Individual and group counseling available within 24 hours by telephone or in Refer to MSM 400 for co-
6. Individual, group, family psychotherapy person, within a time frame appropriate to the occurring and mental health
7. Peer Support Services severity and urgency of the consultation. crisis intervention services
Emergency services available by telephone 24 and limitations.
hours a day, seven days a week. Recovery and
self-help groups are a part of the overall milieu. Peer Support Services can
All other services are individually billed. be utilized for up to 18
hours/72 units annually
before prior authorization is
required.
Individual, group, family
psychotherapy and
counseling services can be
utilized for up to 26 total
sessions for children and
adolescents and up to 18
total sessions for adults
before prior authorization is
required.
BEHAVIORAL HEALTH AND SUBSTANCE
October 1, 2015 ABUSE SERVICES Attachment C Page 4
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care Covered Services Description of Treatment Level Utilization Management
Outpatient Services
Level 2 An evidenced based/best practice model Frequencies and intensity are appropriate to the Prior authorization is
2.1 Intensive providing a minimum amount of skilled objectives of the treatment plan. required on services,
Outpatient structured programming hours per week. except for: Behavioral
Treatment During the day, before or after work setting, Requires a comprehensive interdisciplinary Health/Substance Abuse
evening and/or weekend. Provides a milieu program team approach of appropriately Screens and 24-hour crisis
“real world” environment. The milieu is a credentialed addiction treatment professionals, intervention.
combination of skilled treatment services. including addiction – credentialed physicians
who assess and treat substance-related Post authorization is not
1. Medical and psychiatric consultation disorders. Some staff are cross trained to required for 24-hour crisis
2. Psychopharmacological consultation understand the signs and symptoms of mental intervention.
3. Medication management disorders and to understand and explain the uses
4. 24-hour crisis intervention services face to of psychotropic medications and interactions
face or telephonically available seven with substance-related disorders.
days per week
5. Comprehensive biopsychosocial
assessments
6. Behavioral Health/Substance Abuse
Covered Screens
7. Individual and group counseling
8. Individual, group, family psychotherapy
9. Self-help/recovery groups
2.5 Partial 1. Outpatient hospital setting. Same as above, in addition psychiatric and Prior authorization is
Hospitalization 2. All Level 2.1 services in addition need the medical management. required on services,
direct access to psychiatric, medical except for: Behavioral
and/or laboratory services. Intensity of service required is higher than can Health/Substance Abuse
be provided in Intensive Outpatient Treatment. Screens and 24-hour crisis
intervention.
Post authorization is not
required for 24-hour crisis
intervention.
BEHAVIORAL HEALTH AND SUBSTANCE
October 1, 2015 ABUSE SERVICES Attachment C Page 5
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care Covered Services Description of Treatment Level Utilization Management
Outpatient Services
Level 3 Medical, psychiatric, psychological services, A clinic model that meets the certification Prior authorization is
Residential which are available onsite or through requirement NAC 458.103 for alcohol and drug required on services, after
3.1-3.5 Managed consultation or referral. Medical and abuse programs. Room and board are not a service limitations have
Residential psychiatric consultations are available within reimbursable service through the DHCFP been exceeded.
24 hours by telephone or in person, within a outpatient program.
time frame appropriate to the severity and Post authorization is not
urgency of the consultation. The entity will provide medical, psychiatric, required for substance
psychological services, which are available abuse only crisis
1. 24-hour crisis intervention services face to onsite or through consultation or referral. intervention. Refer to
face or telephonically available seven Medical and psychiatric consultations are MSM 400 for co-occurring
days per week available within 24 hours by telephone or in and mental health crisis
2. Medication management person, within a time frame appropriate to the intervention services and
3. Behavioral Health/Substance Abuse severity and urgency of the consultation. limitations.
Covered Screens Emergency services available by telephone 24
4. Comprehensive biopsychosocial hours a day, seven days a week. Recovery and Peer Support Services can
assessment self-help groups are a part of the overall milieu. be utilized for up to 18
5. Individual and group counseling All other services are individually billed. hours/72 units annually
6. Individual, group, family psychotherapy before prior authorization
7. Peer Support Services is required.
Individual, group, family
psychotherapy and
counseling services can be
utilized for up to 26 total
sessions for children and
adolescents and up to 18
total sessions for adults
before prior authorization
is required.
Intensity of service is
dependent upon individual
and presenting symptoms.
BEHAVIORAL HEALTH AND SUBSTANCE
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ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care Covered Services Description of Treatment Level Utilization Management
Detoxification Services
Inpatient Services
Level 4 Medically Inpatient substance abuse services are those Reference Section 403.10. Prior Authorization
Managed services delivered in freestanding substance required. Reference
Intensive abuse treatment hospitals or general hospitals Inpatient Section 403.10.
Inpatient and with a specialized substance abuse treatment
Withdrawal unit which includes a secure, structured
Management environment, 24-hour observation and
Services supervision by mental health substance abuse
professionals and a structured multi-
disciplinary clinical approach to treatment.
These hospitals provide medical
detoxification and treatment services for
individuals suffering from acute alcohol and
substance abuse conditions.
Services provided in:
1. An acute care general hospital with a
psychiatric unit,
2. A free standing psychiatric (patients ages
22-64 are non-covered), and
3. A licensed chemical dependency specialty
hospital with acute care medical and
nursing staff.
BEHAVIORAL HEALTH AND SUBSTANCE
October 1, 2015 ABUSE SERVICES Attachment C Page 7
ATTACHMENT D
POLICY #04-05 INSTITUTION FOR MENTAL DISEASE (IMD)
A. DESCRIPTION
Nevada Medicaid Fee-for-Service (FFS) shall not reimburse for any services for individuals who are ages
22-64 years that are in an Institution for Mental Disease (IMD). An IMD is defined as a hospital, nursing
facility or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment
or care of persons with mental diseases, and also provides for medical attention, nursing care and related
services.
B. COVERAGE AND LIMITATIONS
1. Institution for Mental Disease (IMD) Exclusion - In accordance with 42 CFR 435.1009(2), Federal
Financial Participation (FFP) is not available for institutionalized individuals who are individuals
under the age of 65 who are patients in an institution for mental diseases (IMD) unless they are
under age 22, and are receiving inpatient psychiatric services under 42 CFR 440.160, which is a
psychiatric hospital or a residential treatment center for recipients under the age of 21 years. See
(2e) for additional clarification.
a. All services are excluded from Medicaid payment while a recipient is admitted to an IMD,
whether the services are provided in or outside the facility.
2. In accordance with 42 CFR 435.1010: Definition of IMD means a hospital, nursing facility or other
institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care
of persons with mental disease, and also provides for medical attention, nursing care and related
services. Whether an institution is an institution for mental diseases is determined by its overall
character being that of a facility established and maintained primarily for the care and treatment of
individuals with mental diseases, whether or not it is licensed as such.
a. Facilities licensed as acute care hospitals and/or nursing facilities with designated
psychiatric beds are reviewed based upon their aggregate bed counts.
b. The Centers for Medicare and Medicaid Services (CMS) Manual for IMD states, alcohol
and other chemical dependency syndromes are classified as mental disorders, which
subject them to the IMD regulations. The manual gives further guidance that services
delivered by laypersons that do not constitute a medical or remedial model such as
Alcoholics Anonymous do not qualify for federal matching funds. The “major factor
differentiating these facilities from other chemical dependency treatment facilities are the
primary reliance on lay staff.” Chemically dependent patients admitted for CD treatment
are counted as mentally ill under the 50% guideline.
c. An institution for individuals with Intellectual and Developmental Disabilities is not
considered an institution for mental diseases.
d. Periods of Absence: Regulation allows for an individual to have a conditional release or
convalescent leave from the IMD. During this time period the patient is not considered to
be in the IMD. Services may be covered by Medicaid during this time period for emergency
or other medical treatment. The periods of absence relate to the course of treatment of the
recipient’s mental disorder. If the patient needs emergency or other medical treatment
MENTAL HEALTH AND ALCOHOL/SUBSTANCE
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ATTACHMENT D
POLICY #04-05 INSTITUTION FOR MENTAL DISEASE (IMD)
during this time period, these services may be covered because the patient is not considered
to be in an IMD. If a patient is transferred while in the IMD for the purpose of obtaining
medical treatment, it is not considered a conditional release and is not a covered service.
1. Convalescent – when a patient is sent home for a trial visit.
2. Conditional release – when a patient is released from the institution on the condition
that the patient receives outpatient treatment or other comparable services.
e. Coverage of services for ages 21 up to 22 years – If a patient is receiving services
immediately prior to turning age 21years, the services continue until the earlier of the date
the individual no longer requires the services or the date the individual reaches 22. In this
extenuating circumstance, IMD service may continue until age 22. The regulation requires
that the patient must be receiving services immediately prior to age 21 and continuously
up to age 22. Services cannot begin during the 21st year.
3. Guidelines for Determining if a facility is an IMD: The CMS has deferred the completion of the
determination if a facility is an IMD to the DHCFP. The DHCFP utilizes the criteria as listed in
the CMS Medicaid Manual for this determination. The criteria include factors such as, but not
limited to:
a. Facility ownership is one single owner or governing body;
b. The Chief Medical Officer is responsible for medical staff activities in all components;
c. The Chief Executive Officer is responsible for administrative activities in all components;
d. The licensure of each component;
e. The geographic location of each facility;
f. The Condition of Participation of each component;
g. The relationship to the State Mental Health Authority;
h. The patient records; that provide evidence of psychiatric/psychological care and treatment;
and
i. The current need for institutionalization for more than 50% of all the patients in the facility
is resulting from mental disease, including but not limited to the bed count.
4. Medicaid may reimburse co pays and/or deductibles for Qualified Medicare Beneficiaries (QMB)
while in an IMD.
(State Medicaid Manual Chapter 4, http://www.cms.gov/Regulations-and-Guidance/Guidance/
Manuals/Paper-Based-Manuals-Items/CMS021927.html )
MENTAL HEALTH AND ALCOHOL/SUBSTANCE
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 500
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
NURSING FACILITIES
500 INTRODUCTION
Nursing Facility (NF) services for individuals age 21 and older is a mandatory Medicaid benefit.
NFs are institutions that provide a full range of nursing services from intermediate care at the lower
level up to and including skilled nursing services. NFs provide health related care and services on
a 24-hour basis to individuals who, due to medical disorders, injuries, developmental disabilities
and/or related cognitive and behavioral impairments, exhibit the need for medical, nursing,
rehabilitative and psychosocial management above the level of room and board. NF services
include services for people who cannot live on their own because they need assistance with certain
activities of daily living such as bathing, dressing, eating, toileting and transferring. NFs also
provide skilled nursing care and related services for individuals who require medical or nursing
care and/or rehabilitation services.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), with the exception of those listed in the NCU manual Chapter 1000.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 501
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
501 AUTHORITY
In 1965, Congress authorized the Medicaid Program by adding Title XIX to the Social Security
Act (SSA). Title XIX of the SSA requires that in order to receive Federal matching funds, certain
basic services including NF services for individuals age 21 and older must be offered to the
categorically needy population in any State program. As an optional service, Nevada Medicaid
also provides NF services for individuals under the age of 21.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 502
Subject:
MEDICAID SERVICES MANUAL RESERVED
502 RESERVED
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 503
Subject:
MEDICAID SERVICES MANUAL POLICY
503 POLICY
503.1 PROVIDER REQUIREMENTS
A NF must comply with the following requirements in order to be eligible to participate in the
Nevada Medicaid program All in-state NFs must:
A. Be licensed by the Division of Public and Behavioral Health (DPBH), Bureau of Health
Care Quality and Compliance (BHCQC) in accordance with the Nevada Revised Statute
(NRS) and the Nevada Administrative Code (NAC).
B. Be certified by the Centers for Medicare and Medicaid Services (CMS) which assures that
the NF meets the federal requirements for participation in Medicaid and Medicare per 42
Code of Federal Regulations (CFR) 483.
C. Be enrolled as an NF provider in the Nevada Medicaid program as described in Chapter
100 of the Medicaid Services Manual (MSM).
D. Accept payment in full for covered services, the amounts paid in accordance with Medicaid
policy and not charge a Medicaid recipient for any services covered by Medicaid
reimbursement.
E. Assure that all claims submitted to Nevada Medicaid’s fiscal agent for NF services are
accurate and timely.
F. Comply with all Federal and State laws, rules and regulations.
Continued participation as a Nevada Medicaid provider will be subject to recertification and
compliance with all Federal and State laws, rules and regulations.
Nevada Medicaid will terminate and NF provider contract upon notice that the NF is no longer
licensed and/or certified to provide NF services.
Nevada Medicaid will honor, abide by and impose any and all State and Federal sanctions as
directed by BHCQC and/or CMS.
Nevada Medicaid staff will refer any possible non-compliance with state and/or federal regulations
to the BHCQC for investigation and follow-up.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 503
Subject:
MEDICAID SERVICES MANUAL POLICY
503.2 PROGRAM PARTICIPATION
A. All Medicaid participating NFs must provide or arrange for services including nursing
services, social services, rehabilitative services, pharmacy services, dietary services,
activity programs and emergency and routine dental services to the extent covered under
the State Plan. In accordance with the federal statutory and regulatory requirements under
42 CFR 483 and the state regulations under NRS 449 and NAC 449, NFs must also provide
treatment and services required by individuals with intellectual disabilities not otherwise
provided or arranged for by the State, and all other ancillary and supportive services
necessary to improve and/or maintain the overall health status of its residents.
B. The NF must ensure that each Medicaid recipient is admitted to the facility by a physician
and has the benefit of continuing heath care under the supervision of a physician. The NF
is responsible to ensure that upon admission, the physician provides to the facility sufficient
information to validate the admission and develop a medical Plan of Care (POC). The POC
must include diet, medications, treatments, special procedures, activities and specialized
rehabilitative services, if applicable, the potential for discharge. Physician’s visits must be
conducted in accordance with federal requirements. Physician’s visits made outside the
requirements must be based upon medical necessity criteria.
C. The NF must maintain records on each recipient in accordance with accepted professional
standards and practices. Recipient records must be complete, accurately documented,
organized and readily available. At a minimum, the record must contain sufficient
information to identify the recipient, a record of the recipient’s assessments, the POC and
services ordered and provided the results of the Pre-Admission Screening and Resident
Review (PASRR) screenings, the results of the Level of Care (LOC) Assessment screening
and progress notes. The record must also contain relevant documentation to support the
Minimum Data Set (MDS) coding. All entries must be signed and dated with the
professional title of the author.
D. Documentation of specialized services provided or arranged for, and the resident’s
response to such services must remain in the active medical record as long as the resident
is recommended to receive specialized services. This documentation must be available for
state and federal reviewers.
E. The facility must report their census information by midnight on the fifth day of each
month. This will include the number of vacant beds in the facility which are available for
resident occupancy.
F. The facility is responsible for ensuring the census information is accurate, complete and
submitted timely.
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G. The facility must submit this report to Nevada Medicaid Central Office by the fifth day of
the month reported. For example, the January 1st census information must be reported to
the Nevada Medicaid Central Office by January 5th.
H. If the number of certified beds has changed, the facility must submit a copy of the
certification to Nevada Medicaid.
I. The provider must provide for the safekeeping of personal effects, funds and other property
of the recipient. The provider must develop policies and procedures to minimize the risk
of theft or loss of the personal property of residents. Recipients and their legal
representatives must be notified of these policies and procedures. The NF must be
adequately covered against liabilities and purchase a surety bond or otherwise provide
assurance of the security of all personal funds deposited with the facility.
503.3 RECIPIENT RESPONSIBILITY
The recipient, upon request, must present:
A. a valid Medicaid card; and
B. any form of identification necessary to utilize other health insurance coverage for any and
all services.
503.4 PRE-ADMISSION SCREENING AND RESIDENT REVIEW (PASRR)
AUTHORITY
Authority to maintain a PASRR program comes from Public Law 100-203 (OBRA 87) in Subtitle
C – Nursing Home Reform Part 2 – Section 1919(b3)(F); Title 42 CFR Section 483.100 – 483.138;
an Interagency Agreement between the Division of Health Care Financing and Policy (DHCFP) –
Nevada Medicaid, the Department of Public and Behavioral Health (DPBH) and the Aging and
Disability Services Division (ADSD); the Nevada State Plan, Attachment 1.2-B, Page 10; NAC
449.74425 and NRS 449.037.
The DHCFP, Nevada Medicaid, is responsible for development of policies and procedures and the
oversight of all operations related to the PASRR program. The DHCFP contracts with the Quality
Improvement Organization (QIO)-like vendor to conduct Level I identification screenings and
PASRR Level II determinations. The DHCFP acts as the mental health/intellectual disabilities
authority for PASRR’s through a Memorandum of Understanding (MOU) with DPBH, and ADSD.
The DPBH is designated to provide and/or follow up on all specialized services. The BHCQC
monitors and investigates compliance with PASRR through the survey process.
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Compliance with all state and federal PASRR regulations is required. Non-compliance with the
PASRR screening requirements may be referred to CMS and/or the BHCQC for investigation.
The provider must assure that every resident is screened in accordance with state and federal
PASRR regulations.
The provider must ensure that facility staff is knowledgeable regarding the PASRR process and
the implications of a facility’s failure to comply with state and federal regulations. The provider
must ensure staff participates in state and federal sponsored PASRR-related training.
The provider must present to state and federal reviewers the active medical record containing the
applicable proof of Level I, and when indicated, Level II screenings completed prior to admission
and the most recent screenings of the individual experienced a significant change in his/her
physical/mental condition.
The provider must provide to state and federal reviewers, documentation supporting the provision
of any specialized services for any individual identified as needing specialized services. This may
include the DPBH or ADSD case manager documentation in the record.
A. DEFINITIONS
LEVEL I IDENTIFICATION SCREENING
A Level I identification screening must be completed by a licensed health care professional
on all applicants to an NF, without exception and regardless of payment source, prior to
placement in a Medicaid-certified NF. The licensed health care professional completing
the Level I Identification Screening form attests that the individual (or appropriate family
and/or guardian) has been informed that he/she is being considered for NF placement. This
screening is also required for residents of an NF any time a Level II screening is requested;
such as, when a current NF resident experiences a significant change in his/her physical or
mental status or a prior PASRR Level II needs to be updated. The purpose of this screening
is to identify any indicators of mental illness, intellectual disabilities or a related condition
and to make referrals for PASRR Level II screenings.
The Level I determination identifies that the individual either has or does not have
indicators of mental illness, intellectual disabilities or a related condition. If there are no
indicators of mental illness, intellectual disabilities or a related condition, the individual is
cleared through PASRR screening for admission to an NF. The QIO-like vendor will issue
a determination letter to the requestor.
If there are indicators of mental illness, intellectual disabilities or a related condition, a
determination letter is given to the requestor and the individual screened and/or their legal
representative that they are being referred for a PASRR Level II screening. A PASRR
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
Level II screening must be completed to determine the appropriateness of placement in an
NF prior to admission to an NF.
It is the responsibility of the discharging facility to request and obtain a Level I screening,
and when indicated, a PASRR Level II screening prior to discharging the individual to any
NF placement.
B. LEVEL II SCREENING
When an individual has been identified with possible indicators of mental illness,
intellectual disabilities or related condition, a PASRR Level II screening must be
completed to evaluate the individual and determine if NF services and/or specialized
services are needed and can be provided in the NF.
There are two types of PASRR Level II screenings. The Pre-Admission Screening (PAS)
refers to a PASRR Level II screening completed on a applicant for NF placement. The
Resident Review (RR) refers to a PASRR Level II screening completed on a current
resident of an NF who experiences a significant change in his/her physical or mental
condition, or had previously been exempted from or was time-limited under a prior PASRR
Level II screening. Within the Level II screening, there are two processes, a categorical
determination or an individual evaluation and determination.
C. PASRR LEVEL II INDIVIDUAL EVALUATION AND DETERMINATION
If a PASRR Level II Individual Evaluation and Determination screening is indicated
through the Level I Identification screening process, the QIO-like vendor’s clinical
reviewers will make the necessary arrangements for the screening and will notify the
requestor.
When the PASRR Level II screening is completed, a Summary of Findings will be provided
by the QIO-like vendor to the requestor in the same manner it was requested. (i.e. If the
request was faxed in, it will be faxed back, if the request was submitted online, the requester
will be able to print the results when completed).
When the facility identifies a significant change in status, as defined in the Resident
Assessment Instrument (RAI) User’s Manual for either the mental or physical status of a
resident, a Resident Review (RR) must be requested, through the submission of a Level I
screening request. The QIO-like vendor will review the information and determine whether
an RR is necessary. If needed, the QIO-like vendor will proceed with the arrangements for
the PASRR Level II evaluation.
The provider must not admit the potential resident until the facility receives confirmation
from the QIO-like vendor of the completion of Level II screening.
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DIVISION OF HEALTH CARE FINANCING AND POLICY 503
Subject:
MEDICAID SERVICES MANUAL POLICY
If the facility admitted a resident under the Exempted Hospital Discharge, for a less than
30 day stay, and the resident is later found to require more than 30 days of NF care, the
facility must request the PASRR Level II (RR) by submitting a completed Level I
identification screening to the QIO-like vendor by the 25th day of the admit date.
The provider must track limitation dates on Exempted Hospital Discharges and Categorical
Determinations. Before any PASRR limitation date, request the PASRR Level II (RR) by
submitting a completed Level I Identification to the QIO-like vendor in a time frame that
allows completion of the PASRR II prior to the limitation date.
The provider must assess all residents on an ongoing basis to identify if a resident (1)
develops mental illness, or (2) a resident who was not previously identified through the
Level I Identification screening as having indicators of MI, IID or RC and is now displaying
indicators, or (3) the facility has identified the need for a “Significant Change in Status
Assessment” (SCSA) MDS. Any of these may indicate the need for a PASRR Level II
screening (RR).
Within 14 days of the identification of a significant change in status, the facility must
complete and submit a Level I identification screening to the QIO-like vendor clinical
reviewers. The QIO-like vendor clinical reviewers will review the information to determine
if a PASRR Level II screening (RR) is indicated. The provider may accept verbal
determinations from the QIO-like vendor.
The provider must not admit an individual who has been determined to not need NF
services.
The provider must report all discharges directly related to a PASRR determination that an
individual is not appropriate for NF services to the Medicaid office on the Nursing Facility
Tracking Form.
503.5 EXEMPTED HOSPITAL DISCHARGE
The only exemption from a PASRR Level II screening is when the Level I Identification screening
showing indicators of mental illness, intellectual disabilities or related condition identifies the
individual meets all the following criteria for an exempted hospital discharge:
A. Is to be admitted to any NF directly from a hospital after receiving acute inpatient care at
the hospital (this does not include admissions from emergency rooms, observation beds or
rehabilitation units);
B. Requires NF services for the condition for which he or she received care in the hospital;
and
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 503
Subject:
MEDICAID SERVICES MANUAL POLICY
C. The attending physician has certified before admission to the NF that the individual is
likely to require less than 30 days of NF services.
This determination will be made only by the QIO-like vendor’s clinical reviewers. If a facility is
requesting to admit under the Exempted Hospital Discharge, supporting proof of the above three
requirements must be submitted with the Level I Identification screening form to the QIO-like
vendor clinical reviewers.
1. ADVANCED GROUP CATEGORICAL DETERMINATION
Before proceeding with a PASRR Level II Individual Evaluation, the QIO-like vendor’s
clinical reviewers will determine that an individual requires NF services, and meets any
one of the following criteria for an Advanced Group Categorical Determination:
a. Convalescent Care from an acute physical illness with required hospitalization and
does not meet all the criteria for an exempted hospital discharge.
b. Terminal Illness in which a physician has certified that life expectancy is six months
or less.
c. Severity of Illness limited to: comatose, ventilator dependent, functioning at brain
stem level, Chronic Obstructive Pulmonary Disease (COPD), Severe Parkinson’s
Disease, Huntington’s Disease, Amyotrophic Lateral Sclerosis (ALS) or
Congestive Heart Failure (CHF). In addition to having one or more of these
diagnoses, due to the severity of the illness, it is anticipated the individual is not
expected to benefit from specialized services.
d. Provisional Admission for cases of:
1. Delirium where and accurate diagnosis cannot be made until the delirium
clears; or
2. Emergency situations requiring protective services with placement in the
NF not to exceed seven days; or
3. Respite to in-home caregivers to whom individuals with MI or IID is
expected to return following a brief NF stay.
If it is determined the individual meets one of the above criteria, the QIO-like
vendor’s clinical reviewer will make a categorical determination. If the
determination is for an advanced group categorical determination, the
determination effective dates may be limited and will require an updated PASRR
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DIVISION OF HEALTH CARE FINANCING AND POLICY 503
Subject:
MEDICAID SERVICES MANUAL POLICY
Level II (RR) if the individual’s stay is expected to exceed the limitation date (see
below).
2. COORDINATION AND/OR PROVISION OF SPECIALIZED SERVICES
The provider must provide or arrange for the provision of specialized services when an
individual has been recommended for such services through the Level II screening process.
The provider must ensure an interdisciplinary team (which includes a physician, qualified
mental health professionals (which may include DPBH and ADSD staff) and other
professionals) develops and supervises and individualized POC which addresses the
ongoing mental health needs of the resident and results in appropriate treatment.
The provider must notify the DPBH/ADSD upon receiving any Level II screening
determination that indicates an individual needs specialized services, to arrange for those
services.
The provider must cooperate with DPBH/ADSD PASRR coordination staff who are
providing or monitoring the provision of specialized services. DPBH/ADSD staff my
contact the facility to arrange for periodic on-site visits with the resident, participate in
interdisciplinary care conferences, document each on-site visit and care conference in the
active medical record (indicating progress or lack of progress with the specialized services
prescribed), and make recommendations for changes to the specialized services needed
based on progress or lack of progress.
503.6 ADMISSIONS FROM OTHER STATES
It is the responsibility of the transferring state/facility to ensure the individual has had a Level I
screening and when indicated, a PASRR Level II screening completed in the state they are
transferring from, prior to sending the individual to a Nevada facility.
It is the receiving Nevada facility’s responsibility to obtain a copy and verify the completion of
the out-of-state screening. The receiving Nevada facility must also complete and submit a Level I
Identification Screening for to the QIO-like vendor to obtain a Nevada screening within one
business day of the admission.
503.7 DISCHARGES OR TRANSFERS
The provider must forward copies of the most recent Level I and, when applicable, Level II
screening to the receiving facility upon discharge or transfer of a resident.
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Subject:
MEDICAID SERVICES MANUAL POLICY
The provider must notify the DPBH PASRR coordination staff of a discharge of any resident who
has been receiving specialized services and provide them with information about where the
individual is being discharged to.
503.7A REIMBURSEMENT
Federal regulation prohibits Medicaid reimbursement to NFs under certain circumstance, such as,
but not limited to:
1. An individual is admitted to an NF without a Level I screening. Medicaid reimbursement
is not available until the date a Level I screening is completed, if there are no indications
of MI, MR or RC.
2. An individual with indicators of MI, MR or RC is admitted to an NF before the completion
of the PASRR Level II evaluation; unless an Exempted Hospital Discharge has been
approved through Level I process (see below). Medicaid reimbursement is not available
until the date the Level II screening is completed indication NF placement is appropriate.
3. A provider who fails to obtain a completed PASRR Level II screening by day 30 of an
admission under the Exempted Hospital Discharge. Medicaid reimbursement is not
available until the date of the PASRR II evaluation is completed indicating NF placement
is appropriate.
4. A provider fails to obtain an RR Level II individual evaluation prior to the limitation date
of a previously limited categorical determination. Medicaid reimbursement is not available
until the PASRR II evaluation is completed indication NF placement is appropriate.
5. A provider fails to request a Nevada screening with one business day of admission when a
resident is admitted to a Nevada NF from out-of-state. No Medicaid reimbursement is
available until the date the Nevada Level I and, when indicated, the Level II is completed.
6. For individuals who have been determined, through the PASRR process, to not need the
services of an NF.
503.7B PASRR HEARINGS
In accordance with 42 CFR 483.204 Subpart E, an individual who has been adversely affected by
any PASRR determination made by the State in the context of either an PAS or an RR, has the
right to appeal that determination.
Please reference Nevada MSM Chapter 3100, for Medicaid recipient hearing policy.
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503.8 LEVEL OF CARE (LOC)
If the individual is Medicaid eligible, an LOC screening must be completed prior to NF admission.
This includes individuals utilizing other insurance as a primary pay source at the time of admission.
If the recipient becomes Medicaid eligible after NF admission, the LOC screening must be
completed prior to obtaining a billing authorization for Medicaid reimbursement.
If an individual becomes Medicaid eligible after death or discharge from an NF, the LOC screening
may be requested and determined retroactively.
The requestor must submit an LOC screening form with the required documentation to the QIO-
like vendor. An LOC determination must be completed by the QIO-like vendor. The NF must
receive a copy of the screening indicating the Medicaid Eligible individual has a nursing facility
level of care prior to admission.
LOC determinations may be time-limited. Reasons for time limitations may include, but are not
limited to: total hip or knee replacement, compound fracture, pneumonia or recent wound care.
These determinations may be limited to 90 days. The provider must monitor LOC determinations
that are time-limited and request an updated LOC determination prior to the expiration date.
It is the NF’s responsibility to verify an LOC determination has been made and the recipient meets
an NF LOC. The NF may contact the QIO-like vendor to obtain verification of the determination
and a copy of the determination letter.
The provider must request an updated LOC determination if a recipient’s condition changes
significantly. For example, if a recipient who was previously determined to meet an NF Standard
or Pediatric Specialty Care I later becomes ventilator dependent, the NF must request a new LOC
determination to establish Ventilator Dependent or Pediatric Specialty Care II. Conversely, if a
recipient’s condition improves and the recipient was previously determined to meet a Pediatric
Specialty Care II, the NF must request a new determination to establish the appropriate LOC.
If it is later discovered that the recipient’s condition warranted an updated screening and the facility
failed to obtain the determination, the fiscal agent may recoup funds paid to the facility
inappropriately.
In the event a recipient is discharged to a community based setting and is later readmitted to the
NF, the NF must contact the QIO-like vendor screening office to determine whether the LOC
determination is still valid (based on the recipient’s current condition), or if a new LOC
determination is needed.
When a recipient does not meet a nursing facility LOC and an NF chooses to admit the recipient,
Medicaid reimbursement will not be authorized for the NF.
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On initial and subsequent screenings, the QIO-like vendor determines whether the LOC provided
or to be provided should be approved based on medical necessity. There are four possible LOC
categories based on the care needs and nursing requirements for each individual as determined by
the LOC assessment. These include:
A. NF Standard;
B. NF Ventilator Dependent;
C. Pediatric Specialty Care I; and
D. Pediatric Specialty Care II.
Each of these categories is associated with a provider specific rate for each free-standing NF.
After an LOC has been established, the NF my also request approval the Behaviorally Complex
Care Program; which also has associated rates.
NF Ventilator Dependent is limited to recipients who are dependent on mechanical ventilation for
a minimum of six out of the 24 hours per day and is an all-inclusive rate. NF and respiratory
therapists are not allowed to bill separately for ventilator management services, small volume
nebulizer treatments, tracheostomy changes, etc.
NF Ventilator Dependent Rate: a physician’s order specifying the ventilator support must
accompany the screening request. Current medical records must verify that the ventilator support
is required for a minimum of six hours within a 24-hour period. The medical records must also
include the date the recipient was placed on the ventilator.
503.9 PEDIATRIC SPECIALTY CARE
Pediatric Specialty Care I and II are limited to recipients who are children from birth to 21 years
of age who require specialized, intensive, licensed skilled nursing care beyond the scope of
services provided to the majority of NF recipients.
The QIO-like vendor must determine the recipient meets both an NF LOC as well as a Pediatric
Specialty Care LOC prior to authorization. Pediatric Specialty Care rates are approved for a
maximum of six months but may be extended with an updated LOC screening and supporting
documentation. If a new authorization is not obtained prior to expiration of the previous specialty
care authorization, the NF will be reimbursed at the NF standard rate until such time a new
pediatric specialty care LOC is determined.
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Documentation must be submitted with request to support all treatment and services listed above.
Time limited treatments may be authorized up to 90 days. Requests for extension may be granted
with supporting documentation.
503.9A PEDIATRIC SPECIALTY CARE I
The patient’s condition requires 24-hour access to nursing care by a Registered Nurse (RN) and
the recipient has one or more of the following items (a-c): (a) A tracheostomy that requires
suctioning, mist or oxygen and at least one treatment listed in the treatment procedures section
below; (b) dependence on Total Parenteral Nutrition (TPN) or other Intravenous (IV) nutritional
support and at least one treatment listed in the treatment procedure section below; (c)
administration of at least two treatment procedures below. See Treatment Procedures below.
503.9B PEDIATRIC SPECIALTY CARE II
The patient’s condition requires 24-hour access to nursing care by an RN and the recipient has one
or more of the following item (a-c); A tracheostomy that requires mechanical ventilation a
minimum of six hours out of 24 hours per day; (b) patient is on a ventilator weaning program
(approval will be time limited); (c) administration of at least three treatment procedure below.
503.9C TREATMENT PROCEDURES
1. Intermittent suctioning at least every eight hours and mist or oxygen as needed;
2. Daily respiratory care (60 minutes or more per day or continuous oxygen and saturation
monitoring or percussion therapy);
3. IV therapy involving:
a. Administration of continuous therapeutic agents; or
b. Hydration; or
c. Intermittent IV drug administration of more than one agent.
4. Peritoneal dialysis treatments requiring at least four exchanges every 24 hours.
5. Tube utilization (nasogastric or gastrostomy; Foley, intermittent catherization; PEG, rectal
tube).
6. Complex wound care (including stage III or IV decubitus wound or recent surgical or other
recent wound) requiring extensive dressing or packing approval will be time limited.
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7. Seizure precautions.
8. Moderate behavior issues (including self-abuse) – describe the problem.
9. Central or Peripherally Inserted Central Catheter (PICC) line management.
10. Maximum assist required (quadriplegia or Hoyer lift).
11. Other special treatment(s) not listed above. The provider must describe in detail.
Provider Qualifications for Pediatric Specialty Care Rates:
In addition to Medicaid contractual obligations and all other provider rules contained in MSM
Chapters 100 and 500, a free-standing NF must meet specified criteria to qualify for Pediatric
Specialty Care rates. An on-site visit by the DHCFP staff is made to verify the NF meets the
following criteria:
12. Physical facility requirements:
a. Pediatric Specialty Care must be provided in a distinct, identifiable unit or area of
the NF.
b. The accommodating beds include contiguous rooms, wing, floor or building of the
NF.
13. Staffing Requirements:
a. The NF must employ an RN as the Pediatric Specialty Care Unit’s head nurse. The
head nurse must have specialized pediatric training and at least one year’s
experience in pediatric nursing.
b. The NF must ensure that an RN with pediatric training and experience is on duty
24 hours per day on the Pediatric Specialty Care Unit.
503.10 BEHAVIORALLY COMPLEX CARE PROGRAM
The Behaviorally Complex Care Program (BCCP) is for those Nevada Medicaid recipients with a
severe, medically-based behavior disorder. Medically-based disorders may include (not all
inclusive) traumatic/acquired brain injury, dementia, Alzheimer’s, Huntington’s Chorea, which
causes diminished capacity for judgement, or a resident, who meets the Medicaid criteria for
nursing facility level of care and who has a medically-based mental health disorder or diagnosis
and exhibits significant behaviors. Those facilities that request and are approved to administer the
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BCCP are reimbursed with a tiered rate established with the intention of providing in-state care
that addresses the recipient’s needs.
NFs must demonstrate that the resident has a history of persistent disruptive behavior that is not
easily altered and requires an increase in resources from nursing facility staff as documented by
one or more of the following behaviors:
A. The resident engages in verbally abusive behavior where he threatens, screams or curses at
others;
B. The resident presents a threat of hitting, shoving, scratching or sexually abusing other
residents.
C. The resident engages in socially inappropriate and disruptive behavior by doing one of the
following:
1. Makes disruptive sounds, noises and screams;
2. Engages in self-abuse acts;
3. Inappropriate sexual behavior;
4. Disrobes in public;
5. Smears or throws food or feces;
6. Hoards; and
7. Rummages through others belongings.
D. The resident refuses assistance with medication administration or activities of daily living.
Presence of elopement or wandering behavior alone, not in conjunction with aggressive or
assaultive behaviors exhibiting a danger to self or others, does not qualify a recipient for the BCCP.
The BCCP is not appropriate for those caring for suicidal individuals. Individuals who are suicidal
should be transferred to an acute facility to ensure their safety and appropriate LOC. The BCCP
may be requested while the recipient is in an acute placement if there is sufficient documentation
to the support a medically based behavior disorder.
503.10A PROVIDER RESPONSIBILITY
Facilities must demonstrate competency to adequately address the individual’s behavior. All
behavior intervention programs must:
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1. Be part of an individualized behavior modification plan;
2. Apply a precisely planned systematic application of the methods and findings of behavioral
science with the intent to reduce observable negative behaviors;
3. Incorporate processes and methodologies that are the least restrictive alternative available
for producing the desired outcomes;
4. Be conducted following only identification and, if feasible, remediation of environmental
and social factors that likely precipitate or reinforce the inappropriate behavior;
5. Incorporate a process for identifying and reinforcing a desirable replacement behavior.
Behavior modification programs include, but are not limited to:
1. Staff training
2. Sensory Stimulation
3. Behavior Management
4. Cognitive Emotion Oriented Therapy
5. Environmental Modification
6. Clinically-Oriented Therapy
Documentation supporting the service need must be provided to the Facilities Unit in DHCFP
Long Term Support Services (LTSS) by a person professionally qualified in the field of psychiatric
mental health as defined in NRS 433.209 and clearly document the severe medically based
behavior disorder or other medical condition prompting the approval of the BCCP.
Tiered rates have been established to cover the broad milieu of accommodations to meet patient
needs. Behaviors and their frequency of occurrence will assist in establishing/requesting the
appropriate Tier Level. The following is a guide for requesting:
Tier 1: Behaviors requiring a minimal amount of intervention or assistance.
Tier 2: Serious behaviors requiring moderate intervention.
Tier 3: Extreme behaviors exhibiting danger to themselves or other requiring frequent
intervention.
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The BCCP care level requires prior authorization. If approved, reauthorization will be required.
Reauthorization timeframes are based on the approved tier. Refer to the Billing Guidelines for
frequency of reauthorization. In addition, facilities are also required to report to the DHCFP, any
change in recipient condition or Tier.
The requested tier will be evaluated based on the frequency and degree of the behaviors exhibited
utilizing the Behaviorally Complex Care Program Evaluation Tool. The behaviors must be
categorized as follows:
Always the recipient always (daily) requires intervention for behaviors.
Usually the recipient requires interventions four or more days per week.
Usually Not the recipient requires interventions, but fewer than four days a week.
Never the recipient does not have behaviors that require interventions.
Each response has a weighted value that must be supported by the medical evidence submitted.
Always = 3; Usually = 2; Usually Not = 1; Never = 0 Maximum weighted value = 18
Tier I 3 to 7 points
Tier II 8 to 13 points
Tier III 14 to 18 points
Facilities may request the BCCP by submitting NMO-7079 and supporting documentation to the
DHCFP. Supporting documentation may include: the face sheet, medication administration
records (MAR), primary care provider progress notes, psychiatric notes and/or group therapy note,
nurses notes, behavioral plan, care plan, behavior monitor logs, interdisciplinary team notes,
behavior management team review and sleep logs. Absence of the listed documentation does not
disqualify approval of the BCCP; the DHCFP staff in the LTSS Facilities Unit or the DHCFP QIO-
like vendor will review all materials submitted to determine whether there is sufficient medical
documentation and justification for the BCCP. After review, the facility and recipient will receive
a Notice of Decision (NOD). The NOD may indicate that:
1. The request is approved at the tier requested;
2. The request is approved for a higher tier than requested;
3. The request is approved for a lower tier than requested; or
4. The request is denied.
Should the BCCP not be approved, the NF will receive the base rate for the applicable quarter.
The BCCP care level is determined independently of any NF LOC.
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503.10B HEARINGS FOR BCCP
Upon receipt of the BCCP NOD, facilities or recipients may ask the DHCFP to perform a re-review
of the original request. The re-review must be based on information and/or documentation not
submitted with the original request. Should the facility not agree with the re-review, a fair hearing
may be requested per MSM Chapter 3100.
503.11 NURSING FACILITY TRACKING FORM
Before an NF can receive reimbursement for services rendered for a Nevada Medicaid recipient,
the facility must submit a Nursing Facility Tracking form in order to receive authorization to bill.
The purpose of the form is to notify the Medicaid Central Office of any admission, service level
change, discharge or death for all Medicaid eligible recipients and to initiate and/or update the
system with necessary information prior to billing.
A Nursing Facility Billing Authorization Letter that indicates specific billing days will be sent to
the Nursing Facility. Upon receipt of the letter, the facility may submit a billing claim form to the
fiscal agent for payment. If it is later discovered that the billing authorization was made in error,
the provider will be subject to recoupment for claims submitted and paid in error. Receipt of a
Billing Authorization Letter does not guaranteed payment.
The facility must review all information of the Nursing Facility Billing Authorization Letter to
verify it contains the correct information. If discrepancies are noted, contact the Medicaid office
immediately to avoid delayed payment. If more than 30 days have elapsed since the tracking form
submission and the facility has not received a Nursing Facility Billing Authorization Letter or been
contacted by Medicaid staff, contact the Nevada Medicaid office.
The facility must submit the Nursing Facility Tracking Form to the Nevada Medicaid Central
Office upon each occurrence for Medicaid eligible individuals:
a. Any admission;
b. Service level update and/or change;
c. New or retro-eligibility determinations;
d. Medicaid Managed Care disenrollment;
e. Hospice enrollment or disenrollment; or
f. Discharge or death.
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If the resident becomes eligible after admission, the tracking form must be submitted upon
notification of the eligibility determination.
Failure of the facility to submit the tracking form may result in payment delays or denials. This
form may be accessed on the DHCFP website at http://www.dhcfp.nv.gov, which includes
completion and submission instructions. The facility should retain a copy for their records.
Billing authorizations become invalid immediately upon discharge from the facility, death, service
level change, enrollment to Hospice coverage or if the recipient becomes ineligible for Medicaid.
Nevada Medicaid does not reimburse NFs for the date of discharge or date of death.
503.11A PROVIDER RESPONSIBILITY
The facility must determine if the recipient has other resources including other insurance coverage
for any and all services and supplies
It is the facility’s responsibility to verify the recipient’s eligibility status monthly by accessing the
Eligibility Verification System (EVS). Refer to MSM Chapter 100 regarding eligibility
information.
If eligibility is determined for prior months (for service dates prior to the existing billing
authorization), the facility must submit another tracking form indicating the eligibility has been
determined retroactively. This will initiate another billing authorization for those service dates.
503.12 THERAPEUTIC LEAVE OF ABSENCES
503.12A COVERAGE AND LIMITATIONS
NFs will be reimbursed their per diem rate for reserving beds for Medicaid recipients who are
absent from the facility on therapeutic leave up to a maximum of 24 days annually. For this
purpose, annually is defined as a calendar year beginning on January 1 and ending on December
31. Further, no portion of the unused leave days may be carried over into the next calendar year.
The facility must maintain accurate leave day records on the recipient’s chart, for review by
Medicaid staff.
A therapeutic leave must include therapeutic or rehabilitative home and community visits with
relatives and friends. Therapeutic leave also includes leave used in preparation for discharge to
community living. Therapeutic leave days are considered overnight stays. Therapeutic leave does
not apply when a recipient is out on pass for short periods of time for visits with family/friends, to
attend church services or other social activities. Therapeutic leave does not include hospital
emergency room visits or hospital stays.
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The absence of a Medicaid recipient from the facility for the purpose of therapeutic leave must be
authorized in writing by the recipient’s attending physician and included in the recipient’s plan of
care.
In those instances where a Medicaid recipient resides in more than one NF within a calendar year,
the receiving facility must determine the number of therapeutic leave days that have been
exhausted by the sending facility within the same calendar year. A record of any leave days must
be a part of the information provided to the receiving facility as part of the transfer documents.
Therapeutic leave days must be authorized by the physician for specific dates. If a recipient fails
to return to the facility within the specified timeframe, Medicaid reimbursement is not available
for dates beyond the physician’s order.
Each therapeutic leave of absence must be authorized by the attending physician’s order to ensure
the recipient is medically stable and capable of safely tolerating the absence.
The physician’s order should specify:
1. The dates the recipient will be out of the facility;
2. Authorize the facility to send necessary medications; and
3. Provide instructions for the family member/friend on how and when to administer the
medications.
A physician’s order such as “may go out on pass” is not acceptable for this purpose. The NF must
provide care instructions for the responsible person who will be accompanying the recipient during
their therapeutic leave of absence.
The NF must reserve and hold the same room and bed for the Medicaid recipient on a therapeutic
leave. The bed may not be occupied by another individual during the period of time in which the
Medicaid recipient is on such leave.
When billing for therapeutic leave of absence days, Revenue Code 183 is used on the billing claim
form. See Provider Billing Manual for specific instructions.
The recipient is responsible to abide by the physician’s order and to return to the facility by the
date authorized by the physician’s order. The recipient must contact the facility to advise them of
any change in the plan regarding therapeutic leave.
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503.13 PATIENT INCOME CHANGES AND PATIENT LIABILITY (PL)
503.13A COVERAGE AND LIMITATIONS
Patient Liability (PL) is determined by the Division of Welfare and Supportive Services (DWSS).
The regulations at 42 CFR 435.725 require that the State (Nevada Medicaid) reduce its payment
to the NF by the amount of the PL. The established PL will be deducted from the Medicaid
reimbursement. If the PL does not exceed billed charges, Medicaid will reimburse the difference
between the established PL and the Medicaid maximum allowable. If the PL exceeds the billed
charges, no Medicaid reimbursement will be made. PL will also be applied to subsequent claims
submitted by provider entitled to PL until monthly obligations are fulfilled.
503.13B PROVIDER RESPONSIBILITY
An NF must notify DWSS immediately whenever there is a change/difference in any income
source, as well as when any additional assets or resources come to the attention of the NF.
DWSS is responsible for determining the amount of PL the resident is responsible for.
When PL is established or changes, the recipient, facility and the fiscal agent are notified of the
amount and effective date. Collection of PL is the facility’s responsibility and should be done on
a monthly basis. If an NF received a notice adjusting the amount of the PL and the facility has
billed and received reimbursement for services, the facility must send a corrected claim to the
fiscal agent to receive the appropriate adjustment within 60 days of the notice.
No PL is to be taken during the first 20 days of a Medicare covered stay. Medicaid reimbursement
will be reduced by the PL amount for all claims including Medicare co-insurance days 21-100 if
applicable. PL is also applied to all other Third Party Liability (TPL) co-insurance claims.
When a recipient is discharged to an independent living arrangement or expires mid-month, PL is
prorated by DWSS and a notice is sent regarding the PL adjustment. The NF must refund any
remaining balance to the recipient or their legal representative as required.
If a Medicaid recipient is transferred during a month from any provider entitled to collect PL, the
discharging provider collects the total PL amount up to billed charges. The balance of the
established PL must be transferred with the recipient at the time of transfer. The transferring and
receiving providers are responsible for negotiating the collection of PL.
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503.14 PERSONAL TRUST FUND MANAGEMENT
503.14A COVERAGE AND LIMITATIONS
An NF resident has the right to manage his or her financial affairs. An NF may manage resident’s
funds upon written authorization from the resident.
503.14B MANAGING RESIDENT FUNDS
NFs must have a system for managing residents’ funds that, at a minimum, fully complies with the
requirements established by Federal las and State regulations.
An NF may not require residents to deposit their personal funds with the NF. The facility must
obtain prior written authorization from the recipient prior to the facility assuming management
from the resident.
A recipient’s personal funds may not be commingled with the NF funds or with the funds of
another person. A recipient’s personal funds that do not exceed $50 may be maintained in a non-
interest-bearing account, interest bearing account or petty cash fund. If a recipient has funds in
excess of $50, these monies must be maintained in an interest-bearing account in a local bank
insured by the Federal Deposit Insurance Corporation (FDIC). Interest earned must be credited to
the recipient’s account. The NF must notify each recipient when the amount in the recipient’s
personal fund account reaches $200 less than the Supplemental Security Income (SSI) resource
limit for one person.
A recipient’s personal needs money is for the exclusive use of the recipient, as desired. The
recipient’s personal funds must not be used to purchase items covered by Medicaid either directly
or indirectly as part of the facility’s daily rate including nursing services, dietary services,
room/bed maintenance, routine personal hygiene items (hair hygiene supplies, comb, brush, bath
soap, disinfecting soaps or specialized cleansing agents when indicated to treat special skin
problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive,
denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant,
incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital
gowns, over the counter drugs, hair and nail hygiene services, bathing and basic personal laundry)
or medically related services. However, should a resident request a certain brand or product type,
not otherwise supplied, the recipient’s personal needs money may be used to purchase those items.
Upon a recipient’s request, specialty items not covered by Medicaid may be purchased for the
recipient. Allowable expenditures are outlined in 42 CFR§ 483.10 but may include a personal
telephone, television, personal comfort items, personal clothing, reading material, gifts purchased
on behalf of the recipient, flowers and plants, and decorative items. The facility must not require
a recipient (or his or her representative) to request any item or service as a condition of admission
or continued stay. In addition, the facility must obtain written authorization from the recipient that
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states what the charge will be. In the event the recipient is unable to sign, the NF must obtain two
signatures from NF staff and accurate accounting records must be kept accounting for each
purchase.
Statements regarding a recipient’s financial record must be available upon request to the recipient
or to the recipient’s legal representative.
Within 30 days of the death of a recipient, the NF must convey the recipient’s funds and a final
accounting of those funds to the individual or probate jurisdiction administering the recipient’s
estate.
503.14C PERSONAL FUND AUDITS
The Division or its representative will periodically audit recipients’ personal trust funds to assure
Federal and State laws, regulations and Medicaid polices are met.
If, as a result of an audit, discrepancies are identified and reported, the facility must submit a plan
of corrective action within 30 days of the report of findings to the auditing agency.
If discrepancies are found at audit, the NF must make restitution to the recipient’s funds improperly
handled, accounted for or dispersed.
A report of the audit findings may be sent to BHCQC and the Medicaid Fraud Control Unit
(MFCU), for follow-up regarding potential deficiencies related to State or Federal regulations.
Misuse of residents’ monies is subject to prosecution under the NRS.
503.14D RECIPIENT RESPONSIBILITY
The recipient has the choice to either manage their own personal funds, or to request that the
facility manage their personal funds. If the recipient desires the facility to manage their personal
funds, the recipient must provide the facility with written authorization to do so.
Medicaid recipients may choose to spend their personal funds on items of personal care such as
professional beauty or barber services or specialty items not covered by Medicaid. In this instance,
the recipient must authorize payment for the specialty items in writing.
503.15 TRANSPORTATION
503.15A COVERAGE AND LIMITATIONS
NFs are responsible for ensuring that all recipients receive appropriate medical care and related
services.
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It is the responsibility of the NF to provide non-emergency transportation (NET) for Medicaid
recipients for all off-site medical and dental appointments and other medically necessary services
after admission and prior to discharge. Medically necessary non-emergency transportation costs
are included in the NF’s rate structure. The NF does not have to provide NET back to the facility
after a hospital admission/discharge.
When a recipient is being admitted to an out-of-state NF, the discharging facility must contact the
DHCFP Out-of-State Coordinator for authorization prior to the admission.
Refer to MSM Chapter 1900 for transportation policies.
503.16 ROUTINE SERVICES AND SUPPLIES
503.16A COVERAGE AND LIMITATIONS
Routine services and supplies are included in per diem rates. Routine NF services include regular
room, dietary services, nursing services, social services, activities, medical supplies, oxygen, the
use of equipment and facilities, and other routine services. Examples of routine services and
supplies include, but are not limited to:
1. All general nursing services including: the administration of oxygen and related
medication; the collection of all laboratory specimens as ordered by a physician such as
blood and urine; injections; hand feeding; incontinency care; normal personal hygiene
which includes bathing, skin care, hair care or nail care (excluding professional barber and
beauty services), shaving, oral hygiene, enemas, etc.
2. Social work services and activity programs: NF staff will provide these services as
necessary in order to carry out the plan of care for the Medicaid recipients.
3. Maintenance therapy programs: facility staff will assist the Medicaid recipients as
necessary under the guidelines of the recipient’s restorative therapy program. Programs are
intended to maintain and/or restore specific function(s).
4. Items which are furnished routinely and relatively uniformly to all residents, such as
gowns, linens, water pitchers, basins, bedpans, etc.
5. Items stocked at nursing stations or on each floor in gross supply and distributed or used
individually such as alcohol, applicators, cotton balls, band aids, disposable gloves,
incontinency care products including disposable diapers, colostomy supplies, catheters,
irrigation equipment, tape, needles, syringes, IV equipment, T.E.D. (anti-embolism)
stockings, hydrogen peroxide, over the counter enemas, tests (Clinitest, Testape, Ketostix,
Accu-chek), tongue depressors, hearing aid batteries, facial tissue, personal hygiene items
(includes soap, moisturizing lotion, powder, shampoo, deodorant, disinfecting soaps or
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specialized cleansing agents, razor, shaving cream, denture adhesive, dental floss,
toothbrushes, toothpaste, denture cups and cleaner, mouthwash, peri-care products,
sanitary napkins and related supplies, etc.).
6. Items which are used by individual residents but which are reusable and expected to be
available, such as canes, crutches, walkers, wheelchairs, Geri chairs, traction equipment,
alternating pressure pad and pump, Intermittent Positive Pressure Breathing (IPPB)
machine, electric nebulizers, other durable medical equipment, oxygen concentrators,
ventilators, etc.
7. Laundry services, including personal clothing.
503.16B ITEMS INCLUDED IN THE PADIATRIC SPECIALTY CARE RATE
All services, durable medical equipment and supplies necessary for the administration of the
treatment procedures listed in the patient care criteria including, but not limited to, respiratory
services, tracheostomy and related services; developmental services, nutritional services,
ambulatory aids, support surfaces and bathing/toiletry services.
Oxygen, and all related equipment and supplies necessary for administration including positive
and negative pressure apparatus.
This includes all oxygen therapy equipment, i.e., oxygen-conserving devices (oxymizer) and
nebulizer (pulmoaide); respiratory equipment, supplies and services; respiratory therapy;
tracheostomy and related services; ventilators, including humidifiers, in-line condensers, in-line
temperature measuring devices, and calibration and maintenance services.
1. Feeding pumps and equipment and services necessary for tube feedings.
2. Tracheostomy speaking valves.
3. Equipment and supplies for continuous IV therapy.
4. Ambulatory assistance equipment, supplies and services, including but not limited to canes
and wheelchairs.
5. Support surfaces, equipment, supplies and services, i.e., alternating pressure pads,
wheelchair cushions, and gel pressure and air fluidized mattresses.
6. Bathing/toileting assistance equipment, supplies, and services, commodes, lifts.
7. Developmental services.
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8. Physical, occupational and speech therapies provided within a supportive or maintenance
program.
503.16C PROVIDER RESPONSIBILITY
The NF must provide routine services and supplies and not charge the Medicaid recipient or
Nevada Medicaid for these services.
The NF must not charge the Medicaid recipient for any item or service not requested by the
recipient.
The facility must inform the Medicaid recipient (or his/her representative) requesting an item or
service for which a charge will be made that there will be a charge for the item or service and the
amount of the charge.
503.17 SERVICES AND SUPPLIES NOT INCLUDED IN PER DIEM RATES
503.17A COVERAGE AND LIMITATIONS
Certain services and supplies are not considered part of the NF’s Medicaid per diem rate. Payment
for these services and supplies may be made to non-NF providers when the criteria for coverage
as outlined in the appropriate MSM is met. The provider of the service or supply may be required
to obtain prior authorization. Reference MSM Chapter 1200 for Pharmacy Services and MSM
Chapter 1300 for DME and Supplies.
Items not included in the Medicaid per diem rate include:
1. Drugs available by prescription only, including compounded prescriptions and TPN
solution and additives.
2. Nutritional supplements in conjunction with tube feedings.
3. Personal appliances and devices, if recommended by a physician, such as eye glasses,
hearing aids, braces, prostheses, etc.
4. Non-standard wheelchairs including power-operated vehicles, wheelchair seating systems,
including certain pressure reducing wheelchair cushions needed for the Medicaid
recipient’s permanent and full-time use, etc.
5. Air fluidized bed units and low air loss bed units.
6. Emergency transportation.
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7. Physical, Occupational and Speech therapy services.
8. Physician services.
9. Laboratory, portable x-ray and other diagnostic services.
10. Repair of medical equipment and appliances which belong to the recipient.
503.17B PROVIDER RESPONSIBILITY
1. Non-NF providers must reference the appropriate MSM for specific coverage and
limitation policies related to the services and supplies not included in the NF per diem.
Providers must abide by the associated rules and prior authorization guidelines before
providing an item or service to a recipient.
2. Provider must check for a valid Medicaid card and question the recipient/legal
representative about other insurance coverage.
503.17C RECIPIENT RESPONSIBILITY
1. Furnish providers with any forms of identification necessary to utilize other health
insurance coverage for any and all services and supplies.
2. Provide written authorization to the provider and NF if purchasing services and supplies
not covered in the per diem.
503.17D AUTHORIZATION PROCESS
Refer to the appropriate chapter of the MSM for the authorization processes related to specific
services and supplies.
503.18 DISCHARGE REQUIREMENTS
The NF must notify the Nevada Medicaid Central Office of a Medicaid recipient’s discharge or
death by sending the Nursing Facility Tracking form.
The NF must provide copies of the recipient’s medical record to those responsible for post-
discharge care including a copy of his or her Advance Directive (AD) (declaration/living will
and/or durable power of health care decision).
Facility to facility transfer: To transfer any Medicaid recipient from on facility to another, the
transferring facility must:
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A. Obtain the physician’s written order for transfer;
B. Obtain written consent from the recipient, his/her family and/or guardian;
C. Notify the Medicaid Central Office of the transfer by sending the Nevada Medicaid
Nursing Facility Tracking form;
D. Transfer necessary medical/social/LOC/PASRR information to the receiving facility;
E. The discharging facility collects the total PL amount up to billed charges. The established
PL will be deducted from the Medicaid reimbursement. If the PL does not exceed billed
charges, Medicaid will reimburse the difference between the established PL and the
Medicaid maximum allowable. If the PL exceeds the billed charges, no Medicaid
reimbursement will be made and the balance of the collected PL must be transferred to the
receiving NF with the recipient at the time of transfer;
F. Document the transfer in the recipient’s medical record.
The admitting facility must submit the NF Tracking form to the Nevada Medicaid Central Office
upon admission.
If it is determined that a Medicaid recipient no longer meets a nursing facility LOC, the facility
will be notified and must facilitate discharge planning and promote appropriate placement. Should
the discharge planner need further assistance, a referral can be made to the FOCIS program.
Program staff can be reached through the DHCFP District Offices. If an NF intends to discharge a
resident, they must provide to the resident/legal representative with a 30-day written notice and
include the name and address of the person to whom the resident/legal representative may appeal
the discharge.
503.19 FREE-STANDING NURSING FACILITY – RUG CASE MIX
The MDS/Resource Utilization Groups (RUG) system is used to classify residents and objectively
determine a free-standing NF’s Case Mix Index (CMI). The RUG classification system was
developed by the CMS and is the basis for resident classification for the Medicare prospective
payment system and numerous other states’ Medicaid systems. Nevada uses the 34-group version
that collapses the special rehabilitation category into four groups. CMS recommends this version
for use with Medicaid NF resident populations. CMS has also developed standard CMI indices
which will be the basis for calculating the average CMI, or score, for each NF under Nevada’s
case-mix system.
Free-standing NFs are reimbursed according to a price-based system. Individual facility rates are
developed from prices established from three separate cost centers: operating, direct health care
and capital. The direct health care component utilizes each facility’s CMI which is calculated four
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times per year for residents in the facility on the first day of each calendar quarter (called the
“picture date”).
Refer to MSM Chapter 700, Rates, for detailed information regarding free-standing NF
reimbursement.
503.19A PROVIDER RESPONSIBILITY
The provider must assure that each resident’s assessment data is complete and accurate in
accordance with federal regulations and the CMS Resident Assessment Instrument (RAI) Users’
Manual.
Comprehensive assessments, quarterly assessments, significant change assessments and annual
assessments using the MDS current version must be conducted in accordance with the
requirements and frequency schedule found at 42 CFR Section 483.20.
The provider must assure that the Occupancy Report is accurate and submitted within the specified
time limit every month.
503.20 FREE-STANDING NURSING FACILITY CASE MIX AND MDS VERIFICATION REVIEW
DESCRIPTION
Nevada Medicaid reimburses free-standing NFs based on the facility’s overall CMI identified from
the MDS. RUG items are identified on the MDS and used to establish each facility’s CMI. In order
to validate that Medicaid reimbursement to NFs is accurate and appropriate, a periodic review of
MDS coding and corresponding medical record documentation is conducted to verify the
information submitted on the MDS to the national repository accurately reflects the care required
by, and provided to residents.
503.20A COVERAGE AND LIMITATIONS
RNs from Medicaid District Offices conduct Case Mix and MDS Verification reviews at every
free-standing Medicaid certified NF at least annually. The review consists of a comparison of
medical record documentation and the coding reported on the MDS, specifically the RUG items
coded with a positive response. On-site resident reviews may also be conducted to verify
documentation and/or information coded on the MDS.
Facilities may be reviewed more frequently when the facility’s error rate is greater than 40%, or
when any significant increase in errors is identified.
Prior to the review, a sampling of residents is determined using the most recently submitted MDS
data and resident listing information. The sampling is selected based on the RUG category of each
resident.
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NFs are contacted by the lead nurse approximately one week prior to a scheduled review. Upon
notification of an upcoming review, facilities are required to provide a current, accurate census of
all residents regardless of their payment source.
A brief entrance meeting is conducted upon the review team’s arrival at the facility. The
administrator or their designated representative, director of nurses and MDS staff are expected
participants in the entrance meeting. Other staff may participate as deemed appropriate by the
facility administrator and the lead nurse.
During the review, as questions arise, reviewers will work with facility staff (primarily the MDS
Coordinator) to obtain clarification and assistance in locating documentation which supports the
reported codes on the MDSs. At this time, review staff may also provide one-to-one training to
facility staff.
Upon completion of the record reviews, review staff will conduct a brief exit meeting to discuss
the findings of the team. A copy of the findings showing the percentage and types of errors
identified will be given to the administrator or their designated representative.
If it is identified that a facility coded and MDS inaccurately, which resulted in the provider being
paid more monies than a correctly-coded MDS would have allowed, Medicaid may require the
facility to submit a corrected MDS to the national repository. Additionally, Medicaid may recoup
monies paid inappropriately.
503.20B PROVIDER RESPONSIBILITY
1. The provider must possess thorough knowledge of the RAI process including the MDS,
Resident Assessment Protocols (RAPs) and Care Plans.
2. The provider must maintain current knowledge of the federal MDS Utilization Guidelines.
3. The provider must maintain current knowledge of the Nevada Medicaid Documentation
Guidelines which may be obtained by accessing the DHCFP website at:
http://www.dhcfp.nv.gov.
4. The provider must promptly provide information requested by the review team.
5. The provider must make certain the appropriate staff attends the entrance and exit
meetings.
6. The provider must prepare in advance and provide to review staff at the beginning of the
entrance meeting:
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a. copies of the selected MDS’ (containing the attestation statement and completion
signatures of staff) which review staff will use during the review and keep as a
permanent part of the facility’s review packet;
b. the active medical records selected for review; and
c. thinned/purged files and records maintained by the facility in various workbooks
which contain information that supports the coding of the MDS.
7. Facility staff responsible for the MDS must be available to Medicaid review staff during
the review process.
8. The provider must analyze the error reports with the appropriate facility staff responsible
for coding the MDS.
9. The provider must identify and make corrections to processes that contribute to inaccurate
MDS coding and maintain documentation supporting the current MDS in the active
medical record.
10. The provider must anticipate and prepare for more frequent reviews when the facility’s
error rate is 40% or higher, or when any significant increase in errors occurs.
503.21 HOSPITAL-BASED NURSING FACILITY
503.21A COVERAGE AND LIMITATIONS
All policies described in this chapter apply to hospital-based NFs with the exception of those
specifically identified for free-standing NFs.
Hospital-based NFs are paid under Medicare reasonable cost-based reimbursement principles
including the routine cost limitation, and the lesser of cost or charges. Payment will follow any
and all applicable Medicare upper payment limitation requirements such that payments will not
exceed the upper payment limitation. The routine cost limit is applied at the time of cost settlement.
Each facility will receive interim payments of the lower of 1) billed charges; or 2) an interim
payment percentage that is the ratio of costs to charges from the facilities most recently audited
cost report.
Refer to the MSM Chapter 700, Rates, for specific details related to hospital-based NF
reimbursement.
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503.21B PROVIDER RESPONSIBILITY
The hospital-based NF charges for services provided to Medicaid recipients should not exceed the
provider’s customary charges to the general public for these services. Hospital-based NFs may bill
for ancillary services in addition to room and board.
The provider must assure that each claim submitted to the Nevada Medicaid’s fiscal agent for NF
services is accurate and timely.
Refer to the Provider Billing Manual for specific billing instructions.
503.22 OUT-OF-STATE NURSING FACILITY PLACEMENT
To request approval for out-of-state placement, the in-state provider, such as a hospital or nursing
facility, completes the questionnaire identified as Out-of-State Questionnaire and submits the
following documentation to Nevada Medicaid, Out-of-State Coordinator:
a. Documentation supporting that all the appropriate NFs in Nevada were contacted for in-
state placement and placement was denied. The documentation should include the reasons
Nevada NFs denied admission.
b. If the recipient was denied admission to in-state NFs due to severe behavior symptoms, a
current psychosocial narrative is required.
c. A PASRR screening indicating NF placement is appropriate.
d. LOC screening indicating the recipient meets NF placement criteria.
e. Written statement from the recipient (recipient’s family/guardian) concurring with out-of-
state placement, indication of who will be responsible for making health care decisions on
the recipient’s behalf, and that the recipient’s (recipient’s family/guardian) acknowledge
that Medicaid benefits end with death.
f. The written statement must also include the understanding that burial and funeral
arrangements must be made outside of Medicaid intervention. Documentation to show that
every effort was made to purchase/obtain a burial policy if the individual does not have
funeral or burial coverage.
1. OUT-OF-STATE NURSING FACILITY
The out-of-state NF must be enrolled as a Nevada Medicaid provider.
a. Admission/Discharge:
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The out-of-state provider must adhere to Nevada Medicaid’s in-state pre-
admission, admission and discharge policies as described in this chapter.
b. Eligibility:
Verification of Medicaid eligibility is the provider’s responsibility.
Eligibility should initially be verified by validating the recipient’s Medicaid
card. Thereafter, eligibility should be verified monthly by utilizing EVS.
The facility is not required to submit the Nursing Facility Tracking Form
until the eligibility determination is issued; however, the out-of-state
provider should contact the Nevada Medicaid Central Office, Out-of-State
Coordinator, when an individual is admitted with a pay source other than
Nevada Medicaid, but an application for Nevada Medicaid has been
submitted.
To prevent disruption of Nevada Medicaid eligibility due to a change of
address by Social Security (Nevada Medicaid recipients must remain
residents of Nevada), when contacting Social Security for any reason,
facility staff must reiterate that the recipient is a Nevada resident who has
been placed out-of-state by Nevada Medicaid.
c. Reimbursement:
Out-of-state NFs are generally reimbursed at their own state’s Medicaid
rate.
If a recipient has a severe medically based behavior disorder or another
medical condition for which care in Nevada was not available, and out-of-
state provider may request a differential “add-on rate” by contacting the
Out-of-State Coordinator at the Medicaid Central Office.
Requests for a differential rate require additional documentation which
justifies the need for additional reimbursement. The documentation must
include a detailed explanation of how the additional reimbursement will be
used for the recipient’s specific care needs including items such as, but not
limited to, additional staffing, specific behavioral programs, specialized
treatments, etc.
d. Billing/Payment Process:
Out-of-state NFs must adhere to Medicaid’s billing policies. Refer to the
Provider Billing Manual and MSM Chapter 100 for complete billing
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instructions.
If a differential rate is approved, a prior authorization (PA) number will be
issued. The PA number must be entered on the billing claim form.
503.22A RECIPIENT RESPONSIBILITY
The recipient (recipient’s family/guardian) must concur with the out-of-state placement.
The recipient (recipient’s family/guardian) must provide any necessary documentation requested
by DWSS to maintain Medicaid eligibility and or utilize other health insurance coverage for any
and all services.
503.22B AUTHORIZATION PROCESS
1. IN-STATE PROVIDER
Out-of-state NF admission requires approval from Nevada Medicaid.
To request approval for out-of-state NF placement, the in-state provider must complete the
Out-of-State Questionnaire and submit it with the necessary information to Nevada
Medicaid’s Central Office, Out-of-State Coordinator.
When the out-of-state placement is approved, verbal authorization will be given to the
requestor and written authorization will follow. After receiving the verbal approval, the
provider may contact the transportation vendor to arrange transportation.
2. OUT-OF-STATE PROVIDERS
After a recipient is approved for an out-of-state placement, Medicaid staff will notify the
out-of-state provider by telephone. In addition, written approval will be sent to the
provider.
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504 HEARINGS
Please reference Medicaid Services Manual (MSM) Chapter 3100 Hearings, for hearings
procedures.
May 1, 2015 NURSING FACILITIES Section 504 Page 1
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column One
Observation Period
B0100 -Clinically Complex Comatose: A pathological state in which neither arousal Physician, nurse practitioner, physician assistant or clinical nurse
Comatose -Impaired Cognition (wakefulness, alertness) nor awareness exists. The person is specialist documentation of specific diagnosis of coma or persistent
(Contributes to ES count) unresponsive and cannot be aroused; he/she does not open eyes, does vegetative state within the 60-day look back period.
not speak and does not move extremities on command or in response
to noxious stimuli (e.g. pain).
Persistent Vegetative State: Some comatose individuals regain
wakefulness but do not display any purposeful behavior or cognition.
Their eyes are open, and they may grunt, yawn, pick with their
fingers and have random body movements. Neurological exam
(7-day look back) shows extensive damage to both cerebral hemispheres.
B0700 -Impaired Cognition Documentation that the resident is able to express or communicate As Evidenced By (AEB) examples describing an accurate picture
Makes Self Understood (Contributes to ES count) requests, needs, opinions, urgent problems and to conduct social of the resident within the observation period.
conversation, whether in speech, writing, sign language or a
combination of these. Deficits in the ability to make one self-
understood can include reduced voice volume and difficulty in
producing sound, or difficulty in finding the right word, making
(7-day look back) sentences, writing and/or gesturing
C0500 -Impaired Cognition Rules for stopping the interview before it is complete: Document date and signature of professional clinical staff (i.e.
Summary Score (BIMS) Stop the interview after completing CO300C if: licensed nurse or licensed social worker) conduction the interview
• All responses have been nonsensical, OR within observation period in the medical records.
• There have been no verbal or written responses to any
question up to this point, OR The interview completion date (the date the interview was actually
• There have been no verbal or written response to some conducted) must be date specific if written in a quarterly, annual or
questions up to this point and for all others, the resident has summary note.
given a nonsensical response.
If the interview is stopped, do the following: The interview completion date in the medical records must match
• Code dash (-) in CO400A, CO400B and CO400C. the signature date for the interview section entered at Z0400.
• Code 99 in the summary score in CO500.
• Code 1, yes in CO600. The BIMS score coded on the MDS should match the score reported
by professional clinical staff.
• Complete the staff assessment for Mental Status CO700-
(7-day look back)
C1000.
C0700 -Impaired Cognition Determine the resident’s short-term memory status by asking If resident is coded with a memory problem (1) at C0700, a memory
Short-Term Memory (Contributes to ES count) him/her to describe an event five minutes after it occurred OR to test must be attempted (see Steps for Assessment in C0700 section
follow through on a direction given five minutes earlier. Observation of RAI manual) and documented As Evidenced By (AEB) example
should be made by staff across all shifts and departments and others within the observation period.
with close contact with the resident.
If the test cannot be conducted (resident will not cooperate, is non-
responsive, etc.) and staff members were unable to make a
determination based on observing the resident, use the standard “no
information” code (a dash “-“) to indicate that the information is not
(7-day look back) available because it could not be assessed.
August 12, 2016 NURSING FACILITIES Attachment A Page 1
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column One
Observation Period
C1000 -Impaired cognition Observation should be made by staff across all shifts and Document the resident’s actual performance in making everyday
Cognitive Skills for Daily (Contributes to ES count) departments and others with close contact with the resident. Focus decisions about tasks or activities of daily living (ADL). Does not
Decision Making on the resident’s actual performance include financial decision making or statements relating to
diagnosis (i.e. dementia). Decisions should relate to the resident’s
Includes choosing clothing, knowing when to go to meals, using life in the facility. Documentation needs to include the observing
environmental clues to organize and plan (e.g. clocks, calendars, staff member’s title and AEB examples of the decisions made by
posted event notices). In the absence of environmental cues seeks the resident within the observation period.
information appropriately (not repetitively) from others in order to
plan their day; using awareness of one’s own strengths and If all residents’ needs are anticipated, then an AEB is required. The
limitations to regulate the day’s events (e.g. asks for help when example needs to be specific not just a reference to the residents’
necessary); acknowledging need to use appropriate assistive safety awareness etc.
equipment such as a walker.
Does NOT include:
Resident’s decision to exercise his/her right to decline treatment or
(7-day look back) recommendations by staff.
D0300 -Clinically Complex Total Security Score defined: Document date and signature of the professional clinical staff (i.e.
Total Severity Score • Sum of all frequency items (D0200 Column 2). licensed nurse or licensed social worker) conducting the interview
(PHQ-9) • Total Severity Score range is 00-27. within the observation period in the medical records.
• Score >=10 resident is depressed.
• Score <=10 resident is not depressed. The interview completion date (the date the interview was actually
Total Severity Score interpreted: conducted) must be date specific if written in a quarterly, annual or
• 20-27; severe depression. summary note.
• 15-19; moderately severe depression.
The interview completion date in the medical records must match
• 10-14; moderate depression
the signature date for the interview section entered at Z0400.
• 5-9; mild depression.
• 1-4; minimal depression.
The PHQ-9 score coded on the MDS should match the score
(7-day look back) reported by professional clinical staff.
D0500A, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Little interest or pleasure • Example that demonstrates resident’s lack of interest or
in doing things pleasure in doing things.
(14-day look back)
D0500B, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Feeling or appearing • Example that demonstrates resident’s feeling or appearing
down, depressed or down, depressed or hopeless.
hopeless
(14-day look back)
August 12, 2016 NURSING FACILITIES Attachment A Page 2
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column One
Observation Period
D0500C, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Trouble falling or staying • Example that demonstrates resident’s trouble falling or
asleep, or sleeping too staying asleep, or sleeping too much
much
(14-day look back)
D0500D, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Feeling tired or having • Example that demonstrates resident’s feeling tired or having
little energy little energy.
(14-day look back)
D0500E, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Poor appetite or • Example that demonstrates resident’s poor appetite or
overeating overeating.
(14-day look back)
D0500F, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Indicating that he/she • Example that demonstrates resident’s indication that she/he
feels bad about self, or is feels bad about self, or is a failure or has let self or family
a failure, or has let self or down.
family down.
(14-day look back)
D0500G, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Trouble concentrating on • Example that demonstrates resident’s trouble concentrating
things, such as reading on things, such as reading the newspaper or watching TV.
the newspaper or
watching TV
(14-day look back)
D0500H, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Moving or speaking so • Example that demonstrates resident’s moving or speaking
slowly that other people so slowly that other people have noticed. Or the opposite-
have noticed. Or the being so fidgety or restless that she/he has been moving
opposite-being so fidgety around a lot more than usual.
or restless that she/he has
been moving around a lot
more than usual
(14-day look back)
August 12, 2016 NURSING FACILITIES Attachment A Page 3
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column One
Observation Period
D0500I, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
States that life isn’t • Example that demonstrates resident’s statements that life
worth living, wishes for isn’t worth living, wishes for death, or attempts to harm self.
death, or attempts to
harm self
(14-day look back)
D0500J, Column 2 -Clinically Complex If resident is unable or unwilling to be interviewed; refer to Staff Document As Evidenced By (AEB) example within the observation
Staff assessment Assessment of Mood (D0500A-J). period – must include frequency.
Being short tempered, • Example that demonstrates resident’s being short tempered,
easily annoyed easily annoyed.
(14-day look back)
D0600 -Clinically Complex Total Severity Score defined: Documentation needs to include staff interviewed (e.g. day shift
Total Severity Score • Sum of all frequency items (D0500 Column 2) nurse, activities personnel). Staff interviewed should be from a
(PHQ-9-OV) • Total Severity Score range is 00-30. variety of shifts and staff who know the resident well.
• Score >=9.5 resident is depressed
• Score <=9.5 resident is not depressed Document date and signature of the professional clinical staff (i.e.
Total Severity Score interpreted: licensed nurse or licensed social worker) performing assessment
• 20-30; severe depression within the observation period.
• 15-19; moderately severe depression.
The PHQ-9-OV score coded on the MDS should match the score
• 10-14; moderate depression.
reported by professional clinical staff.
• 5-9; mild depression.
(14-day look back) • 1-4; minimal depression
E0100A -Behavior Problems Hallucinations defined: Document As Evidenced By (AEB) example within the observation
Hallucinations • Example of a resident’s perception of the presence of period.
something that is not actually there.
• Auditory, visual, tactile, olfactory or gustatory false sensory
(7-day look back) perceptions that occur in the absence of any real stimuli.
E0100B -Behavior Problems Delusions defined: Document As Evidenced By (AEB) example within the observation
Delusions • Example of a fixed, false belief not shared by others that a period.
resident holds even in the face of evidence to the contrary.
Does NOT include:
• A resident’s expression of a false belief when easily accepts
(7-day look back) a reasonable alternative explanation.
E0200A -Behavior Problems • Example and frequency of physical behavior symptoms Document As Evidenced By (AEB) example within the observation
Physical behavioral directed toward others. period – must include frequency.
symptoms directed • Hitting, kicking, pushing, scratching, abusing other
toward others sexually.
(7-day look back)
August 12, 2016 NURSING FACILITIES Attachment A Page 4
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column One
Observation Period
E0200B -Behavior Problems • Example and frequency of verbal behavior symptoms Document As Evidenced By (AEB) example within the observation
Verbal behavioral directed toward other. period – must include frequency.
symptoms directed • Threatening others, screaming at other, cursing at others.
toward others
(7-day look back)
E0200C -Behavior Problems • Example and frequency of other behavior symptoms NOT Document As Evidenced By (AEB) example within the observation
Other behavioral directed toward others. period – must include frequency.
symptoms not directed • Hitting or scratching self, pacing, rummaging, public sexual
toward others acts, disrobing in public, throwing or smearing food or
bodily waste, or verbal/vocal symptoms like screaming,
(7-day look back) disruptive sounds.
E0800 -Behavior Problems Example of the resident’s rejection of care (e.g. blood work, taking Document As Evidenced By (AEB) example within the observation
Rejection of Care medications, ADL assistance) that is necessary to achieve the period – must include frequency.
Presence and frequency resident’s goal for health and well-being.
When rejection/decline of care is first identified, it is investigated to
determine if the rejection/decline of care is a matter of the resident’s
choice. Education is provided (risks and benefits) and the resident’s
choice becomes part of the plan of care. On future assessments, this
(7-day look back) behavior would not be coded again in this item.
E0900 -Behavior Problems Example and frequency of wandering from place to place without a Document As Evidenced By (AEB) example within the observation
Wandering – Presence specified course or known direction. period – must include frequency.
and frequency Does NOT include:
• Pacing, walking for exercise or out of boredom.
• Traveling via a planned course to another specific place
(7-day look back) (dining room or activity).
ADL Self-Performance -Extensive Services • Documentation 24 hour/7 days within the observation The facility must provide one source document (i.e. ADL flow
-Rehabilitation period while in the facility. sheet, nurses or staff notes) containing data reported over all
G0110A, Bed Mobility -Special Care • Initials and dates to authenticate the services provided. shifts/departments for the 7-day observation period to support MDS
-Clinically Complex • Signatures to authenticate initials of staff providing services. coding.
G0110B, Transfers -Impaired Cognition ADL Keys:
-Behavior Problems For either ADL grids, or electronic data collection tools, the key for
G0110H, Eating -Reduced Physical self-performance and support provided must be equivalent to the
Functions intent and definition of the MDS key.
G0110I, Toilet Use ADLs NOT supported:
• If there is no ADL key associated with the values, the ADL
Column 1 ONLY values will be considered unsupported.
• ADL keys with words for self-performance such as limited,
extensive, etc., without the full definitions will be
considered unsupported.
• ADL tools that lack codes for all possible MDS coding
(7-day look back) options will be considered unsupported.
August 12, 2016 NURSING FACILITIES Attachment A Page 5
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column One
Observation Period
ADL Support -Extensive Services ADL support measures the highest level of support provided by the The facility must provide one source document (i.e. ADL flow
-Rehabilitation staff over the last seven days, even if that level of support only sheet, nurses or staff notes) containing data reported over all
G0110A, Bed Mobility -Special Care occurred once. This is a different scale and is entirely separate from shifts/departments for the 7-day observation period to support MDS
-Clinically Complex the ADL self-performance assessment. coding.
G0110B, Transfers -Impaired Cognition
-Behavior Problems
G0110I, Toilet Use -Reduced Physical
Functions
Column 2 ONLY
(7-day look back)
H0200C -Rehabilitation Documentation must show that the following requirements have “Program” is defined as a specific approach that is organized,
Current toileting program -Impaired Cognition been met: planned, documented, monitored and evaluated by a licensed nurse
or trial -Behavior Problems • Implementation of an individualized toileting program that (not co-signed) and provided during the observation period based
-Reduced Physical was based on an assessment of the resident’s unique voiding on an assessment of the resident’s needs. Evaluation must include
Functions pattern. statement if program should be continued, discontinued or changed.
• Evidence that the program was communicated verbally and All components must be present to support MDS coding.
through a care plan, flow records and a written report.
• Resident’s response to the program and evaluation by a The program or trial must be recorded in the individual resident
licensed nurse provided during the observation period. record. “All residents are encouraged to use the bathroom before
• Toileting plan that is being managed during days of the 7- and after meals” is not sufficient to take credit for a program or trial.
day look back period with some type of systematic toileting
program The individual resident’s toileting schedule must be daily (7 days a
• A specific approach that is organized, planned, documented, week), available and easily accessible to all staff. No time
monitored and evaluated. documentation is required for this item.
Does NOT include:
• Less than four days of a systematic toileting program.
• Simply tracing continence status.
• Changing pads or wet garments.
(7-day look back)
• Random assistance with toileting or hygiene.
H0500 -Rehabilitation Documentation must show that the following requirements have “Program” is defined as a specific approach that is organized,
Bowel toileting program -Impaired Cognition been met: planned, documented, monitored and evaluated by a licensed nurse
-Behavior Problems • Implementation of an individualized, resident-specific (not co-signed) and provided during the observation period based
-Reduced Physical bowel toileting program that was based on an assessment of on an assessment of the resident’s needs. Evaluation must include
Functions the resident’s unique bowel pattern. statement if program should be continued, discontinued or changed.
• Evidence that the program was communicated verbally and All components must be present to support MDS coding.
through a care plan, flow records and a written report.
• Resident’s response to the program and evaluation by a The program or trial must be recorded in the individual resident
licensed nurse provided during the observation period. record. “All residents are encouraged to use the bathroom before
Does NOT include: and after meals” is not sufficient to take credit for a program or trial.
• Simply tracking of bowel continence status.
• Changing pads or soiled garments. The individual resident’s toileting schedule must be daily (7 day a
• Random assistance with toileting or hygiene. week), available and easily accessible to all staff. No time
(7-day look back) documentation is required for this item.
August 12, 2016 NURSING FACILITIES Attachment A Page 6
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
Section I: Active Diagnosis in the Last 7 Days Criteria
Active Diagnosis look back period Documented Diagnosis look back period The monthly recap may be used for diagnosis if it is signed and
Diagnosis that has a direct relationship to the resident’s A healthcare practitioner documented diagnosis in the last 60 days dated by the physician, nurse practitioner, physician assistant or
functional status, cognitive status, mood or behavior, that has a relationship to the resident’s functional status, cognitive clinical nurse specialist within the look back period.
medical treatments, nursing monitoring or risk of death status, moor or behavior, medical treatments, nursing monitoring
during the 7-day look back period. or risk of death during the 7-day look back period. ADL documentation cannot be used to document active
treatment, as all residents receive ADL assistance.
Step 1
Identify diagnosis in the 60-day look back period.
Step 2
Determine diagnosis status: active or inactive in the 7-day look back period.
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
I2000 -Special Care Inflammation of the lungs; most commonly of bacterial or viral Physician, nurse practitioner, physician assistant or clinical nurse
Pneumonia -Clinically Complex origin. specialist documentation of specific diagnosis of pneumonia
(Contributes to ES count) An active physician diagnosis must be present in the medical within the observation period is required.
record.
Does NOT include: Documentation of current (within 7-day look back period)
• A hospital discharge note referencing pneumonia during a treatment of diagnosis must be present in the medical record. X-
hospitalization. ray report signed by radiologist may be used to confirm
(60-7-day look back) diagnosis.
I2100 -Clinically Complex Morbid condition associated with bacterial growth in the blood. Physician, nurse practitioner, physician assistant or clinical nurse
Septicemia (Contributes to ES count) Septicemia can be indicated once a blood culture has been ordered specialist documentation of specific diagnosis of septicemia
and drawn. A physician’s working diagnosis of septicemia can be within the observation period is required.
accepted provided the physician has documented the septicemia
diagnosis in the resident’s clinical record. Urosepsis is not Documentation of current (within 7-day look back period)
considered for MDS review verification. treatment of diagnosis must be present in the medical record.
Does NOT include:
• A hospital discharge note referencing septicemia during
(60-7-day look back) hospitalization.
I2900 -Clinically Complex An active physician documented diagnosis must be present in the Diagnosis can be accepted from the monthly order recap if the
Diabetes Mellitus (Contributes to ES count) medical record. recap is signed and dated by the healthcare practitioner within the
observation period and the diagnosis is being treated.
(60-7-day look back) May include diet controlled diabetes.
I4300 -Special Care A speech or language disorder caused by disease or injury to the Diagnosis can be accepted from the monthly order recap it the
Aphasia (Contributes to ES count) brain resulting in difficulty expressing thoughts (i.e. speaking, recap is signed and dated by the healthcare practitioner within the
writing) or understanding spoken or written language. Includes observation period and the documentation of active treatment
(60-7-day look back) aphasia due to CVA. involved which would indicate the resident does have aphasia.
I4400 -Special Care Paralysis related to developmental brain defects or birth trauma. Diagnosis can be accepted from the monthly order recap if the
Cerebral Palsy (Contributes to ES count) Includes spastic quadriplegia secondary to cerebral palsy. recap is signed and dated by the healthcare practitioner within the
(60-7-day look back) observation period and the diagnosis is being treated.
August 12, 2016 NURSING FACILITIES Attachment A Page 7
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
I4900 -Clinically Complex Hemiplegia/hemiparesis: Paralysis/partial paralysis (temporary or Diagnosis can be accepted from the monthly order recap if the
Hemiplegia/ (Contributes to ES count) permanent impairment of sensation, function, motion) of both limbs recap is signed and dated by the healthcare practitioner within the
Hemiparesis on one side of the body. Usually caused by cerebral hemorrhage, observation period and the diagnosis is being treated.
thrombosis, embolism or tumor.
Right or left sided weakness or CVA will not be accepted for this
(60-7-day look back) item.
I5100 -Special Care Paralysis (temporary or permanent impairment of sensation, Diagnosis can be accepted from the monthly order recap if the
Quadriplegia (Contributes to ES count) function, motion) of all four limbs. Usually caused by cerebral recap is signed and dated by the healthcare practitioner within the
hemorrhage, thrombosis, embolism, tumor or spinal cord injury. observation period and the diagnosis is being treated.
(Spastic quadriplegia, secondary to cerebral palsy, should not be
(60-7-day look back) coded as quadriplegia.)
I5200 -Special Care Chronic disease affecting the central nervous system with Diagnosis can be accepted from the monthly order recap if the
Multiple Sclerosis (MS) (Contributes to ES count remissions and relapses of weakness, paresthesia, speech and visual recap is signed and dated by the healthcare practitioner within the
(60-7-day look back) disturbances. observation period and the diagnosis is being treated.
JI550A -Special Care The route (rectal, oral, etc.) of temperature measurement to be Documentation of specific occurrences of fever in the
Fever (Contributes to ES count) consistent between the baseline and the elevated temperature. observation period.
• Fever of 2.4 degrees above the baseline.
• A baseline temperature established prior to the observation A baseline temperature must be established and documented
period. prior to the observation period for comparison.
(7-day look back) • A temperature of 100.4 on admission is a fever.
JI550B -Special Care Documentation of regurgitation of stomach contents, may be caused Documentation of vomiting in the observation period including
Vomiting (Contributes to ES count) by many factors (e.g. drug toxicity, infection, psychogenic). description of vomitus (type and amount).
(7-day look back)
JI550C -Special Care Documentation does require two or more of the three dehydration Documentation of signs of dehydration in the observation period.
Dehydrated -Clinically Complex indicators.
(Contributes to ES count) Does include:
• Usually takes in less than 1500cc of fluid daily.
One or more clinical signs of dehydration, including but
not limited to dry mucous membranes, poor skin turgor,
cracked lips, thirst, sunken eyes, dark urine, new onset or
increased confusion, fever, abnormal lab values, etc.
• Fluid loss that exceeds intake daily.
Does NOT include:
• A hospital discharge note referencing dehydration during
hospitalization unless two of the three dehydration
indicators are present and documented.
(7-day look back ) • A diagnosis of dehydration.
August 12, 2016 NURSING FACILITIES Attachment A Page 8
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
JI550D -Clinically Complex Documentation of frank or occult blood. Documentation of specific occurrences on internal bleeding in
Internal Bleeding (Contributes to ES count) • Black, tarry stools. the observation period including description.
• Vomiting “coffee grounds.”
• Hematuria.
• Hemoptysis
• Severe epistaxis (nosebleed) requires packing.
Does NOT include:
• Nosebleeds that are easily controlled, menses or UA with
(7-day look back) a small amount of red blood cells.
K0300 -Special Care Documentation that compares the resident’s weight in the current Must have a documented weight within the current observation
Weight Loss (Contributes to ES count) observation period with his/her weight at two snapshots in time. period (within 30 days of ARD) for comparison.
• Weight loss of 5% a point closest to 30 days preceding
current observation period. Documentation, including dates with weights and prescribed diet
• Weight loss of 10% at a point closest to 180 days preceding if applicable are required.
current observation period.
Mathematically round weights prior to completing the weight loss
calculation.
Physician prescribed weight loss regimen is a weight reduction plan
ordered by the resident’s physician with the care plan goal of weight
reduction. May employ a calorie restricted diet or other weight loss
(30- and 180-day look diets and exercise. Also includes planned dieresis for weight loss. It
back) is important that weight loss is intentional.
K0510A either as not a -Extensive Services Documentation of IV administration (while a resident or while not Documentation of parenteral/IV administration during the
resident (1) or as a -ADL Score a resident) for nutrition or hydration. observation period which may include medicine administration
resident (2) Does include: records (MARs) and treatment records.
Parenteral/IV Feeding • IV fluids or hyperalimentation, including total parenteral
nutrition (TPN), administered continuously or For fluids given while not a resident, facility records are required
intermittently. with amounts administered.
• IV at KVO (keep vein open).
• IV fluids contained in IV Piggybacks.
• Hypodermoclysis and sub-Q ports in hydration therapy.
• IV fluids can be coded in K0510A if needed to prevent
dehydration if the additional fluid intake is specifically
needed for nutrition and hydration.
The following items are NOT to be coded in K0510A:
• IV medications – Code these when appropriate in
O0100H, IV Medications.
• IV fluids used to reconstitute and/or dilute medications for
IV administration.
August 12, 2016 NURSING FACILITIES Attachment A Page 9
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
• IV fluids administered as a routine part of an operative or
diagnostic procedure or recovery room stay.
• IV fluids administered solely as flushes.
(7-day look back) • IV fluids administered during chemotherapy or dialysis
K0510B either 1 or 2 -Special Care Documentation of any type of feeding tube for nutrition and Presence of the feeding tube is sufficient to code this item.
Feeding Tube -Clinically Complex hydration while a resident or while not a resident.
(Contributes to ES count) • Documentation of any type of tube that can deliver
-ADL Score food/nutritional substance directly into the GI system
Does include:
(7-day look back) • NG tubes, gastrostomy tubes, J-tubes, PEG tubes.
K0710A -Special Care Documentation must support the proportion of all calories actually Dietary notes can be used to support MDS coding.
Calorie intake through -Clinically Complex received for nutrition or hydration through parenteral or tube
parenteral or tube (Contributes to ES count) feeding.
feeding -ADL Score
For residents receiving PO nutrition and tube feeding,
documentation must demonstrate how the facility calculated
the % of calorie intake the tube feeding provided and include:
• Total calories from parenteral route.
• Total calories from tube feeding route.
• Calculation used to find percentage of calories consumed
(7-day look back) by artificial routes.
K0710B -Special Care Documentation must support average fluid intake per day by IV Dietary notes may be used to support MDS coding.
Average Fluid Intake -Clinically Complex and/or tube feeding.
Intake by IV or tube (Contributes to ES count) Documentation to include evidence of the average fluid intake
feeding -ADL Score This is calculated by reviewing the intake records, adding the total per day by IV or tube feeding during the entire seven days’
amount of fluid received each day by IV and/or tube feedings only. observation period. Refers to the actual amount of fluid the
Divide the week’s total fluid intake by the number of days in the resident received by these modes (not the amount ordered).
observation period. This will provide the average fluid intake per
(7-day look back) day.
M0300A -Special Care Documentation of history of pressure ulcer if ever classified at a Documentation must indicate the number of pressure ulcers on
No. of Stage 1 (Contributes to ES count) deeper stage than is currently observed. any part of the body observed during the observation period.
• Staging if the wound bed is partially covered by eschar or
M0300B1 slough, but the depth of tissue loss can be measured. Pressure ulcer staging must be clearly defined by description
No. of Stage 2 • Description of the ulcer including the stage. and/or measurement in order to support MDS coding during the
Does NOT include: observation period
M0300C1 • Reverse staging.
No. of Stage 3 • Pressure ulcers that are healed before the look back period Documentation must include date, clinician signature, and
(these are coded at M0900). credentials.
August 12, 2016 NURSING FACILITIES Attachment A Page 10
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
M0300D1 • Coding unstageable when the wound bed is partially
No. of Stage 4 covered by eschar or slough, but the depth of tissue loss
can be measured.
M0300F1
No. of unstageable
(7-day look back)
M1030 -Clinically Complex Venous Ulcers: Ulcers caused by peripheral venous disease, which Documentation must indicate the number of venous or arterial
No. of Venous/Arterial (Contributes to ES count) most commonly occur proximal to the medial or lateral malleolus ulcers observed during the observation period.
Ulcers above the inner or outer ankle, or on the lower calf area of the leg.
Documentation must include date, clinician signature and
Arterial Ulcers: Ulcers caused by peripheral artery disease, which credentials.
commonly occur on the tips and tops of the toes, tops of the foot, or
(7-day look back) distal to the medial malleolus.
M1040A -Clinically Complex Documentation of signs and symptoms of infection of the foot. Documentation of signs and symptoms of infection of the foot
Infection of the foot (Contributes to ES count) Does include: must be present in the medical record to support the MDS coding.
• Cellulitis.
• Purulent drainage. Documentation to include description and location of the
Does NOT include: infection. Documentation must include date, clinician signature
• Ankle problems. and credentials.
(7-day look back) • Pressure ulcers coded in M0300-M0900.
M1040B -Clinically Complex Documentation of signs and symptoms of foot ulcer or lesions. Documentation of sign and symptoms of foot ulcer or other
Diabetic foot ulcer (Contributes to ES count) • Description of foot ulcer and/or open lesions such as lesion on the foot must be present in the medical record to support
location and appearance. the MDS coding.
M1040C Does NOT include:
Other open lesion on • Pressure ulcers coded in M0300-M0900. Documentation must include date, clinician signature and
the foot • Pressure ulcers that occur on residents with diabetes credentials.
(7-day look back) mellitus.
M1040D -Special Care Does include: Documentation of signs and symptoms of open lesion other than
Open lesions other than (Contributes to ES count) • Skin ulcers that develop as a result of diseases and ulcers, rashes or cuts must be present in the medical record to
ulcers, rashes, cuts conditions such as syphilis and cancer. support the MDS coding.
• Description of the open lesion such as location and
appearance Documentation must include date, clinician signature and
• Documentation in the care plan. credentials.
Does NOT include:
• Pressure ulcers coded in M0300-M0900. RAI manual examples are not all inclusive, other lesions will be
• Skin tears, cuts, abrasions. considered for inclusion in this item (i.e. shingles lesions or
(7-day look back) weeping wounds).
M1040E -Special Care Does include: Documentation of a surgical wound must be present in the
Surgical Wounds (Contributes to ES count) • Any healing and non-healing, open or closed surgical medical record to support the MDS coding during the observation
incisions, skin grafts or drainage site on any part of the period.
body.
August 12, 2016 NURSING FACILITIES Attachment A Page 11
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
• Pressure ulcers that are surgically repaired with grafts and Cannot be coded after the site is healed even though cleansing
flap procedures. and a dressing may still be applied (example healed stoma or G-
• Description of the surgical wound such as location and tube site). Documentation must include date, clinician signature
appearance. and credentials.
Does NOT include:
• Healed surgical sites and stomas or lacerations that require
suturing or butterfly closure.
• PICC sites, central line sites, IV sites
(7-day look back) • Pressure ulcers that have been surgically debrided.
M1040F -Clinically Complex Documentation to include a description of the appearance of the Documentation of signs and symptoms of second and third-
Burns (Contributes to ES count) second or third-degree burns. degree burns must be present in the medical record to support
Does include: MDS coding during the observation period.
• Second or third-degree burns only; may be in any stage of
healing. Documentation must include date, clinician signature and
• Skin and tissue injury caused by heat or chemicals. credentials.
Does not include:
(7-day look back) • First-degree burns (changes in skin color only).
M1200A -Special Care Equipment aimed at relieving pressure away from areas of high risk. Documentation and/or description of pressure relieving, reducing
Pressure Relieving (Contributes to ES count) Does include: or redistributing devices in the medical record to support MDS
Device/Chair • Foam, air, water, gel or other cushioning. coding during the observation period.
• Pressure relieving, reducing, redistributing devices.
M1200B Does NOT include: Each device must be documented separately (e.g. “Pressure
Pressure Relieving • Egg crate cushions of any type. relieving for chair/bed” will not be accepted).
Device/Bed • Doughnut or ring devices.
Use of the device must be noted in the medical record at least on
time during the observation period. Additionally, the term
“pressure relieving,” “pressure reducing” or “pressure
redistributing” needs to be verifiable through manufacture
(7-day look back) documentation and available upon request by the review team.
M1200C -Special Care The turning/repositioning program is specific as to the approaches “Program” is defined as a specific approach that is organized,
Turning/repositioning (Contributes to ES count) for changing the resident’s position and realigning the body. The planned, documented, monitored and evaluated by a licensed
program program should specify the intervention (e.g. reposition on side, nurse (not co-signed) and provided during the observation period
pillows between knees), and frequency (e.g. every two hours). based on an assessment of the resident’s needs. Evaluation must
include statement if program should be continued, discontinued
Progress notes, assessments and other documentation (as directed or changed. All components must be present to support MDS
by facility policy), should support that the turning/repositioning coding.
program is monitored and reassessed to determine the effectiveness
of the intervention. The goals of the program must be measurable and must occur a
minimum of seven days per week.
August 12, 2016 NURSING FACILITIES Attachment A Page 12
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
Evaluation by a licensed nurse during the observation period is
required: Co-signing by the nurse will not be accepted.
Documentation must be specific if the program is for
maintenance or improvement and must include a description of
the resident’s response to the program within the observation
period. Does not include: “Standard of Care Statement,” (i.e. two
(7-day look back) hour turning).
M1200D -Special Care Documentation of dietary intervention(s) to prevent or treat specific Nutrition and/or hydration interventions for the purpose of
Nutrition/hydration (Contributes to ES count) skin conditions. preventing or treating specific skin conditions (i.e. wound
intervention to manage • Description of specific skin condition. healing) ONLY.
skin problems Does include:
• Vitamins and/or supplements. The MAR’s must note that the medication, vitamin or
supplement is for treatment of a skin condition to support MDS
(7-day look back) coding of this item.
M1200E -Special Care Documentation to include any intervention for treating pressure Documentation of pressure ulcer treatment must include
Pressure Ulcer Care (Contributes to ES count) ulcers coded in Current Number of Unhealed Pressure Ulcers at intervention, date and clinician signature with credentials in the
each Stage (M0300 A-G). medical record to support MDS coding.
Does include:
• Use of topical dressings.
• Enzymatic, mechanical or surgical debridement.
• Wound irrigations.
• Negative pressure wound therapy (NPWT).
(7-day look back) • Hydrotherapy.
M1200F -Special Care Documentation to include any intervention for treating or protecting Documentation of surgical wound treatment must include
Surgical Wound Care (Contributes to ES count) any type of surgical wound. intervention, date and clinician signature with credentials in the
Does include: medical record to support MDS coding.
• Topical cleaning.
• Wound irrigation.
• Application of antimicrobial ointments.
• Application of dressings of any type.
• Suture/staple removal.
• Warm soaks or heat application.
Does NOT include:
• Post-operative care following eye or oral surgery.
• Surgical debridement of pressure ulcer.
(7-day look back)
• The observation of the surgical wound.
August 12, 2016 NURSING FACILITIES Attachment A Page 13
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
M1200G -Special Care Documentation of application of non-surgical dressing (with or Documentation of application of non-surgical dressing to body
Application of non- (Contributes to ES count) without topical medications) to the body other than to the feet. part other than the feet must include dressing type, date and
surgical dressings; other Does include: clinician signature with credentials in the medical record to
than to the feet • Dressing application even once. support MDS coding.
• Dry gauze dressings.
• Dressings moistened with saline or other solutions.
• Transparent dressings.
• Hydrogel dressings.
• Dressings with hydrocolloid or hydro active particles.
Does NOT include:
• Dressing application to the ankle.
(7-day look back)
• Dressing for pressure ulcer on the foot.
M1200H -Special Care Documentation of application of ointment/medications (used to Documentation of application of ointment/medication used to
Application of (Contributes to ES count) treat or prevent a skin condition) other than to the feet. treat or prevent a skin condition other than to the feet must
ointments/medications Does include: include product, date and clinician signature with credentials in
other than to the feet • Topical creams. the medical record to support MDS coding.
• Powders.
(7-day look back) • Liquid sealants.
M1200I -Clinically Complex Documentation of dressing changes to the feet (with or without Documentation of intervention to treat any foot wound or ulcer
Application of dressings (Contributes to ES count) topical medication). other than a pressure ulcer must include treatment, date and
(feet) • Interventions to treat any foot wound or ulcer other than a clinician signature with credentials in the medical record to
(7-day look back) pressure ulcer. support MDS coding.
N0300 -Clinically Complex Documentation includes the number of days that the resident Documentation of number of days injections given must include
Injections (Contributes to ES count) received any medication, antigen, vaccine, etc., by subcutaneous, clinician signature and credentials in the medical record to
intramuscular or intradermal injection while resident is in facility. support MDS coding.
Does include:
• Subcutaneous pumps, only the number of days that the Source document for this item may include MAR and/or Diabetic
resident actually required a subcutaneous injection to administration flow sheet.
restart the pump.
(7-day look back) • Insulin injections.
O100A, either as not a -Clinically Complex Documentation to include the administration of any type of Documentation of chemotherapy administration, including
resident (1) or as a (Contributes to ES count) chemotherapy (anticancer drug) given by any route for the sole MAR, while a resident or while not a resident must include date,
resident (2) purpose of cancer treatment. clinician signature and credentials.
Chemotherapy
Administration Record from the treating facility is required with
date, clinician’s signature/credentials in the medical record to
(14-day look back) support MDS coding.
August 12, 2016 NURSING FACILITIES Attachment A Page 14
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
O0100B, either as not -Special Care Does include: Administration Record from the treating facility is required with
a resident (1) or as a (Contributes to ES count) • Intermittent radiation therapy. date and clinician’s signature/credentials in the medical record to
resident (2) • Radiation administered via radiation implant. support MDS coding.
Radiation • A nurse’s note that resident went out for radiation
treatment will be sufficient if there is a corresponding
(14-day look back) physician order.
O0100C, either as not -Clinically Complex Documentation must include the administration of oxygen. Documentation of oxygen therapy while a resident or while not a
a resident (1) or as a (Contributes to ES count) • The administration of oxygen continuously or resident with liter flow with date and signature/credentials of
resident (2) intermittently via mask, cannula, etc. clinician/staff in the medical record to support MDS coding.
Oxygen Therapy • Code when used in BiPAP/CPAP
Does NOT include:
(14-day look back) • Hyperbaric oxygen for wound therapy.
O0100D, either as not -Extensive Services Documentation of ONLY nasopharyngeal or tracheal suctioning. Documentation of suctioning while a resident or while not a
a resident (1) or as a • Nasopharyngeal suctioning. resident with signature/credentials of clinician in the medical
resident (2) • Tracheal suctioning. record to support MDS coding.
Suctioning Does NOT require:
(14-day look back) • Oral suctioning.
O0100E, either as not Extensive Services Documentation of tracheostomy and/or cannula cleansing. Documentation of treatment while a resident or while not a
a resident (1) or as a Does include: resident with signature/credentials of clinician in the medical
resident (2) • Changing a disposable cannula. record to support MDS coding.
Tracheostomy Care
(14-day look back)
O0100F, either as not -Extensive Services Documentation of any type of electrically or pneumatically Documentation of ventilator use while a resident or while not a
a resident (1) or as a powered closed system mechanical ventilator support devices. resident with the date and signature/credentials of clinician in the
resident (2) Does include: medical record to support MDS coding.
Ventilator or Respirator • Any resident who was in the process of being weaned off
the ventilator or respirator in the last 14 days.
Does NOT include:
• CPAP or BiPAP in this field.
O0100H, either as not -Extensive Services Documentation of IV medication by push, epidural pump or drip Documentation of IV medication administration must include
a resident (1) or as a administration through a central or peripheral port. signature/credentials of clinician in the medical record to support
resident (2) Does include: MDS coding.
IV Medication • Any drug or biological (contrast material).
• Epidural, intrathecal and Baclofen pumps.
• Additives such as electrolytes and insulin, which are added
to the resident’s TPN or IV fluids.
Does NOT include:
• Saline or heparin flush to keep a heparin lock patent, or IV
fluids without medications.
• Subcutaneous pumps.
August 12, 2016 NURSING FACILITIES Attachment A Page 15
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
• IV medications administered only during chemotherapy of
(14-day look back) dialysis.
O0100I, either as not a -Clinically Complex Documentation must include transfusions of blood or any blood Documentation must include product infused and signature/
resident (1) or as a (Contributes to ES count) products administered directly into the blood stream. credentials of clinician in the medical record to support the MDS
resident (2) Does NOT include: coding.
Transfusions • Transfusions administered during dialysis or
(14-day look back) Chemotherapy.
O0100J, either as not -Clinically Complex Documentation must include evidence that peritoneal or renal Documentation must include evidence that peritoneal or renal
a resident (1) or as a (Contributes to ES count) dialysis occurred at the facility or another facility. dialysis occurred at the facility or another facility.
resident (2) Does include:
Dialysis • Hemofiltration. Administration Record from the treating facility is required with
• Slow Continuous Ultrafiltration (SCUF). date and clinician’s signature/credentials in the medical record to
• Continuous Arteriovenous Hemofiltration (CAVH). support MDS coding.
• Continuous Ambulatory Peritoneal Dialysis (CAPD).
Does NOT include:
(14-day look back) • IV, IV medication and blood transfusion during dialysis.
O0400A, 1, 2 & 3 -Rehabilitation Documentation of direct therapy minutes with associated Documentation of direct therapy minutes with associated
initials/signature(s) to be cited in the medical chart on a daily basis initials/signature(s) to be cited in the medical chart on a daily
O0400B, 1, 2 & 3 Individual therapy to support the total number of minutes of direct therapy provided. basis to support the total number of minutes of direct therapy
-Treatment of one resident at a • Only therapy provided while a resident in the facility. provided.
O0400C, 1, 2 & 3 time • Skilled therapy ONLY.
Therapy minutes • Physician order, treatment plan and assessment. Includes:
Concurrent therapy • Actual therapy minutes ONLY. • Only therapy provided while a resident in the facility.
-Treatment of two residents at • Time provided for each therapy must be documented • Skilled therapy ONLY.
the same time in line-of-sight separately. • Therapy that is physician ordered, treatment planned and
for Part A only. Does include: assessed.
Residents may not be treated • Subsequent reevaluations. • Actual therapy minutes ONLY.
concurrently for Part B – instead •
• Set-up time. Time provided for each therapy must be documented
report under Group therapy.
• Co-treatment when minutes are split between disciplines separately.
and do not exceed the total time.
Group therapy
• Therapy treatment inside or outside the facility. Accepted documentation for therapy minutes can only be the
-Treatment of two or four computer-generated therapy log/grid that is submitted for
Does NOT include:
residents at the same time – Part billing to CMS.
A only. Therapy services not medically reasonable and necessary.
-Treatment of two or more • Therapy provided prior to admission.
residents at the same time – Part • Initial evaluation.
B only. • Conversion of units to minutes.
• Rounding to the nearest 5th minute.
• Therapy services that are not medically reasonable and
necessary.
• Therapy provided as restorative nursing.
August 12, 2016 NURSING FACILITIES Attachment A Page 16
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
• Services provided by aides.
• Services provided by a speech-language pathology
(7-day look back) assistant.
O0400A4 -Rehabilitation Documentation of direct therapy days with associated initials/ Documentation includes number of days and signature/
signature(s) to be cited in the medical chart on a daily basis to credentials of clinician in medical record to support MDS coding.
O0400B4 support the total number of days of direct therapy provided.
• Treatment for 15 minutes or more during the day. Accepted documentation for therapy minutes can only be the
O0400C4 Does NOT include: computer-generated therapy log/grid that is submitted for
Therapy days • Treatment for less than 15 minutes during the day. billing to CMS.
(7-day look back)
O0400D, 2 -Special Care A day of therapy is defined as 15 minutes or more of treatment Documentation of therapy days with associated
Respiratory Therapy (Contributes to ES count) in a 24-hour period. initials/signature(s) to be cited in the medical record on a daily
days Does include: basis to support MDS coding.
• Subsequent reevaluation time. • Only therapy provided while a resident in the facility.
• Set-up time. • Therapy must be physician ordered, treatment planned,
Does NOT include: and assessed.
• Therapy provided prior to admission. Oxygen on its own is not a respiratory therapy.
• Time spent on documentation or initial evaluation.
• Conversion of units to minutes.
• Rounding to the nearest 5th minute.
• Therapy services that are not medically necessary.
Services that are provided by a qualified professional (respiratory
therapists, respiratory nurse). Respiratory therapy services include
coughing, deep breathing, heated nebulizers, aerosol treatments,
assessing breath sounds and mechanical ventilation, etc., which
must be provided by a respiratory therapist or trained respiratory
(7-day look back) nurse.
O500A-J -Rehabilitation Documentation must include the five criteria to meet the definition “Program is defined as a specific approach that is organized,
Restorative Nursing -Impaired Cognition of a restorative nursing program: planned, documented, monitored and evaluated by a licensed
Programs -Behavior Problems • Measurable objectives and interventions must be nurse (not co-signed) and provided during the observation period
-Reduced Physical Functions documented in the care plan and in the medical record. based on an assessment of the resident’s needs. Evaluation must
• Evidence of periodic evaluation by a licensed nurse must include statement if program should be continued, discontinued
be present in the resident’s medical record. Periodic or changed. All components must be present to support MDS
evaluation is defined as an evaluation by a licensed nurse coding.
within the observation period.
• Staff must be trained in the proper techniques to promote Program validation must include initials/signature(s) on a daily
resident involvement in the activity. basis to support the total days and minutes of nursing restorative
• Restorative nursing program activity must be supervised programs provided. Evaluation by a licensed nurse is required
by an RN or LPN. No more than four residents per within the observation period.
supervising staff personnel.
August 12, 2016 NURSING FACILITIES Attachment A Page 17
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
MDS 3.0 Location, RUG-III Categories Minimum documentation and Review Standards Required Nevada Specific Requirements
Field Description, Impacted during the Specific Observation Period Denoted in Column
Observation Period One
**When residents are part of a group, provide documentation Includes:
to identify the group, program, minutes and initials of person • Days for which 15 or more minutes of restorative
providing program. nursing was provided within a 24-hour period for a
minimum of six days.
Does NOT require: • Time provided for each restorative program must be
Physician orders. documented separately.
MDS review staff may ask to review the training records of the
facilities restorative program staff.
When residents are part of a group, provide documentation to
identify the number of residents in the group and how many staff
members are assisting. At least one staff member must be a
(7-day look back) Restorative Nursing Assistant (RNA) or licensed staff person.
O0600 -Clinically Complex Documentation must include evidence of an exam by the physician Document the number of days a physician or other authorized
Physician examination (Contributes to ES count) or other authorized practitioners. Record the number of days that practitioner examined the resident. Includes medical doctors,
a physician progress note reflects that a physician examined the doctors of osteopathy, podiatrists, dentists, and authorized
resident (or since admission if less than 14 days ago). physician assistants, nurse practitioners or clinical nurse
specialists working in collaboration with the physician.
Does include:
• Partial or full exam in facility or in physician’s office.
Does NOT include:
• Exams conducted prior to admission or readmission.
• Exams conducted during an ER visit or hospital
observation stay.
(14-day look back) • Exam by a Medicine Man.
O0700 -Clinically Complex Does include: Document the number of days a physician or other authorized
Physician orders (Contributes to ES count) • Written, telephone, fax or consultation orders for new or practitioner changed the resident’s orders. Includes medical
altered treatment. doctors, doctors of osteopathy, podiatrists, dentists, and
• Orders written on the day of admission as a result of an authorized physician assistants, nurse practitioners or clinical
unexpected change/deterioration in condition or injury are nurse specialists working in collaboration with the physician.
considered as new or altered treatment orders and should
be counted as a day with order changes. Does not include sliding scale dose change based on guidelines
Does NOT include: already ordered.
• Standard admission orders, return admission orders,
renewal orders or clarifying orders without changes.
• Activation of a PRN order already on file.
• Monthly Medicare certification.
• Orders written by a pharmacist.
(14-day look back)
• Orders for transfer of care to another physician.
August 12, 2016 NURSING FACILITIES Attachment A Page 18
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
Review Procedures
Supporting Documentation Related to the MDS/Case Mix Documentation Review:
a. Any corrections made including but not limited to, the Activities of Daily Living (ADL) grid must have an associated
note of explanation per correction within the observation period.
b. A quarterly, annual or summary note will not substitute for documentation which is date specific to the to the observation
period.
c. Improper or illegible corrections will not be accepted for the MDS case mix documentation review.
d. All documentation, including corrections, must be part of the original legal medical record.
e. Any and all MDS coding and interpretation questions shall be referred to the local State RAI Coordinator.
f. Late entry documentation more than 72 hours from the ARD will not be accepted.
Signature Date at Z0400:
a. Interview items (BIMS and PHQ-9) must be conducted during the observation periods stated in the RAI Manual and the
signature date entered at Z0400 must be prior to or on the ARD.
b. The signature date for these interview items entered at Z0400 must match the date the interview was actually conducted
in the medical records. If these dates do not match, facility will not receive credits for these interview items due to
conflicting documentation.
c. In the rare situation that interview items were collected (completed) by two people or by the same person but on different dates,
(e.g. half of the interview questions were conducted on the next day), each person must enter the signature date at Z0400 and
indicate specific interview questions conducted (e.g. D0200 2.A through D; D0200 2.E through I and D0300) in sections.
d. The definition of “date collected” and “date completed” date information was collected and coding decision were made. They
are one, the same date. This is not the same as the data entry date.
August 12, 2016 NURSING FACILITIES Attachment A Page 19
Nevada Supportive Documentation Guidelines
Available online at: http://dhcfp.nv.gov/pgms/LTSS/LTSSnursing (Resources/MDS Guidelines)
Resource Utilization Group, Version III, Revised
For MDS 3.0 Assessments with an ARD on or after 10/01/2016 based on MDS 3.0 RAI Manual
Electronic Health Records (EHR)
a. The facility must grant access to requested medical records in a read-only or other secure format.
b. The facility is responsible for ensuring data backup and security measures are in place.
c. Access to HER must not impede the review process.
d. Medicaid recipients must have their PASRR and LOC in the active EHR.
August 12, 2016 NURSING FACILITIES Attachment A Page 20
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
June 29, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, HIPAA PRIVACY AND CIVIL
RIGHTS OFFICER Jessica Kemmerer
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 600 – PHYSICIAN SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 600 – Physician Services are being
proposed to allow physician assistants who possess a National Commission on Certification
Physician Assistant certification and who also work in a military treatment facility, do not have to
be licensed in their state of practice; clarification of incident-to billing; add reference of
medication-assisted treatment services with DATA 2000 waiver for new and established patients;
add information on Ordering, Prescribing, and Referring (OPR) providers; clarification of family
planning services including birth control and FA-56/HHS-687 Sterilization Consent Form;
clarification of maternity care services throughout section with specific clarification on home
births, obstetric centers, description of covered prenatal screening and diagnostic testing including
the coverage of Chromosome Microarray Analysis, and clarification of FA-54, 55, 57 forms for
abortion services; moved hysterectomy services out of maternity care services and into its own
section along with clarification of FA-50 Hysterectomy Acknowledgement Form; clarification of
gynecologic exams; moved organ transplant services into its own section; clarification of plan of
care requirements and non-covered services in community paramedicine services; clarification on
gender reassignment services to allow for any licensed qualified mental health care professional
within their scope of their license to provide authentic letters for surgery.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: Including but not limited to, Registered Dietician (Provider Type
(PT 15), Special Clinics (PT 17) – Family Planning (PT 17 Specialty 166), Genetics (PT 17
Specialty 167), Licensed Birth Centers (PT 17 Specialty 169), Public Health Clinic (PT 17
Specialty 174), School Based Health Centers (PT 17 Specialty 179), Rural Health Clinic (PT 17
Specialty 180), Community Health Clinic State Health Division (PT 17 Specialty 195), Special
Children’s Clinic (PT 17 Specialty 196), TB Clinic (PT 17 Specialty 197), HIV (PT 17 Specialty
198), Physician, M.D., Osteopath, D.O. (PT 20), Podiatrist (PT 21), Advanced Practice Registered
Nurses (PT 24), Community Paramedicine (PT 32 Specialty 249), Chiropractor (PT 36), Nurse
Anesthetist (PT 72), Nurse Midwife (PT 74), and Physician Assistant (PT 77).
Page 1 of 4
Financial Impact on Local Government: There is no anticipated fiscal impact known at this time.
These changes are effective July 1, 2021.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 09/21 MTL 04/20, 14/18, 23/17, 25/15
Chapter 600 – Physician Services Chapter 600 – Physician Services
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
600 Introduction Updated language to the following health care
professionals: Nurse Midwives; Emergency Medical
Technician, Advanced Emergency Medical
Technician, and Paramedics with community
paramedicine endorsement; certification of National
Commission on Certification Physician Assistants to
those that work in a military treatment facility.
“Disclaimer” – Replaced the term Physician with
Provider as an all-inclusive description of the
providers in the chapter. Updated the definition of
“Primary Care Provider.”
601 Authority Updated the names of each NRS chapter. Added
regulations from the Department of Defense.
603.1A Coverage and Added that providers shall follow current national
Limitations guidelines, recommendations, and standards of care.
603.1A(2)(b) Clarification of incident-to billing.
603.1A(6) Added reference of Federal Emergency Services
Program (also known as Emergency Medicaid Only).
Refer to MSM 200, Hospital Services, Attachment A,
Policy #02-02.
603.2(B)(8) Provider Office Added reference of Medication-Assisted Treatment
Services (MAT) services. Refer to MSM Chapter 3800,
Medication-Assisted Treatment.
603.2(H) Added reference of the Advisory Committee on
Immunization Practices for all childhood and adult
vaccinations.
Page 2 of 4
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
603.2(I) Added information on Ordering, Prescribing, and
Referring Providers.
603.3 Family Planning Clarification of family planning services including:
Services providers shall follow current national guidelines,
recommendations, and standards of care; the
description of the types of birth control covered;
updated FA-56/HHS-687 Sterilization Consent Form;
and a pelvic exam or pap smear is not required for
self-administered birth control.
603.4 Maternity Care Clarification of coverage in maternity care services
regarding home births and obstetric centers.
providers shall follow current national guidelines,
recommendations, and standards of care
603.4A Stages of Maternity Added reference of MSM 200, Hospital Services,
Care Attachment A, Policy #02-02, Federal Emergency
Services Program for allowable services to non-U.S.
citizens.
603.4A(2)(c) Updated #6 regarding newborn hearing screens.
(6) – (7) Added #7 on newborn screening blood analysis.
603.4B Fetal Non-Stress Changed name of section. Clarification that providers
Testing shall follow current national guidelines,
recommendations, and standards of care. Removed
descriptive clinical information.
603.4C Maternal/Fetal Changed name of section. Moved all ultrasound
Ultrasound Studies information under one section. Removed descriptive
clinical information.
603.4D Prenatal Screening Created new section. Described all covered prenatal
and Diagnostic screening and diagnostic testing including coverage of
Testing Chromosome Microarray Analysis.
603.4E Abortion / Clarification of FA-54, 55, 57 forms for abortion
Termination of services.
Pregnancy
603.5 Hysterectomy Moved Hysterectomy out of Maternity Care and into
its own section. Clarification of FA-50 Hysterectomy
Acknowledgement Form.
Page 3 of 4
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
603.6 Gynecologic Exam Removed “Annual” from the section name.
Clarification of gynecological exams and providers
shall follow current national guidelines,
recommendations, and standards of care.
604.2 Community Clarification of Plan of Care requirements and non-
Paramedicine covered services.
Services -
Coverage and
Limitations
605 Organ Transplant Moved Organ Transplant Services from section
Services 603.11(F)(3)(m) and 603.11(F)(4) Provider Services
in Outpatient Setting into new section 605 and 605.1
for Organ Transplant Services.
607.1(E)(d)(1) Gender Clarification on gender reassignment services to allow
Reassignment for any licensed qualified mental health care
Services – professional within their scope of their license to
Documentation provide authentic letters for surgery.
Requirements
Page 4 of 4
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
PHYSICIAN SERVICES
600 INTRODUCTION ............................................................................................................................ 1
601 AUTHORITY ................................................................................................................................... 1
602 RESERVED ...................................................................................................................................... 1
603 PROVIDERS AND LICENSED PROFESSIONAL POLICY......................................................... 1
603.1 PROVIDER'S ROLE IN RENDERING SERVICES ....................................................................... 1
603.1A COVERAGE AND LIMITATIONS ................................................................................................ 1
603.2 PROVIDER OFFICE SERVICES .................................................................................................... 3
603.2A AUTHORIZATION PROCESS ....................................................................................................... 8
603.3 FAMILY PLANNING SERVICES .................................................................................................. 8
603.4 MATERNITY CARE .................................................................................................................... 10
603.4A STAGES OF MATERNITY CARE ............................................................................................... 11
603.4B FFETAL NON-STRESS TESTING ............................................................................................... 14
603.4C MATERNAL/FETAL ULTRASOUND STUDIES ....................................................................... 14
603.4D PRENATAL SCREENING AND DIAGNOSTIC TESTING ....................................................... 17
603.4E ABORTION/TERMINATION OF PREGNANCY ....................................................................... 18
603.5 HYSTERECTOMY ........................................................................................................................ 18
603.6 GYNECOLOGIC EXAM ............................................................................................................... 20
603.7 CHIROPRACTIC SERVICES POLICY ........................................................................................ 20
603.8 PODIATRY .................................................................................................................................... 20
603.9 PROVIDER SERVICES PROVIDED IN RURAL HEALTH CLINICS ...................................... 22
603.10 ANESTHESIA ................................................................................................................................ 24
603.11 PROVIDER SERVICES IN OUTPATIENT SETTING ................................................................ 24
603.12 SERVICES IN THE ACUTE HOSPITAL SETTING ................................................................... 30
603.13 PROVIDER'S SERVICES IN NURSING FACILITIES ............................................................... 35
603.14 PROVIDER'S SERVICES IN OTHER MEDICAL FACILITIES ................................................. 36
604 COMMUNITY PARAMEDICINE SERVICES .............................................................................. 1
604.1 COMMUNITY PARAMEDICINE PROVIDER QUALIFICATIONS ........................................... 1
604.2 COVERAGE AND LIMITATIONS ................................................................................................ 1
605 ORGAN TRANSPLANT SERVICES ............................................................................................. 1
605.1 COVERAGE AND LIMITATIONS ................................................................................................ 1
606 PREVENTITIVE HEALTH SERVICES ......................................................................................... 1
606.1 COVERED SERVICES .................................................................................................................... 1
606.2 NON-COVERED SERVICES .......................................................................................................... 1
606.3 PRIOR AUTHORIZATIONS ........................................................................................................... 1
606.4 BILLING REQUIREMENTS ........................................................................................................... 1
607 GENDER REASSIGNMENT SERVICES....................................................................................... 1
Page 1 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
607.1 COVERAGE AND LIMITATIONS ................................................................................................ 1
608 MEDICAL NUTRITION THERAPY .............................................................................................. 1
608.1 POLICY ............................................................................................................................................ 1
608.2 COVERAGE AND LIMITATIONS ................................................................................................ 1
608.3 PRIOR AUTHORIZATION REQUIREMENTS ............................................................................. 3
608.4 PROVIDER QUALIFICATIONS .................................................................................................... 3
608.5 PROVIDER RESPONSIBILITY...................................................................................................... 3
609 HEARINGS ...................................................................................................................................... 1
ATTACHMENT A
6-01 RESERVED FOR FUTURE USE .................................................................................................... 1
6-02 WOUND MANAGEMENT ............................................................................................................. 2
6-03 OUTPATIENT HOSPITAL BASED HYPERBARIC OXYGEN THERAPY................................ 3
6-04 INTRATHECAL BACLOFEN (ITB) THERAPY ........................................................................... 4
6-05 RESERVED FOR FUTURE USE .................................................................................................... 6
6-06 VAGUS NERVE STIMULATOR (VNS) ........................................................................................ 7
6-07 BARIATRIC SURGERY FOR MORBID OBESITY ...................................................................... 9
6-08 HYALGAN AND SYNVISC INJECTIONS ................................................................................. 11
6-09 END STAGE RENAL DISEASE SERVICES ............................................................................... 12
6-10 DIABETIC OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES ........................... 14
6-11 BOTULINUM TOXIN ................................................................................................................... 16
6-12 RESERVED FOR FUTURE USE .................................................................................................. 17
6-13 SCHOOL BASED HEALTH CENTER ......................................................................................... 18
Page 2 of 2
MTL 09/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 600
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
600 INTRODUCTION
The Nevada Medicaid Program is dependent upon the participation and cooperation of Nevada
providers and other licensed professionals who provide health care to Medicaid recipients.
Licensed professionals providing services within the scope of their license are recognized by
Nevada as independently contracted Medicaid providers. The policy in this chapter is specific to
the following identified health care professionals:
A. Advanced Practice Registered Nurse APRN;
B. Certified Registered Nurse Anesthetists (CRNA);
C. Chiropractors (DC);
D. Nurse Midwives (NM);
E. Emergency Medical Technicians, Advanced Emergency Medical Technicians, and
Paramedics with community paramedicine endorsement;
F. Physicians (M.D. and D.O. including those in a teaching hospital);
G. Physician Assistants (PA/PA-C);
1. Physician Assistants who are employed at a Military Treatment Facility (MTF) and
who possess a National Commission on Certification Physician Assistants
(NCCPA) certification are considered to be allowable Nevada Medicaid providers.
With the NCCPA certification, physician assistants employed at a MTF will not be
required to be licensed in the state of practice.
H. Podiatrists (DPM); and
I. Registered Dietitians.
To enroll as a provider for the Division of Health Care Financing and Policy (DHCFP) in the
Nevada Medicaid Program, the above listed licensed professionals working within their scope of
practice must be authorized by the licensing authority of their profession to practice in the state
where the service is performed at the time the state services are provided. Specific service
exclusions will be noted in policy.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), with the exception of the four areas where Medicaid and NCU policies differ
as documented in the NCU Services Manual, Chapter 1000.
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The DHCFP encourages integrated interventions as defined by the Substance Abuse and Mental
Health Services Administration (SAMHSA). Please reference Medicaid Services Manual (MSM)
Chapter 400, Mental Health and Alcohol and Substance Abuse Services for specific policy.
Disclaimer: The term “Provider” used throughout this chapter is an all-inclusive description
relative to the above identified providers working within their respective scope of practice and
does not equate one professional to another. It serves only to make the document more reader -
friendly. A “Primary Care Provider” (PCP) is considered to be a Physician (M.D/D.O.), Advance
Practice Registered Nurse (APRN), or Physician Assistant (PA) with a specialty in general
practice, family practice, internal medicine, pediatrics, obstetrics/gynecology, or nurse midwifery.
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601 AUTHORITY
A. Medicaid is provided in accordance with the requirements of Title 42 Code of Federal
Regulation (42 CFR) Part 440, Subparts A and B; and Ssections 1929 (a), 1902 (e), 1905
(a), 1905 (p), 1915, 1920, and 1925 of the Social Security Act.
B. Regulations for services furnished by supervising physicians in teaching settings are found
in 42 CFR Part 415; Subpart D. Key portion is defined in [Reg. 415.172(a)].
C. The State Legislature sets forth standards of practice for licensed professionals in the
Nevada Revised Statutes (NRS) for the following Specialists:
1. Section 330 of the Public Health Service (PHS) Act;
2. NRS Chapter 634 – Chiropractic Physicians and Chiropractors’ Assistants;
3. NRS Chapter 629 – Healing Arts Generally;
4. NRS Chapter 632 – Nursing;
5. NRS Chapter 630 – Physicians, Physician Assistants, Medical Assistants,
Perfusionists and Practitioners of Respiratory Care;
6. NRS Chapter 633 - Osteopathic Medicine;
7. NRS Chapter 635 – Podiatric Physicians and Podiatry Hygienists;
8. NRS Chapter 640E – Registered Dietitians
9. NRS Chapter 450B – Emergency Medical Services;
10. NRS Chapter 449 – Medical Facilities and Other Related Entities;
11. Section 1861 of the Social Security Act;
12. Section 1905 of the Social Security Act;
13. Section 1461 of the Omnibus Budget Reconciliation Act of 1990;
14. Department of Defense 6025.13-R – Military Health System Clinical Quality
Assurance Program Regulation;
15. Air Force Instruction 44-119 – Medical Quality Operations.
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602 RESERVED
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603 PROVIDERS AND LICENSED PROFESSIONAL POLICY
603.1 PROVIDER’S ROLE IN RENDERING SERVICES
603.1A COVERAGE AND LIMITATIONS
1. Nevada Medicaid reimburses for covered medical services that are reasonable and
medically necessary, ordered or performed by a physician or under the supervision of a
physician, APRN or other licensed health care provider listed in Section 601 – Authority,
and that are within the scope of practice of their license as defined by state law. Providers
shall follow current national guidelines, recommendations, and standards of care. The
provider must:
a. Examine the recipient;
b. Make a diagnosis;
c. Establish a plan of care; and
d. Document these tasks in the appropriate medical records for the recipient before
submitting claims for services rendered. Documentation is subject to review by a
state authority or contracted entity.
2. Services must be performed by the provider or by a licensed professional working under
the personal supervision of the provider.
a. The following are examples of services that are considered part of the billable visit
when it is provided under the direct and professional supervision of the provider:
1. An injection of medication;
2. Diagnostic test like an electrocardiogram (ECG);
3. Blood pressure taken and recorded;
4. Dressing changes; and
5. Topical application of fluoride.
b. Providers or their designee may not bill Medicaid for services provided by,
including and not limited to, any of the following professionals below. All
providers must enroll into their designated provider type and bill for the services
they provided. Nevada Medicaid will neither accept nor reimburse for professional
billing of services or supplies rendered by anyone other than the provider under
whose name and provider number the claim is submitted. Refer to MSM Chapter
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100, Medicaid Payments to Providers, for additional information regarding
incident-to billing.
1. Another Provider;
2. Psychologist;
3. Medical Resident (unless teaching physician);
4. Therapist, including Physical Therapist (PT), Occupational Therapist (OT),
Speech Therapist (SP), Respiratory Therapist (RT);
5. Counselor/Social Worker;
6. Advanced Practice Registered Nurse (APRN) (other than diagnostic tests
done in the office which must be reviewed by the physician);
7. Physician Assistants (PA/PA-C);
8. Certified Registered Nurse Anesthetist (CRNA);
9. Pharmacist;
10. Nurse Midwife (NM);
11. Emergency Medical Technician, Advanced Emergency Medical
Technician, and Paramedic with community paramedicine endorsement; or
12. Any other provider that has a designated Nevada Medicaid provider type.
3. Teaching Physicians
Medicaid covers teaching physician services when they participate in the recipient’s care.
The teaching physician directs no more than four residents at any given time and is in such
proximity as to constitute immediate availability. The teaching physician’s documentation
must show that he or she either performed the service or was physically present while the
resident performed the key and critical portions of the service. Documentation must also
show participation of the teaching physician in the management of the recipient and
medical necessity for the service. When choosing the appropriate procedure code to bill,
consideration is based on the time and level of complexity of the teaching physician, not
the resident’s involvement or time.
Nevada Medicaid follows Medicare coverage guidelines for Teaching Physicians, Interns,
and Residents including the exceptions as outlined by Medicare’s policy.
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4. Out-of-State Providers
a. If a prior authorization is required for a specific outpatient or inpatient service in-
state, then a prior authorization is also required for an out-of-state outpatient or
inpatient service by the Nevada Medicaid Quality Improvement Organization
(QIO)-like vendor. Conversely, if a prior authorization is not required for a service
in-state (i.e. office visit, consultation), then a prior authorization is not required for
the same service out-of-state. Refer to MSM Chapter 1900, Transportation
Services, for out-of-state transportation policy. The QIO-like vendor’s
determination will consider the availability of the services within the State. If the
recipient is being referred out-of-state by a Nevada provider, the Nevada provider
is required to obtain the prior authorization and complete the referral process.
Emergency care will be reimbursed without prior authorization.
b. When in-state medical care is unavailable for Nevada recipients residing near state
borders (catchment areas) the contiguous out-of-state provider/clinic is considered
the Primary Care Provider (PCP). All in-state benefits and/or limitations apply.
c. All servicing providers must enroll in the Nevada Medicaid program prior to billing
for any services provided to Nevada Medicaid recipients. See MSM Chapter 100,
Medicaid Program.
5. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program
The EPSDT program provides preventive health care to recipients under the age of 21 years
old who are eligible for medical assistance. The purpose of the EPSDT program is the
prevention of health problems through early detection, diagnosis, and treatment. The
required screening components for an EPSDT examination are to be completed according
to the time frames on a periodicity schedule that was adopted by the American Academy
of Pediatrics and the DHCFP. See MSM Chapter 1500, Healthy Kids Program.
6. Federal Emergency Services Program (also known as Emergency Medicaid Only)
Professional services provided to an alien/non-citizen may be covered if the condition meets
the definition provided in Section 1903(v)(1-3) of the SSA, 42 CFR 440.255 and NRS
422.065. Refer to MSM Chapter 200, Hospital Services, Attachment A, Policy #02-02, Federal
Emergency Services Program for policy details.
603.2 PROVIDER OFFICE SERVICES
Covered services are those medically necessary services when the provider either examines the
patient in person or is able to visualize some aspect of the recipient’s condition without the
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interposition of a third person’s judgment. Direct visualization would be possible by means of X-
rays, electrocardiogram (ECG) and electroencephalogram (EEG) tapes, tissue samples, etc.
Telehealth services are also covered by Nevada Medicaid. See MSM Chapter 3400, Telehealth
Services for the complete coverage and limitations for Telehealth.
A. Consultation Services
A consultation is a type of evaluation and management service provided by a provider and
requested by another provider or appropriate source, to either recommend care for a
specific condition or problem or determine whether to accept responsibility for ongoing
management of the patient’s entire care. A consultant may initiate diagnostic and/or
therapeutic services at the same or subsequent visit. The written or verbal request for
consult may be made by a provider or other appropriate source and documented in the
patient’s medical record by either the consulting or requesting provider or appropriate
source. The consultant’s opinion and any services that are ordered or performed must also
be documented in the patient’s medical record and communicated by written report to the
requesting provider or appropriate source. When a consultant follows up on a patient on a
regular basis or assumes an aspect of care on an ongoing basis, the consultant becomes a
manager or co-manager of care and submits claims using the appropriate hospital or office
codes.
1. When the same consultant sees the same patient during subsequent admissions, the
provider is expected to bill the lower-level codes based on the medical records.
2. A confirmatory consultation initiated by a patient and/or their family without a
provider request is a covered benefit. Usually, requested second opinions
concerning the need for surgery or for major non-surgical diagnostic and
therapeutic procedures (e.g., invasive diagnostic techniques such as cardiac
catheterization and gastroscopy) third opinion will be covered if the first two
opinions disagree.
B. New and Established Patients
1. The following visits are used to report evaluation and management services
provided in the provider’s office or in an outpatient or other ambulatory facility:
a. Minimal to low level visits - Most patients should not require more than
nine office or other outpatient visits at this level by the same provider or by
providers of the same or similar specialties in a three-month period. No prior
authorization is required.
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b. Moderate visits - Generally, most patients should not require more than 12
office or other outpatient visits at this level by the same provider or by
providers of the same or similar specialties in a 12-month calendar year. No
prior authorization is required.
c. High severity visits – Generally, most patients should not require more than
two office or other outpatient visits at this level by the same provider or by
providers of the same or similar specialties in a 12-month period. Any
exception to the limit requires prior authorization.
2. Documentation in the patient’s medical record must support the level of service
and/or the medical acuity which requires more frequent visits and the resultant
coding. Documentation must be submitted to Medicaid upon request. A review of
requested reports may result in payment denial and a further review by Medicaid’s
Surveillance and Utilization Review (SUR) Unit.
3. Medicaid does not reimburse providers for telephone calls between providers and
patients (including those in which the provider gives advice or instructions to or on
behalf of a patient) except documented psychiatric treatment in crisis intervention
(e.g. threatened suicide).
4. New patient procedure codes are not payable for services previously provided by
the same provider or another provider of the same group practice and same
specialty, within the past three years.
5. Some of the procedures or services listed in the Current Procedural Terminology
(CPT) code book are commonly carried out as an integral component of a total
service or procedure and have been identified by the inclusion of the term “separate
procedure”. Do not report a designated “separate procedure” in addition to the code
for the total procedure or service of which it is considered an integral component.
A designated “separate procedure” can be reported if it is carried out independently
or is considered to be unrelated or distinct from other procedures/services provided
at the same time.
6. Physical therapy administered by a Physical Therapist (PT) on staff or under
contract in the provider’s office requires a prior authorization before rendering
service.
If the provider bills for physical therapy, the provider, not the PT, must have
provided the service.
A provider may bill an office visit in addition to physical therapy, on the same day
in the following circumstances:
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a. A new patient examination which results in physical therapy on the same
day;
b. An established patient with a new problem or diagnosis; and/or
c. An established patient with an unrelated problem or diagnosis.
Reference MSM Chapter 1700, Therapy for physical therapy coverage and
limitations.
7. Provider administered drugs are a covered benefit under Nevada Medicaid.
Reference MSM Chapter 1200, Prescribed Drugs for coverage and limitations.
8. Medication-Assisted Treatment (MAT) services provided by a physician, APRN,
physician assistant, or nurse midwife with a DATA 2000 waiver are available for
recipients who meet medical necessity with an opioid use disorder. Refer to MSM
Chapter 3800, Medication-Assisted Treatment for coverage and limitations.
9. Non-Covered Provider Services
a. Investigational or experimental procedures not approved by the Food and
Drug Administration (FDA).
b. Reimbursement for clinical trials and investigational studies.
c. Temporomandibular Joint (TMJ) related services (see MSM Chapter 1000,
Dental).
C. Referrals
When a prior authorization is required for either in-state or out-of-state services, the
referring provider is responsible for obtaining a prior authorization from the QIO-like
vendor. If out-of-state services are medically necessary, the recipient must go to the nearest
out-of-state provider for services not provided in-state. It is also the responsibility of the
referring provider to obtain the authorization for a recipient to be transferred from one
facility to another, either in-state or out-of-state.
D. Hospice
Adult recipients enrolled in hospice have waived their rights to Medicaid payments for any
Medicaid services related to the terminal illness and related conditions for which hospice
was elected. Providers should contact the designated hospice provider to verify qualifying
diagnosis and treatment. Reference MSM Chapter 3200, Hospice for coverage and
limitations.
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E. Home Health Agency (HHA)
HHA services provide periodic nursing care along with skilled and non-skilled services
under the direction of a qualified provider. The provider is responsible for writing the orders
and participating in the development of the plan of care. Reference MSM Chapter 1400,
Home Health Agency for coverage and limitations.
F. Laboratory
Reference MSM Chapter 800, Laboratory Services for coverage and limitations for
laboratory services.
G. Diagnostic Testing
Reference MSM Chapter 300, Radiology Services for coverage and limitations for
diagnostic services.
H. Vaccinations
Vaccinations are a covered benefit for Nevada Medicaid recipients as a preventative health
services benefit.
1. Childhood vaccinations: All childhood vaccinations, per the latest
recommendations of the Advisory Committee on Immunization Practices (ACIP),
are covered without prior authorization under the Healthy Kids Program for
children under the age of 21 years old. Refer to MSM Chapter 1500, Healthy Kids
Program, for more information on childhood vaccinations.
2. Adult vaccinations: All adult vaccinations, per the latest recommendations of the
ACIP, are covered without prior authorization for those 21 years of age or older.
Refer to MSM Chapter 1200, Prescribed Drugs, for more information on adult
vaccinations.
I. Ordering, Prescribing, and Referring (OPR) Providers
OPR providers do not bill Nevada Medicaid for services rendered, but may order,
prescribe, or refer services/supplies for Medicaid recipients.
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603.2A AUTHORIZATION PROCESS
Certain provider services require prior authorization. There is no prior authorization requirement
for allergy testing, allergy injections or for medically necessary minor office procedures unless
specifically noted in this chapter. Contact the QIO-like vendor for prior authorization information.
603.3 FAMILY PLANNING SERVICES
State and federal regulations grant the right for eligible Medicaid recipients of either sex of child-
bearing age to receive family planning services provided by any participating clinics, physician,
physician assistant, APRN, nurse midwife, or pharmacy.
Females, who are enrolled for pregnancy-related services only, are covered for all forms of family
planning, including tubal ligation and birth control implantation up to 60 days post-partum
including the entire month in which the 60th day falls.
Abortions (surgical or medical) and/or hysterectomies are not included in Family Planning
Services. These procedures are a Medicaid benefit for certain therapeutic medical diagnoses.
Family Planning Services and supplies are for the primary purpose to prevent and/or space
pregnancies. Providers shall follow current national guidelines, recommendations, and standards
of care, including but not limited to, American College of Obstetricians and Gynecologists
(ACOG) and/or U.S. Preventive Services Task Force (USPSTF).
A. Prior authorization is not required for:
1. Provider services.
2. Physical examination.
3. Pap smears.
4. FDA approved birth control drugs and delivery devices/methods, including but not
limited to the following:
a. Intrauterine contraceptive device (IUD);
Note: When a woman has an IUD inserted, she may no longer be eligible
for Medicaid when it is time to remove the device. There is no
process for Medicaid reimbursement when the recipient is not
Medicaid-eligible.
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b. Birth control pills;
c. Diaphragm/cervical cap;
d. Contraceptive foam and/or jelly;
e. Condoms;
f. Implanted contraception capsules/devices;
Note: When a woman has a contraceptive implant inserted, she may no
longer be eligible for Medicaid when it is time to remove the
implant. There is no process for Medicaid reimbursement when the
recipient is not Medicaid-eligible.
g. Contraceptive injections;
Note: If contraceptive injections are administered in the providers office,
the provider may bill for the drug itself with a National Drug Code
(NDC) and the intramuscular administration CPT code. Refer to
MSM Chapter 1200, Prescribed Drugs for Outpatient
Pharmaceuticals.
h. Vaginal contraceptive suppositories;
i. Contraceptive dermal patch;
j. Contraceptive ring and/or other birth control methods.
5. Vasectomy or tubal ligation (age 21 years or over). In accordance with federal
regulations, the recipient must fill out a sterilization consent form at least 30 days
prior to the procedure. The provider is required to send the consent form to the
fiscal agent with the initial claim. See the QIO-like vendor website to access the
FA-56 Sterilization Consent Form which is also the HHS-687 form.
B. Medicaid has removed all barriers to family planning counseling/education provided by
qualified providers (e.g. Physicians, Physician Assistants, APRN, Nurse Midwife, Rural
Health Clinics, Federally Qualified Health Centers, Indian Health Programs, etc.). The
provider must provide adequate counseling and information to each recipient when they
are choosing a birth control method. If appropriate, the counseling should include the
information that the recipient must pay for the removal of any implants when the removal
is performed after Medicaid eligibility ends.
C. Family planning education is considered a form of counseling intended to encourage
children and youth to become comfortable discussing issues such as sexuality, birth control
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and prevention of sexually transmitted disease. It is directed at early intervention and
prevention of teen pregnancy. Family planning services may be provided to any eligible
recipient of childbearing age (including minors who may be considered sexually active).
D. Insertion of Long-Acting Reversible Contraceptives (LARC) immediately following
delivery is a covered benefit for eligible recipients. LARC insertion is a covered benefit
post discharge as medically necessary.
E. Family Planning Services are not covered for those recipients, regardless of eligibility,
whose age or physical condition precludes reproduction.
F. A pelvic exam or pap smear is not required for self-administered birth control.
603.4 MATERNITY CARE
Maternity Care is a program benefit which includes antepartum care, labor and delivery, and
postpartum care provided by a physician, physician assistant, APRN, and/or a nurse midwife.
Maternity care services can be provided in the home, office, hospital, or obstetric center settings.
All maternity care providers are allowed to provide services within all settings that are allowed per
their scope of practice and licensure.
Provider shall follow current national guidelines, recommendations, and standards of care for
maternity care services, including but not limited to, USPSTF, ACOG, Society of Maternal-Fetal
Medicine, and the American College of Nurse Midwives.
Per NRS 449.0155 “Obstetric Center” means a facility that is not part of a hospital and provides
services for normal, uncomplicated births. This is also Nevada’s legal term for a birth center or
freestanding birth center. Nevada Administrative Code (NAC) regulations for Obstetric Centers
are located in NAC 449.6113 – 449.61178. Please also refer to MSM Chapter 200, Hospital
Services, Attachment A, Policy #02-01, Birth Centers.
For women who are eligible for pregnancy-related services only, their eligibility begins with
enrollment and extends up to 60 days postpartum including the entire month in which the 60th day
falls. She is eligible for pregnancy related services only which are prenatal care and postpartum
services, including family planning education and services. Recipients under age 21 years old, and
eligible for pregnancy only, are not entitled to EPSDT services.
It is the responsibility of the treating provider to employ a care coordination mechanism to
facilitate the identification and treatment of high-risk pregnancies. “High-Risk” is defined as a
probability of an adverse outcome to the woman and/or her baby greater than the average
occurrence in the general population. Home and obstetric center births and corresponding
pregnancy services are appropriate for recipients with low-risk pregnancies, intended vaginal
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delivery, and no reasonably foreseeable expectation of complication. Recipients that are eligible
for Obstetric Center services is outlined in NAC 449.61134. If assessments suggest the likelihood
of complications that could make the delivery high-risk, then services will be reimbursed when
provided by a provider in the hospital setting.
For those females enrolled in a managed care program, the Managed Care Organization (MCO)
physicians are responsible for making referrals for early intervention and case management
activities on behalf of those women. Communication and coordination between the MCO
physicians, service physicians, and MCO staff is critical to promoting optimal birth outcomes.
603.4A STAGES OF MATERNITY CARE
1. Antepartum care includes the initial and subsequent history, physical examinations,
recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and
monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly
visits until delivery totaling approximately 13 routine visits. Any other visits or services
within this time period for non-routine maternity care should be coded separately. Non-
emergency antepartum care is not a covered benefit for non-U.S. citizens/aliens who have
not lawfully been admitted for permanent residence in the United States or permanently
residing in the United States under the color of the law. Refer to MSM Chapter 200,
Hospital Services, Attachment A, Policy #02-02, Federal Emergency Services Program for
allowable services to non-U.S. citizens.
2. Labor and delivery services include home delivery, admission to the hospital, or obstetric
center, the admission history and physical examination, management of uncomplicated
labor, vaginal delivery (with or without an episiotomy/operative delivery (vacuum or
forceps)), or cesarean delivery in hospital setting. Medical problems complicating labor
and delivery management may require additional resources and should be billed utilizing
the CPT codes in the Medicine and Evaluation and Management Services sections in
addition to codes for maternity care.
a. In accordance with standard regulations, vaginal deliveries with a hospital stay of
three days or less and cesarean-section deliveries with a hospital stay of four days
or less do not require prior authorization. Reference MSM Chapter 200, Hospital
Services for inpatient coverage and limitations.
b. Non-Medically Elective Deliveries
1. Reimbursement for Avoidable Cesarean Section
To make certain that cesarean sections are being performed only in cases of
medical necessity, Nevada Medicaid will reimburse providers for
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performing cesarean sections only in instances that are medically necessary
and not for the convenience of the provider or patient. Elective cesarean
sections must be prior authorized and will be reimbursed at the vaginal
delivery rate.
2. Early Induction of Labor (EIOL)
Research shows that early elective induction (<39 weeks gestation) has no
medical benefit and may be associated with risks to both the mother and
infant. Based upon these recommendations, Nevada Medicaid will require
prior authorization for hospital admissions for EIOL prior to 39 weeks to
determine medical necessity.
Nevada Medicaid encourages providers to review the “Early Elective
Deliveries Toolkit” compiled by the March of Dimes, the California
Maternity Quality Care Collaborative, and the California Department of
Public Health, Maternal, Child and Adolescent Health Division at
http://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-
deliveries-toolkit. The aim of the toolkit is to offer guidance and support to
providers, clinical staff, hospitals and healthcare organizations in order to
develop quality improvement programs which will help to eliminate
elective deliveries <39 weeks gestation.
3. Progesterone therapy to prevent preterm birth.
Preterm birth is determined when a baby is born prior to 37 weeks of
pregnancy. Women who have a history of preterm birth are at greater risk
of future preterm births. Progesterone therapy is a hormone therapy
designed to prevent the onset of preterm birth.
Nevada Medicaid covers services related to the prevention of preterm birth.
Progesterone therapies are initiated between 16 and 20 weeks of pregnancy,
with weekly injections until 37 weeks.
Please see PT 20, 24, 74, and 77 Billing Guides for specific coverage and
limitations.
c. Provider responsibilities for the initial newborn examination and subsequent care
until discharge includes the following:
1. The initial physical examination done in the home, obstetric center, or
hospital delivery room is a rapid screening for life threatening anomalies
that may require immediate billable attention.
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2. Complete physical examination is done within 24 hours of delivery but after
the six-hour transition period when the infant has stabilized. This
examination is billable.
3. Brief examinations should be performed daily until discharge. On day of
discharge, provider may bill either the brief examination or discharge day
code, not both.
4. Routine circumcision of a newborn male is a Medicaid benefit for males up
to one year of age. For males older than one year of age, a prior
authorization is required to support medical necessity.
5. If a newborn is discharged from a hospital or obstetric center less than 24
hours after delivery, Medicaid will reimburse newborn follow-up visits in
the provider’s office or recipient’s home up to four days post-delivery. This
is also allowable for all home births.
6. All newborns must receive a hearing screen in accordance with NRS
442.540 and corresponding NAC 442.850. This testing and interpretation
are included in the facility per diem rate. Hearing screening is not required
if parent or legal guardian objects in writing. If a baby is born in the home
setting, the nurse midwife may not have the necessary equipment to conduct
the hearing screen. Therefore, a referral can be made to a hearing specialist.
7. All newborns must receive a newborn screening blood analysis in
accordance with NRS 442.008 and corresponding NAC 442.020 – 442.050.
This testing is included in the facility per diem rate. Newborn screening is
not required if parent or legal guardian objects in writing.
3. Postpartum care includes hospital, office visits, and home visits following vaginal or
cesarean section delivery. Women, who are eligible for Medicaid on the last day of their
pregnancy, remain eligible for all pregnancy related and postpartum medical assistance
including family planning education and services for 60 days immediately following the
last day of pregnancy, including the entire month in which the 60th day falls. Pregnancy
related only eligible women are not covered for any Medicaid benefits not directly related
to their pregnancy.
4. Reimbursement: If a provider provides all or part of the antepartum and/or postpartum care
but does not perform delivery due to termination of the pregnancy or referral to another
provider, then reimbursement is based upon the antepartum and postpartum care CPT
codes. A global payment will be paid to the delivering provider, when the pregnant woman
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has been seen seven or more times by the delivering provider. If the provider has seen the
pregnant woman less than seven times with or without delivery, the provider will be paid
according to the Fee-for-Service (FFS) visit schedule using the appropriate CPT codes. For
MCO exceptions to the global payment please refer to MSM Chapter 3600, Managed Care
Organization. Please refer to MSM Chapter 700, Rates and Supplemental Reimbursement
for more information.
603.4B FETAL NON-STRESS TESTING
1. Fetal Non-Stress testing (NST) is a means of fetal surveillance for most conditions that
place the fetus at high risk for placental insufficiency. Providers shall follow current
national guidelines, recommendations, and standards of care for the indications,
techniques, and timing of the appropriate antepartum fetal surveillance methods and
management guidelines.
2. Home uterine activity monitoring service may be ordered for a recipient who has a current
diagnosis of pre-term labor and a history of pre-term labor/delivery with previous
pregnancies. Reference MSM Chapter 1300, Durable Medical Equipment (DME) for
coverage and limitation guidelines.
603.4C MATERNAL/FETAL ULTRASOUND STUDIES
Obstetrical ultrasound of a pregnant uterus is a covered benefit of Nevada Medicaid when it is
determined to be medically necessary for the woman and/or the fetus.
Per CPT guidelines, an obstetrical ultrasound includes determination of the number of gestational
sacs and fetuses, gestational sac/fetal structure, qualitative assessment of amniotic fluid
volume/gestational sac shape, and examination of the maternal uterus and adnexa. The patient’s
record must clearly identify all high-risk factors and ultrasound findings.
1. Coverage and Limitations
A first trimester ultrasound may be covered to confirm viability of the pregnancy, to rule
out multiple births and better define the Estimated Date of Confinement (EDC).
One second trimester or third trimester ultrasound per pregnancy with detailed anatomic
examination is considered medically necessary to evaluate the fetus for fetal anatomic
abnormalities. Refer to most current ACOG guidance for a list of qualified indications.
An initial screening ultrasound due to late entry prenatal care is a covered benefit. The use
of a second ultrasound in the third trimester for screening purposes is not covered.
Subsequent ultrasounds, including biophysical profiles should clearly identify the findings
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from the previous abnormal scan and explain the high-risk situation which makes repeated
scans medically necessary. The patient’s record must clearly identify all high- risk factors
and ultrasound findings.
It is policy to perform ultrasound with detailed fetal anatomic study only on those
pregnancies identified as being at risk for structural defects (e.g. advanced maternal age,
prior anomalous fetus, medication exposure, diabetes, etc.).
a. Ultrasound coverage includes, but is not limited to:
1. Suspected abnormality in pregnancy, such as:
a. Suspected ectopic pregnancy;
b. Suspected hydatiform mole;
c. Threatened or missed abortion;
d. Congenital malformation, fetal or maternal;
e. Polyhydramnios;
f. Oligohydramnios;
g. Placenta previa;
h. Abruptio placenta; or
i. Vaginal bleeding.
2. Medical conditions threatening the fetus and/or delivery, such as:
a. Suspected abnormal presentation;
b. Suspected multiple gestation;
c. Significant difference between the size of the uterus and the
expected size based on EDC (> 3 cm);
d. Elevated maternal serum alpha-fetoprotein;
e. Suspected fetal death;
f. Suspected anatomical abnormality of uterus;
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g. Maternal risk factors, such as family history of congenital anomalies
or chronic systemic disease (hypertension, diabetes, sickle cell
disease, anti-phospholipid syndrome, poorly controlled
hyperthyroidism, Hemoglobinopathies, cyanotic heart disease,
systemic lupus erythematosus) or substance abuse;
h. Suspected macrosomia; or
i. Intrauterine Growth Retardation-IUGR (≤ 15th percentile of the
combined biometrical parameters-biparietal diameter, head
circumference, abdominal circumference, head/abdominal
circumference ration, length of femur and length of humerus, and
estimated fetal weight).
3. Confirmation of the EDC when clinical history and exam are uncertain. In
general, a single ultrasound performed between 14 and 24 weeks is
sufficient for this purpose.
4. Diagnosis of “decreased fetal movement” (accompanied by other clinical
data, i.e. abnormal kick counts).
5. Follow up ultrasounds which may be considered medically necessary if the
study will be used to alter or confirm a treatment plan.
b. Non-coverage – Ultrasound is not covered when it fails to meet the medical
necessity criteria listed above or for the reasons listed below:
1. When the initial screening ultrasound (regardless of trimester) is within
normal limits or without a significant second diagnosis.
2. When used solely to determine the sex of the neonate, or to provide the
mother with a picture of the baby.
2. Provider Responsibility
For repeat evaluations, documentation should include, at a minimum:
a. Documentation of the indication for the study (abnormality or high-risk factors);
b. Crown-rump length (CRL);
c. Biparietal diameter (BPD);
d. Femur length (FL);
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e. Abdominal circumference (AC);
f. Re-evaluation of organ system;
g. Placental location;
h. Number of fetuses (embryos);
i. Amniotic fluid volume assessment (qualitative or quantitative)
1. Oligohydramnios; or
2. Polyhydramnios.
j. Intrauterine growth restriction (IUGR).
For a list of maternal/fetal ultrasound codes, please refer to the Provider Type (PT) 20, 24,
74, and 77 Billing Guides.
NOTE: The use of the diagnosis of “Supervision of High-Risk Pregnancy” or
“Unspecified Complications of Pregnancy” without identifying the specific
high risk or complication will result in non-payment.
603.4D PRENATAL SCREENING AND DIAGNOSTIC TESTING
Nevada Medicaid covers current national guidelines, recommendations, and standards of care for
prenatal screening and diagnostic testing.
1. Screening includes:
a. First trimester and second trimester screenings. This does not include coverage of
cell-free fetal DNA screening.
2. Diagnostic testing includes obtaining specimens through amniocentesis and chorionic
villus sampling (CVS) to conduct diagnostic testing such as:
a. Karyotype chromosomal testing, fluorescence in situ hybridization (FISH) testing,
and chromosomal microarray analysis.
3. Comprehensive patient pretest and post-test genetic counseling from a provider regarding
the benefits, limitations, and results of chromosome screening and testing is essential.
Nevada Medicaid does not reimburse for genetic counselors but does reimburse for
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providers that are physicians (M.D./D.O.), physician assistants, APRNs, or nurse
midwives.
4. All prenatal chromosomal screening and diagnostic testing should not be ordered without
informed consent, which should include discussion of the potential to identify findings of
uncertain significance, nonpaternity, consanguinity, and adult-onset disease.
603.4E ABORTION/TERMINATION OF PREGNANCY
1. Reimbursement is available for an induced abortion to save the life of the mother, only
when a provider has attached a signed certification to the claim that on the basis of his/her
professional judgment, and supported by adequate documentation, the life of the mother
would be endangered if the fetus were carried to term. Refer to the QIO-like vendor website
to access the abortion certification form. Providers may use the FA-57 Certification
Statement for Abortion to Save the Life of the Mother form or substitute any form that
includes the required information.
2. Reimbursement is available for induced abortion services resulting from a sexual assault
(rape) or incest. A copy of the appropriate declaration statement must be attached to the
claim. Refer to the QIO-like vendor website to access the abortion declaration forms.
Providers may use the FA-54 Abortion Declaration (Rape) form or the FA-55 Abortion
Declaration (Incest) form or substitute any form that includes the required information. The
Nevada mandatory reporting laws related to child abuse and neglect must be followed for
all recipients under the age of 18 years old and providers are still required to report the
incident to Child Protective Services (CPS) through the Division of Child and Family
Services (DCFS) or, in some localities, through County Child Welfare Services.
3. Reimbursement is available for the treatment of incomplete, missed, or septic abortions
under the criteria of medical necessity. The claim should support the procedure with
sufficient medical information and by diagnosis. No certification or prior authorization is
required.
NOTE: Any abortion that involves inpatient hospitalization requires a prior
authorization from the QIO-like vendor. See MSM Chapter 200, Hospital
Services, Authorization Requirements for further information.
603.5 HYSTERECTOMY
According to federal regulations, a hysterectomy is not a family planning (sterilization) procedure.
Hysterectomies performed solely for the purpose of rendering a female incapable of reproducing
are not covered by Medicaid. All hysterectomy certifications must have an original signature of
the physician certifying the forms. Refer to the FA-50 Nevada Medicaid Hysterectomy
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Acknowledgement Form on the QIO-like vendor website. A stamp or initial by billing staff is not
acceptable. Payment is available for hysterectomies as follows:
1. Medically Necessary – A medically necessary hysterectomy may be covered only when
the physician securing the authorization to perform the hysterectomy has informed the
recipient or her representative, if applicable, orally and in writing before the surgery is
performed that the hysterectomy will render the recipient permanently incapable of
reproducing, and the recipient or her representative has signed a written FA-50
Hysterectomy Acknowledgement Form.
2. When a hysterectomy is performed as a consequence of abdominal exploratory surgery or
biopsy, the FA-50 Nevada Medicaid Hysterectomy Acknowledgement Form is also required.
Therefore, it is advisable to inform the recipient or her authorized representative prior to
the exploratory surgery or biopsy.
3. Emergency – The physician who performs the hysterectomy certifies in writing that the
hysterectomy was performed under a life-threatening emergency situation in which the
physician determined prior acknowledgment was not possible. The completed FA-50
Nevada Medicaid Hysterectomy Acknowledgment Form must be attached to each claim
form related to the hysterectomy (e.g., surgeon, hospital, and anesthesiologist). The
physician must include a description of the nature of the emergency and this certification
must be dated after the emergency. The recipient does not have to sign this form. An
example of this situation would be when the recipient is admitted to the hospital through
the emergency room for immediate medical care and the recipient is unable to understand
and respond to information pertaining to the Hysterectomy Acknowledgement Form due
to the emergency nature of the admission.
4. Sterility – The physician who performs the hysterectomy certifies in writing that the
recipient was already sterile at the time of the hysterectomy and needs to include a
statement regarding the cause of the sterility. The completed FA-50 Nevada Medicaid
Hysterectomy Acknowledgment Form, which is also the federal HHS-687 form, must be
attached to each claim form related to the hysterectomy. The recipient does not have to
sign the form. (For example, this form would be used when the sterility was
postmenopausal or the result of a previous surgical procedure.)
5. Hysterectomies Performed During a Period of Retroactive Eligibility – Reimbursement is
available for hysterectomies performed during periods of retroactive eligibility. In order
for payment to be made in these cases, the physician must submit a written statement
certifying one of the following conditions was met:
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a. He or she informed the woman before the operation the procedure would make her
sterile. In this case, the recipient and the physician must sign the written statement;
or,
b. The woman met one of the exceptions provided in the physician’s statement. In this
case, no recipient signature is required. Claims submitted for hysterectomies
require the authorization number for the inpatient admission. The authorization
process will ensure the above requirements were met. Payment is not available for
any hysterectomy performed for the purpose of sterilization or which is not
medically necessary.
603.6 GYNECOLOGIC EXAM
Nevada Medicaid reimburses providers for preventative gynecological examinations. The
examinations may include a breast exam, pelvic exam, sexually transmitted disease screening, and
tissue collection if needed (also known as Pap Smear). Pelvic exams and pap smears should not be
required for self-administered birth control. Providers shall follow current national guidelines,
recommendations, and standards of care, including but not limited to, ACOG and/or USPSTF.
603.7 CHIROPRACTIC SERVICES POLICY
Medicaid will pay for a chiropractic manual manipulation of the spine to correct a subluxation if
the subluxation has resulted in a neuro-musculoskeletal condition for which manipulation is the
appropriate treatment.
Services are limited to Medicaid eligible children under 21 years of age.
A. Prior authorization is not required for:
Four or less chiropractic office visits (emergent or non-emergent) for children under 21
years of age in a rolling 365 days. The visits must be as a direct result of an EPSDT
screening examination, diagnosing acute spinal subluxation.
B. Prior authorization is required for:
Chiropractic visits for children under 21 years of age whose treatment exceeds the four
visits. The provider must contact the Nevada Medicaid QIO-like vendor for prior
authorization.
603.8 PODIATRY
Podiatry services are rendered by a podiatrist. Podiatrists are medical specialists who diagnose,
treat and care for: injury, disease or other medical conditions affecting the foot, ankle, and structure
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of the leg. Podiatrists perform surgical procedures and prescribe corrective devices, medications,
and physical therapy.
A. Prior Authorization and Limitations
1. Policy limitations regarding diagnostic testing (not including x-rays), therapy
treatments and surgical procedures which require prior authorization, remain in
effect. Orthotics ordered as a result of a podiatric examination or a surgical
procedure must be billed using the appropriate Centers for Medicare and Medicaid
Services (CMS) Healthcare Common Procedural Coding System (HCPCS) code.
Medicaid will pay for the orthotic in addition to the office visit.
2. Radiology Service
a. Radiology services are covered when deemed medically necessary; refer to
MSM Chapter 300, Radiology Services for services and prior authorization
requirements.
3. Laboratory Services
a. Laboratory services are covered when deemed medically necessary; refer to
MSM Chapter 800, Laboratory Services for services and prior authorization
requirements.
4. Prescription Drugs
a. Prescription drugs are covered when deemed medically necessary; refer to
MSM Chapter 1200, Prescribed Drugs for services and prior authorization
requirements.
5. Telehealth Services
a. Telehealth services are covered when deemed medically necessary; refer to
MSM Chapter 3400, Telehealth Services for services and prior
authorization requirements.
B. Covered Services
1. Evaluation and Management Services
a. Evaluations, examinations, consultations, treatments, health supervision.
b. Office visits, home visits, hospital visits, emergency room visits, nursing
home visits.
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2. Surgical Procedures
a. Multiple surgeries.
b. Mycotic procedures.
c. Casting/strapping/taping.
1. These procedures are covered when performed by a podiatrist for
the treatment of fractures, dislocations, sprains, strains and open
wounds (related to podiatrist’s scope of practice) and require prior
authorization.
3. Infection and Inflammation Services
a. Trimming of nails, cutting or removal of corns and calluses are allowed if
either infection or inflammation is present.
C. Non-Covered Services
1. Preventive care including the cleaning and soaking of feet and the application of
creams to insure skin tone.
2. Routine foot care in the absence of infection or inflammation. Routine foot care
includes the trimming of nails, cutting or removal of corns and calluses.
a. Preventive care and routine foot care can be provided by Outpatient
Hospitals, APRN, physician, or physician assistant.
603.9 PROVIDER SERVICES PROVIDED IN RURAL HEALTH CLINICS
A. Rural Health Clinic (RHC)
1. Medicaid covered outpatient services provided in RHCs are reimbursed at an all-
inclusive per recipient per encounter rate. Regardless of the number or types of
providers seen, only one encounter is reimbursable per day.
This all-inclusive rate includes any one or more of the following services and
medical professionals:
a. Physician (MD/DO);
b. Dentist;
c. Advance Practice Registered Nurse (APRN);
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d. Physician Assistant (PA/PA-C);
e. Certified Registered Nurse Anesthetist (CRNA);
f. Nurse Midwife (NM);
g. Psychologist;
h. Licensed Clinical Social Worker (LCSW);
i. Registered Dental Hygienist;
j. Podiatrist (DPM);
k. Radiology;
l. Optometrist (OD);
m. Optician (including dispensing of eyeglasses); and
n. Clinical Laboratory.
2. Encounter codes are used for primary care services provided by the RHCs in the
following areas:
a. Core visits include the following:
1. Medical and dental office visits, patient hospital visits, injections
and oral contraceptives;
2. Women’s annual preventive gynecological examinations; and
3. Colorectal screenings.
b. Home visits; or
c. Family planning education.
1. Up to two times a calendar year the RHC may bill for additional
reimbursement along with the encounter rate.
3. For billing instructions for RHC, please refer to PT 17 Special Clinics Billing
Guide.
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B. Indian Health Programs (IHP)
Please refer to MSM Chapter 3000, Indian Health.
603.10 ANESTHESIA
Medicaid payments for anesthesiology services provided by physicians and Certified Registered
Nurse Anesthetists (CRNAs) are based on the CMS base units.
A. Each service is assigned a base unit which reflects the complexity of the service and
includes work provided before and after reportable anesthesia time. The base units also
cover usual preoperative and post-operative visits, administering fluids and blood that are
part of the anesthesia care, and monitoring procedures.
B. Time for anesthesia procedures begins when the anesthesiologist/CRNA begins to prepare
the recipient for the induction of anesthesia and ends when the anesthesiologist/CRNA is
no longer in personal attendance, and the recipient is placed under postoperative
supervision.
C. All anesthesia services are reported by use of the anesthesia CPT codes. Nevada Medicaid
does not reimburse separately for physical status modifiers or qualifying circumstances.
D. Using the CPT/ASA codes, providers must indicate on the claim the following:
1. Type of surgery;
2. Length of time;
3. Diagnosis;
4. Report general anesthesia and continuous epidural analgesia for obstetrical
deliveries using the appropriate CPT codes; and
5. Unusual forms of monitoring and/or special circumstances rendered by the
anesthesiologist/CRNA are billed separately using the appropriate CPT code.
Special circumstances include but are not limited to nasotracheal/bronchial catheter
aspiration, intra-arterial, central venous and Swan-Ganz lines, transesophageal
echocardiography, and ventilation assistance.
603.11 PROVIDER SERVICES IN OUTPATIENT SETTING
A. Outpatient hospital-based clinic services include non-emergency care provided in the
emergency room, outpatient therapy department/burn center, observation area, and any
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established outpatient clinic sites. Visits should be coded using the appropriate
Evaluation/Management (E/M) CPT code (e.g. office visit/observation/etc.). Do not use
emergency visit codes.
Services requiring prior authorization include the following:
1. Hyperbaric Oxygen Therapy for chronic conditions (reference Attachment A,
Policy #6-03 for Coverage and Criteria);
2. Bariatric surgery for Morbid Obesity (reference Attachment A, Policy #6-07 for
Coverage and Criteria);
3. Cochlear implants (See MSM Chapter 2000, Audiology Services);
4. Diabetes training exceeding 10 hours (reference Attachment A, Policy #6-10 for
Coverage and Criteria);
5. Vagus nerve stimulation (reference Attachment A, Policy #6-06 for Coverage and
Criteria); and
6. Services requiring authorization per Ambulatory Surgical Center (ASC) list.
B. Emergency Department Policy
Nevada Medicaid uses the prudent layperson standard as defined in the Balanced Budget
Act of 1997 (BBA). Accordingly, emergency services are defined as “a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe pain) such
that a prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in placing the
health of the recipient (or, with respect to a pregnant woman, the health of the woman or
her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious
function of any bodily organ or part.” The threat to life or health of the recipient
necessitates the use of the most accessible hospital or facility available that is equipped to
furnish the services. The requirement of non-scheduled medical treatment for the
stabilization of an injury or condition will support an emergency.
1. Prior authorization will not be required for admission to a hospital as a result of a
direct, same day admission from a provider’s office and/or the emergency
department. The requirement to meet acute care criteria is dependent upon the QIO-
like vendor’s determination. The QIO-like vendor will continue to review and
perform the retrospective review for these admissions based upon approved criteria.
Prior authorization is still required for all other inpatient admissions. See MSM
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Chapter 200, Hospital Services for additional information regarding emergency
admissions and retrospective reviews.
2. Direct physical attendance by a physician is required in emergency situations. The
visit will not be considered an emergency unless the physician’s entries into the
record include his or her signature, the diagnosis, and documentation that he or she
examined the recipient. Attendance of a physician assistant does not substitute for
the attendance of a physician in an emergency situation.
3. Physician’s telephone or standing orders, or both, without direct physical
attendance does not support emergency treatment.
4. Reimbursement for physician–directed emergency care and/or advanced life
support rendered by a physician located in a hospital emergency or critical care
department, engaged in two-way voice communication with the ambulance or
rescue personnel outside the hospital is not covered by Medicaid.
5. Services deemed non-emergency and not reimbursable at the emergency room level
of payment are:
a. Non-compliance with previously ordered medications or treatments
resulting in continued symptoms of the same condition;
b. Refusal to comply with currently ordered procedures or treatments;
c. The recipient had previously been treated for the same condition without
worsening signs or symptoms of the condition;
d. Scheduled visit to the emergency room for procedures, examinations, or
medication administration. Examples include, but are not limited to, cast
changes, suture removal, dressing changes, follow-up examinations, and
consultations for a second opinion;
e. Visits made to receive a “tetanus” vaccination in the absence of other
emergency conditions;
f. The conditions or symptoms relating to the visit have been experienced
longer than 48 hours or are of a chronic nature, and no emergency medical
treatment was provided to stabilize the condition;
g. Medical clearance/screenings for psychological or temporary detention
ordered admissions; and
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h. Diagnostic x-ray, diagnostic laboratory, and other diagnostic tests provided
as a hospital outpatient service are limited to physician ordered tests
considered to be reasonable and necessary for the diagnosis and treatment
of a specific illness, symptom, complaint, or injury or to improve the
functioning of a malformed body member. For coverage and limitations,
reference MSM Chapter 300 for Radiology and Diagnostic Services and
MSM Chapter 800 for Laboratory Services.
C. Therapy Services (OT, PT, RT, ST)
Occupational, Physical, Respiratory and Speech Therapy services provided in the hospital
outpatient setting are subject to the same prior authorization and therapy limitations found
in the MSM Chapter 1700, Therapy.
D. Observation Services Provided by The Physician
1. Observation services are provided by the hospital and supervising physician to
recipients held but not admitted into an acute hospital bed for observation.
Consistent with federal Medicare regulations, Nevada Medicaid reimburses
hospital “observation status” for a period up to, but no more than 48 hours.
2. Observation services are conducted by the hospital to evaluate a recipient’s
condition or to assess the need for inpatient admission. It is not necessary that the
recipient be located in a designated observation area such as a separate unit in the
hospital, or in the emergency department in order for the physician to bill using the
observation care CPT codes, but the recipient’s observation status must be clear.
3. If observation status reaches 48 hours, the physician must make a decision to:
a. Send the recipient home;
b. Obtain authorization from the QIO-like vendor to admit into the acute
hospital; or
c. Keep the recipient on observation status with the understanding neither the
physician nor the hospital will be reimbursed for any services beyond the
48 hours.
4. The physician must write an order for observation status, and/or an observation stay
that will rollover to an inpatient admission status.
See MSM Chapter 200, Hospital Services for policy specific to the facility’s
responsibility for a recipient in “observation status.”
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E. End Stage Renal Disease (ESRD) Outpatient Hospital/Free-Standing Facilities. The term
“end-stage renal disease” means the stage of kidney impairment that appears irreversible
and permanent and requires a regular course of dialysis or kidney transplantation to
maintain life.
1. Treatment of ESRD in a physician-based (i.e. hospital outpatient) or independently
operated ESRD facility certified by Medicare is a Medicaid covered benefit.
Medicaid is secondary coverage to Medicare for ESRD treatment except in rare
cases when the recipient is not eligible for Medicare benefits. In those cases, private
insurance and/or Medicaid is the primary coverage.
2. ESRD Services, including hemodialysis, peritoneal dialysis and other
miscellaneous dialysis procedures are Medicaid covered benefits without prior
authorization.
3. If an established recipient in Nevada requires out-of-state transportation for ESRD
services, the physician or the facility must initiate contact and make financial
arrangements with the out-of-state facility before submitting a prior authorization
request to the non-emergency transportation (NET) broker. The request must
include dates of service and the negotiated rate. (This rate cannot exceed
Medicare’s reimbursement for that facility) Refer to MSM Chapter 1900,
Transportation Services for requirements of non-emergency transportation.
4. Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Nutrition (IPN) are
covered services for hemodialysis and Continuous Ambulatory Peritoneal Dialysis
(CAPD) recipients who meet all of the requirements for Parenteral and Enteral
Nutrition coverage. The recipient must have a permanently inoperative internal
body organ or function. Documentation must indicate that the impairment will be
of long and indefinite duration.
5. Reference Attachment A, Policy #6-09 for ESRD Coverage.
F. Ambulatory Surgical Centers (ASC) Facility and Non-Facility Based
Surgical procedures provided in an ambulatory surgical facility refers to freestanding or
hospital-based licensed ambulatory surgical units that can administer general anesthesia,
monitor the recipient, provide postoperative care and provide resuscitation as necessary.
These recipients receive care in a facility operated primarily for performing surgical
procedures on recipients who do not generally require extended lengths of stay or extensive
recovery or convalescent time.
Outpatient surgical procedures designated as acceptable to be performed in a provider’s
office/outpatient clinic, ambulatory surgery center or outpatient hospital facility are listed
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on the QIO-like vendor’s website. For questions regarding authorization, the provider
should contact the QIO-like vendor.
1. Prior authorization is not required when:
a. Procedures listed are to be done in the suggested setting or a setting which
is a lower level than suggested;
b. Procedures are part of the emergency/clinic visit.
2. Prior authorization is required from the QIO-like vendor when:
a. Procedures are performed in a higher-level facility than it is listed in the
ASC surgical list (e.g., done in an ASC but listed for the office);
b. Procedures on the list are designated for prior authorization;
c. Designated podiatry procedures; and
d. The service is an out-of-state service and requires a prior authorization if
that same service was performed in-state.
3. Surgical procedures deemed experimental, not well established, or not approved by
Medicare or Medicaid are not covered and will not be reimbursed for payment.
Below is a list of definitive non-covered services.
a. Cosmetic Surgery: The cosmetic surgery exclusion precludes payment for
any surgical procedure directed at improving appearance. The condition
giving rise to the recipient’s preoperative appearance is generally not a
consideration. The only exception to the exclusion is surgery for the prompt
repair of an accidental injury or the improvement of a malformed body
member, to restore or improve function, which coincidentally services some
cosmetic purpose. Examples of procedures which do not meet the exception
to the exclusion are facelift/wrinkle removal (rhytidectomy), nose hump
correction, moon-face, etc.;
b. Fabric wrapping of abdominal aneurysm;
c. Intestinal bypass surgery for treatment of obesity;
d. Transvenous (catheter) pulmonary embolectomy;
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e. Extracranial-Intracranial (EC-IC) Arterial bypass when it is performed as a
treatment for ischemic cerebrovascular disease of the carotid or middle
cerebral arteries;
f. Breast reconstruction for cosmetic reasons, however breast reconstruction
following removal of a breast for any medical reason may be covered;
g. Stereotactic cingulotomy as a means of psychosurgery to modify or alter
disturbances of behavior, thought content, or mood that are not responsive
to other conventional modes of therapy, or for which no organic
pathological cause can be demonstrated by established methods;
h. Radial keratotomy and keratoplasty to treat refractive defects. Keratoplasty
that treats specific lesions of the cornea is not considered cosmetic and may
be covered;
i. Implants not approved by the FDA; Partial ventriculectomy, also known as
ventricular reduction, ventricular remodeling, or heart volume reduction
surgery;
j. Gastric balloon for the treatment of obesity;
k. Cochleostomy with neurovascular transplant for Meniere’s Disease; and
l. Surgical procedures to control obesity other than bariatric for morbid
obesity with significant comorbidities. See Attachment A, Policy #6-07 for
policy limitations.
603.12 SERVICES IN THE ACUTE HOSPITAL SETTING
A. Admissions to acute care hospitals both in and out-of-state are limited to those authorized
by Medicaid’s QIO-like vendor as medically necessary and meeting Medicaid benefit
criteria. Refer to MSM Chapter 200, Hospital Services for authorization requirements.
B. Physicians may admit without prior approval only as outlined in MSM Chapter 200,
Hospital Services, Authorization Requirements.
C. All other hospital admissions both in-state and out-of-state must be prior authorized by the
QIO-like vendor. Payment will not be made to the facility or to the admitting physician,
attending physician, consulting physician, anesthesiologist, or primary/assisting surgeon if
the authorization is denied by the QIO-like vendor.
D. Attending physicians are responsible for ordering and obtaining prior authorization for all
transfers from the acute hospital to all other facilities.
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E. Physicians may admit recipients to psychiatric and/or substance abuse units of general
hospitals (regardless of age), or freestanding psychiatric and substance abuse hospitals for
recipients 65 years of age and older or those under the age of 21 years old. All admissions
must be prior authorized by the QIO-like vendor with the exception of a psychiatric
emergency. Refer to MSM Chapter 400, Mental Health and Alcohol and Substance Abuse
Services for coverage and limitations.
F. Inpatient Hospital Care
1. Routine Inpatient Hospital Care is limited to reimbursement for one visit per day
(same physician or physicians in the same group practice) except when extra care
is documented as necessary for an emergency situation (e.g., a sudden serious
deterioration of the recipient’s condition).
2. The global surgical package includes the following when provided by the physician
who performs the surgery, whether in the office setting, out-patient or in-patient:
a. Preoperative visits up to two days before the surgery;
b. Intraoperative services that are normally a usual and necessary part of a
surgical procedure;
c. Services provided by the surgeon within the Medicare recommended global
period of the surgery that do not require a return trip to the operating room;
and follow-up visits related to the recovery from the surgery which are
provided during this time by the surgeon, and
d. Post-surgical pain management.
3. The surgeon’s initial evaluation or consultation is considered a separate service
from the surgery and is paid as a separate service, even if the decision, based on the
evaluation, is not to perform the surgery. If the decision to perform a major surgery
(surgical procedures with a 90-day global period) is made on the day of or the day
prior to the surgery, separate payment is allowed for the visit on which the decision
is made, however supporting documentation may be requested. If post payment
audits indicate documentation is insufficient to support the claim, payment will be
adjusted accordingly.
4. If a recipient develops complications following surgery that requires the recipient
to be returned to the operating room for any reason for care determined to be
medically necessary, these services are paid separately from the global surgery
amount. Complications that require additional medical or surgical services but do
not require a return trip to the operating room are included in the global surgery
amount.
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5. Payment may be made for services by the surgeons that are unrelated to the
diagnosis for which the surgery was performed during the post-operative period.
Supportive documentation may be requested. Services provided by the surgeon for
treating the underlying condition and for a subsequent course of treatment that is
not part of the normal recovery from the surgery are also paid separately. Full
payment for the procedure is allowed for situations when distinctly separate but
related procedures are performed during the global period of another surgery in
which the recipient is admitted to the hospital for treatment, discharged, and then
readmitted for further treatment.
6. Payment for physician services related to patient-controlled analgesia is included
in the surgeon’s global payment. The global surgical payment will be reduced if
post-payment audits indicate that a surgeon’s recipients routinely receive pain
management services from an anesthesiologist. For a list of covered codes, please
refer to the billing manual.
7. For information on payment for assistant surgeons, please refer to the billing
manual.
8. There is no post-operative period for endoscopies performed through an existing
body orifice. Endoscopic surgical procedures that require an incision for insertion
of a scope will be covered under the appropriate major or minor surgical policy
which will include a post-operative period according to the Medicare recommended
global period.
9. For some dermatology services, the CPT descriptors contain language, such as
“additional lesion”, to indicate that multiple surgical procedures have been
performed. The multiple procedure rules do not apply because the RVU’s for these
codes have been adjusted to reflect the multiple nature of the procedure. These
services are paid according to the unit. If dermatologic procedures are billed with
other procedures, the multiple surgery rules apply. For further information, please
refer to the billing manual.
10. Critical Care
Critical Care, the direct delivery of medical care by a physician or physicians for a
critically ill or critically injured recipient to treat a single or multiple vital organ
system failure and/or to prevent further-life threatening deterioration of the
recipient’s conditions, is reimbursed by Medicaid. Reimbursement without
documentation is limited to a critical illness or injury which acutely impairs one or
more vital organ systems such that there is a high probability of imminent or life-
threatening deterioration in the recipient’s condition. Critical care involves high
complexity decision making to assess, manipulate, and support vital system
functions. Examples of vital organ system failure include, but are not limited to:
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central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic,
and/or respiratory failure. Although critical care typically requires interpretation of
multiple physiologic parameters and/or application of advanced technology, critical
care may be provided in life threatening situations when these elements are not
present.
a. Critical care may be provided on multiple days, even if no changes are made
in the treatment rendered to the recipient, provided that the recipient’s
condition continues to require the level of physician attention described
above. Providing medical care to a critically ill, injured, or post-operative
recipient qualifies as a critical care service only if both the illness or injury
and the treatment being provided meet the above requirements.
b. Critical care is usually, but not always, given in a critical care area, such as
the coronary care unit, intensive care unit, pediatric intensive care unit,
respiratory care unit, or the emergency care facility.
c. Services for a recipient who is not critically ill but happen to be in a critical
care unit, are reported using other appropriate evaluation/management
(E/M) codes.
d. According to CPT, the following services are included in reporting critical
care when performed during the critical period by the physicians providing
critical care: the interpretation of cardiac output measurements, chest x-
rays, pulse oximetry, blood gases, and information data stored in computers
(e.g., ECGs, blood pressures, hematologic data) gastric intubation,
temporary transcutaneous pacing, ventilatory management and vascular
access procedures. Any services performed which are not listed above
should be reported separately.
e. Time spent in activities that occur outside of the unit or off the floor (e.g.,
telephone calls, whether taken at home, in the office, or elsewhere in the
hospital) may not be reported as critical care since the physician is not
immediately available to the patient.
11. Neonatal and Pediatric Critical Care
a. Neonatal and Pediatric Critical Care CPT codes are used to report services
provided by a single physician directing the care of a critically ill
neonate/infant. The same definitions for critical care services apply for the
adult, child, and neonate. The neonatal and pediatric critical care codes are
global 24-hour codes (billed once per day) and are not reported as hourly
services consistent with CPT coding instructions.
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b. Neonatal critical care codes are used for neonates (28 days of age or less)
and pediatric critical care codes are used for the critically ill infant or young
child age 29 days through 71 months of age, admitted to an intensive or
critical care unit. These codes will be applicable as long as the child
qualifies for critical care services during the hospital stay.
c. If the physician is present for the delivery and newborn resuscitation is
required, the appropriate E&M code can be used in addition to the critical
care codes.
d. Care rendered under the pediatric critical care codes includes management,
monitoring, and treatment of the recipient including respiratory, enteral and
parenteral nutritional maintenance, metabolic and hematologic
maintenance, pharmacologic control of the circulatory system,
parent/family counseling, case management services, and personal direct
supervision of the health care team in the performance of cognitive and
procedural activities.
e. In addition to critical services for adults, the pediatric and neonatal critical
care codes also include the following procedures:
1. peripheral vessel catheterization;
2. other arterial catheters;
3. umbilical venous catheters;
4. central vessel catheters;
5. vascular access procedures;
6. vascular punctures;
7. umbilical arterial catheters;
8. endotracheal intubation;
9. ventilator management;
10. bedside pulmonary function testing;
11. surfactant administration;
12. continuous positive airway pressure (CPAP);
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13. monitoring or interpretation of blood gases or oxygen saturation;
14. transfusion of blood components;
15. oral or nasogastric tube placement;
16. suprapubic bladder aspiration;
17. bladder catheterization; and
18. lumbar puncture.
Any services performed which are not listed above, may be reported
separately.
f. Initial and Continuing Intensive Care Services are reported for the child who
is not critically ill, but requires intensive observation, frequent interventions
and other intensive care services, or for services provided by a physician
directing the continuing intensive care of the Low Birth Weight (LBW)
(1500-2500 grams) present body weight infant, or normal (2501-5000
grams) present body weight newborn who does not meet the definition of
critically ill, but continues to require intensive observation, frequent
interventions, and other intensive care services.
603.13 PROVIDER’S SERVICES IN NURSING FACILITIES
A. Provider services provided in a Nursing Facility (NF) are a covered benefit when the
service is medically necessary. Provider visits must be conducted in accordance with
federal requirements for licensed facilities. Reference MSM Chapter 500, Nursing
Facilities for coverage and limitations.
B. When the recipient is admitted to the NF in the course of an encounter in another site of
service (e.g., hospital ER, provider’s office), all E/M services provided by that provider in
conjunction with that admission are considered part of the initial nursing facility care when
performed on the same date as the admission or readmission. Admission documentation
and the admitting orders/plan of care should include the services related to the admission
he/she provided in the other service sites.
C. Hospital discharge or observation discharge services performed on the same date of NF
admission or readmission may be reported separately. For a recipient discharged from
inpatient status on the same date of nursing facility admission or readmission, the hospital
discharge services should be reported as appropriate. For a recipient discharged from
observation status on the same date of NF admission or readmission, the observation care
discharge services should be reported with the appropriate CPT code.
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603.14 PROVIDER’S SERVICES IN OTHER MEDICAL FACILITIES
A. Intermediate Care Facility for Individuals with Intellectual Disabilities) ICF/IID
A provider must certify the need for ICF/IID care prior to or on the day of admission (or if
the applicant becomes eligible for Medicaid while in the ICF/IID, before the Nevada
Medicaid Office authorizes payment.) The certification must refer to the need for the
ICF/IID level of care, be signed and dated by the provider and be incorporated into the
resident’s record as the first order in the provider’s orders.
Recertification by a physician or an APRN for the continuing need for ICF/IID care is
required within 365 days of the last certification. In no instance is recertification acceptable
after the expiration of the previous certification. For further information regarding ICF/IID
refer to MSM Chapter 1600, Intermediate Care for Individuals with Intellectual
Disabilities.
B. Residential Treatment Center (RTC)
Physician services, except psychiatrists are not included in the all-inclusive facility rate for
RTCs. Please reference MSM Chapter 400, Mental Health and Alcohol and Substance
Abuse Services.
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604 COMMUNITY PARAMEDICINE SERVICES
Nevada Medicaid reimburses for medically necessary community paramedicine services which
are designed to provide health care services to the medically underserved. Community
Paramedicine services fill patient care gaps in a local health care system and prevent duplication
of services while improving the healthcare experience for the recipient. Prevention of unnecessary
ambulance responses, emergency room visits, and hospital admissions and readmissions can result
in cost reductions for the DHCFP.
604.1 COMMUNITY PARAMEDICINE PROVIDER QUALIFICATIONS
A. The following Nevada-licensed providers may provide community paramedicine services
for Nevada Medicaid recipients:
1. Emergency Medical Technician (EMT);
2. Advanced Emergency Medical Technician (AEMT); or
3. Paramedic.
B. Required endorsement:
1. Community paramedicine endorsement from the Nevada Division of Public and
Behavioral Health, Office of Emergency Medical Services; or
2. Community paramedicine endorsement from the Southern Nevada Health District’s
Board of Health.
C. Must be enrolled as a Nevada Medicaid provider and employed by a permitted Emergency
Medical System (EMS) agency.
D. Must possess a scope of service agreement, based upon the provider’s skills, with the
Medical Director of the EMS agency under which they are employed.
1. The Medical Director of the EMS agency providing community paramedicine
services must be enrolled as a Nevada Medicaid Provider.
604.2 COVERAGE AND LIMITATIONS
Community paramedicine services are delivered according to a recipient-specific plan of care
under the supervision of a Nevada-licensed EMS agency medical director and coordinated with a
primary care provider (PCP). The plan of care is to be developed after an appropriate assessment
and does not have to be in place before community paramedicine services are started but must be
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developed while the recipient is receiving community paramedicine services. If a recipient does
not have a PCP, the plan of care must include establishing a medical home with a PCP. It is
expected that all health care providers delivering care to community paramedicine recipients
coordinate the patient’s care to avoid duplication of services to the recipient.
A. The following services can be provided within a community paramedicine provider’s scope
of practice as part of a community paramedicine visit when requested in plan of care:
1. Evaluation/health assessment;
2. Chronic disease prevention, monitoring and education;
3. Medication compliance;
4. Vaccinations.
5. Laboratory specimen collection and point of care lab tests;
6. Hospital discharge follow-up care;
7. Minor medical procedures and treatments within their scope of practice as approved
by the EMS agency’s medical director;
8. A home safety assessment; and
9. Telehealth originating site.
B. Non-covered services:
1. Travel time;
2. Mileage;
3. Services related to hospital-acquired conditions or complications resulting from
treatment provided in a hospital;
4. Emergency response; for recipients requiring emergency response, the EMS
transport will be billed under the ambulance medical emergency code;
5. Duplicated services;
6. Personal Care Services; and
7. Mental and behavioral health/crisis intervention.
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C. For a list of covered procedure and diagnosis codes, please refer to the PT 32, Specialty
249 Billing Guide.
D. Prior authorization is not required for community paramedicine services.
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605 ORGAN TRANSPLANT SERVICES
605.1 COVERAGE AND LIMITATIONS
Organ transplantation and associated fees are a limited benefit for Nevada Medicaid recipients.
Non-Citizens/Aliens are not eligible for organ transplants. Refer to MSM Chapter 200, Hospital
Services, Attachment A, Policy #02-02, Federal Emergency Services Program for eligible
emergency conditions.
A. The following organ transplants, when deemed the principal form of treatment are covered:
1. Bone Marrow/Stem Cell – allogeneic and autologous;
a. Non-covered conditions for bone marrow/stem cell:
1. Allogeneic stem cell transplantation is not covered as treatment for
multiple myeloma;
2. Autologous stem cell transplantation is not covered as treatment for
acute leukemia not in remission, chronic granulocytic leukemia,
solid tumors (other than neuroblastoma) and tandem transplantation
for recipients with multiple myeloma;
2. Corneal – allograft/homograft;
3. Kidney – allotransplantation/autotransplantation; and
4. Liver – transplantation for children (under 21 years old) with extrahepatic biliary
atresia or for children or adults with any other form of end-stage liver disease.
Coverage is not provided with a malignancy extending beyond the margins of the
liver or those with persistent viremia.
B. Prior authorization is required for bone marrow, corneal, kidney, and liver transplants from
Medicaid’s contracted QIO-like vendor.
1. A transplant procedure shall only be approved upon a determination that it is a
medically necessary treatment by showing that:
a. The procedure is not experimental and/or investigational based on Title 42,
CFR, Chapter IV (Centers for Medicare & Medicaid) and Title 21, CFR,
Chapter I FDA;
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b. The procedure meets appropriate Medicare criteria;
c. The procedure is generally accepted by the professional medical community
as an effective and proven treatment for the condition for which it is
proposed, or there is authoritative evidence that attests to the proposed
procedures safety and effectiveness; and
d. If the authorization request is for chemotherapy to be used as a preparatory
therapy for transplants, an approval does not guarantee authorization for any
harvesting or transplant that may be part of the treatment regimen.
2. A separate authorization is required for inpatient/outpatient harvesting or
transplants, both in-state and out-of-state.
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606 PREVENTIVE HEALTH SERVICES
Preventive medicine/health refers to health care that focuses on disease (or injury) prevention.
Preventive health also assists the provider in identifying a patient’s current or possible future health
care risks through assessments, lab work and other diagnostic studies. The U.S. Preventive
Services Task Force (USPSTF) is an independent volunteer panel of national experts in prevention
and evidence-based medicine authorized by the U.S. Congress. The Task Force works to improve
the health of all Americans by making evidence-based recommendations about clinical preventive
services. Each recommendation has a letter grade (an A, B, C, D grade or an I statement) based on
the strength of the evidence and the balance of benefits and harms of a preventive service.
606.1 COVERED SERVICES
Nevada Medicaid reimburses for preventive health services for men, women and children as
recommended by the USPSTF A and B recommendations. For the most current list of reimbursable
preventive services, please see the USPSTF A and B recommendations located at
https://www.uspreventiveservicestaskforce.org/.
Family planning related preventive health services as recommended by the USPSTF are a covered
benefit.
606.2 NON-COVERED SERVICES
Preventive health services not cataloged or that do not have a current status as either an A or B
recommendation by the USPSTF are not covered.
606.3 PRIOR AUTHORIZATIONS
Prior authorizations are not required for preventive health services that coincide with the USPSTF
A and B recommendations.
606.4 BILLING REQUIREMENTS
Most preventive health services may be performed as part of an office visit, hospital visit or global
fee and may not be billed separately. Please see the Preventive Services Billing Guide or the
USPSTF website.
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607 GENDER REASSIGNMENT SERVICES
Transgender Services include treatment for gender dysphoria (GD), formerly known as gender
identity disorder (GID). Treatment of GD is a Nevada Medicaid covered benefit, including both
hormonal and surgical modalities, and psychotherapy, based on medical necessity. Genital
reconstruction surgery (GRS) describes a number of surgical procedure options for the treatment
of GD.
According to the World Professional Association for Transgender Health (WPATH), the
organization that promotes the standards of health care for transsexual, transgender and gender
nonconforming individuals, through the articulation of Standards of Care, gender dysphoria is
defined as discomfort or distress caused by a discrepancy between a person’s gender identity and
that person’s sex assigned at birth (and the associated gender role and/or primary and secondary
sex characteristics).
607.1 COVERAGE AND LIMITATIONS
A. Hormone Therapy
1. Hormone therapy is covered for treatment of GD based on medical necessity; refer
to MSM Chapter 1200, Prescribed Drugs, for services and prior authorization
requirements.
B. Genital Reconstruction Surgery
1. Genital reconstruction surgery is covered for recipients that are sufficiently
physically fit and meet eligibility criteria under Nevada and federal laws.
2. Prior authorization is required for all genital reconstruction surgery procedures.
3. To qualify for surgery, the recipient must be 18 years of age or older.
4. Male-to-Female (MTF) recipient, surgical procedures may include:
a. breast/chest surgery; mammoplasty
b. genital surgery; orchiectomy, penectomy, vaginoplasty, clitoroplasty,
vulvoplasty, labiaplasty, urethroplasty, prostatectomy
5. Female-to-Male (FTM) recipient, surgical procedures may include:
a. breast/chest surgery; mastectomy
b. genital surgery; hysterectomy/salpingo-oophorectomy, phalloplasty,
vaginectomy, vulvectomy, scrotoplasty
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6. Augmentation mammoplasty for MTF recipients is a covered benefit only when
12 continuous months of hormonal (estrogen) therapy has failed to result in breast
tissue growth of Tanner Stage 5 on the puberty scale, as determined by the
provider, or the recipient has a medical contraindication to hormone therapy.
7. All legal and program requirements related to providing and claiming
reimbursement for sterilization procedures must be followed when transgender
care involves sterilization. Refer to MSM Chapter 600, Section 603.4B for
information regarding sterilization services.
8. Refer to the Documentation Requirements section below for additional criteria.
C. Mental Health Services
1. Mental health services are covered for treatment of GD based on medical
necessity; refer to MSM Chapter 400, Mental Health and Alcohol and Substance
Abuse Services for services and prior authorization requirements.
D. Non-Covered Services
1. Payment will not be made for the following services and procedures:
a. cryopreservation, storage and thawing of reproductive tissue, and all
related services and costs;
b. reversal of genital and/or breast surgery;
c. reversal of surgery to revise secondary sex characteristics;
d. reversal of any procedure resulting in sterilization;
e. cosmetic surgery and procedures including:
1. neck tightening or removal of redundant skin;
2. breast, brow, face or forehead lifts;
3. chondrolaryngoplasty (commonly known as tracheal shave);
4. electrolysis;
5. facial bone reconstruction, reduction or sculpturing, including jaw
shortening and rhinoplasty;
6. calf, cheek, chin, nose or pectoral implants;
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7. collagen injections;
8. drugs to promote hair growth or loss;
9. hair transplantation;
10. lip reduction or enhancement;
11. liposuction;
12. thyroid chondroplasty; and
13. voice therapy, voice lessons or voice modification surgery.
E. Documentation Requirements
1. The recipient must have:
a. persistent and well-documented case of GD;
b. capacity to make a fully informed decision and give consent for treatment.
According to the American Medical Association (AMA) Journal of Ethics,
in health care, informed consent refers to the process whereby the patient
and the health care practitioner engage in a dialogue about a proposed
medical treatment’s nature, consequences, harms, benefits, risks and
alternatives. Informed consent is a fundamental principle of health care.
c. comprehensive mental health evaluation provided in accordance with
WPATH standards of care; and
d. prior to beginning stages of surgery, obtained authentic letters from two
qualified licensed mental health professionals who have independently
assessed the recipient and are referring the recipient for surgery. The two
letters must be authenticated and signed by:
1. a licensed qualified mental health care professional working within
the scope of their license who have independently assessed the
recipient;
a. one with whom the recipient has an established ongoing
relationship; and
b. one who only has an evaluative role with the recipient.
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2. Together, the letters must establish the recipient have:
a. a persistent and well-documented case of GD;
b. received hormone therapy appropriate to the recipient’s
gender goals, which shall be for a minimum of 12 months in
the case of a recipient seeking genital reconstruction surgery,
unless such therapy is medically contraindicated or the
recipient is otherwise unable to take hormones;
c. lived for 12 months in a gender role congruent with the
recipient’s gender identity without reversion to the original
gender, and has received mental health counseling, as
deemed medically necessary during that time; and
d. significant medical or mental health concerns reasonably
well-controlled; and capacity to make a fully informed
decision and consent to the treatment.
3. When a recipient has previously had one or more initial surgical
procedures outlined in this chapter, the recipient is not required to
provide referral letters to continue additional surgical procedures, at
discretion of the surgeon. The surgeon must ensure this is clearly
documented in the recipient’s medical record.
2. Documentation supporting medical necessity for any of the above procedures must
be clearly documented in the recipient’s medical record and submitted when a prior
authorization is required.
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608 MEDICAL NUTRITION THERAPY
Medical Nutrition Therapy (MNT) is nutritional diagnostic, therapy and counseling services for
the purpose of management of nutrition related chronic disease states. MNT involves the
assessment of an individual’s overall nutritional status followed by an individualized course of
nutritional intervention treatment to prevent or treat medical illness. MNT is provided by a licensed
and Registered Dietitian (RD) working in a coordinated, multidisciplinary team effort with the
Physician, Physician’s Assistant (PA) or Advanced Practice Registered Nurse (APRN) referred to
as provider throughout this policy and takes into account a person’s food intake, physical activity,
and course of any medical therapy including medication and other treatments, individual
preferences, and other factors. This level of instruction includes individualized dietary assessment
that is above basic nutrition counseling.
Nevada Medicaid considers medical nutrition therapy medically necessary for diabetes, obesity,
heart disease and hypertension where dietary adjustment has a therapeutic role, when it is
prescribed by a provider and furnished by a RD. The only providers that should submit claims for
medical nutrition therapy are RDs. Other qualified health care professionals may provide medical
nutrition therapy; however, they must submit a claim for evaluation and management services.
608.1 POLICY
Medicaid will reimburse for MNT services rendered to Medicaid eligible individuals in accordance
with the Nevada Medicaid coverage authority. MNT services must be medically necessary to
address nutrition related behaviors that contribute to diabetes, obesity, heart disease and
hypertension. Services must be rendered according the written orders of the Physician, PA or an
APRN. The treatment regimen must be designed and approved by an RD.
All services must be documented as medically necessary and be prescribed on an individualized
treatment plan.
608.2 COVERAGE AND LIMITATIONS
A. MNT is initiated from a referral from a provider that can refer and includes information on
labs, medications and other diagnoses. MNT includes:
1. A comprehensive nutritional and lifestyle assessment determining nutritional
diagnosis.
2. Planning and implementing a nutritional intervention and counseling using
evidence-based nutrition practice guidelines to achieve nutritional goals and
desired health outcomes.
July 1, 2021 PHYSICIAN SERVICES Section 608 Page 1
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 608
Subject:
MEDICAID SERVICES MANUAL POLICY
3. Monitoring and evaluating an individual’s progress over subsequent visits with a
RD.
B. Coverage of services includes:
1. Initial nutrition and lifestyle assessment.
2. One-on-one or group nutrition counseling.
3. Follow-up intervention visits to monitor progress in managing diet.
4. Reassessments as necessary during the 12-rolling month episode of care to assure
compliance with the dietary plan.
5. Four hours maximum in the first year.
a. Additional hours are permitted if treating provider determines a change in
medical condition, diagnosis or treatment regimen requires a change in
MNT.
b. Additional hours beyond the maximum four hours in the first year require
prior authorization.
c. Documentation should support the patient’s diagnosis of the specific
condition, along with the referral from the provider managing the patient’s
condition.
d. The documentation should also include a comprehensive plan of care,
individualized assessment and education plan with outcome evaluations for
each session, as well as referring provider feedback.
e. There should be specific goals, evaluations and outcome measures for each
session documented within the patient’s records.
6. Two hours maximum per 12 rolling month period in subsequent years.
7. Services may be provided in a group setting. The same service limitations apply in
the group setting.
C. MNT is not to be confused with Diabetic Outpatient Self-Management Training (DSMT)
1. Nevada Medicaid considers DSMT and MNT complementary services. This means
Medicaid will cover both DSMT and MNT without decreasing either benefit as
long as the referring provider determines that both are medically necessary.
2. See MSM Chapter 600, Attachment A, Policy #6-10 for DSMT coverage.
PHYSICIAN SERVICES Section 608 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 608
Subject:
MEDICAID SERVICES MANUAL POLICY
D. MNT is only covered for the management of diabetes, obesity, heart disease and
hypertension-related conditions.
E. MNT may be provided through Telehealth services. See MSM Chapter 3400 for the
Telehealth policy.
608.3 PRIOR AUTHORIZATION REQUIREMENTS
Prior authorization is required when recipients require additional or repeat training sessions
beyond the permitted maximum number of hours of treatment. This can occur if there is a change
of diagnosis, medical condition or treatment regimen related to a nutritionally related disease state.
608.4 PROVIDER QUALIFICATIONS
In order to be recognized and reimbursed as an MNT provider, the provider must meet the
following requirements:
A. Licensed and RD under the qualifications of NRS 640E.150. An RD is an individual who
has earned a bachelor’s degree or higher education from an accredited college or university
in human nutrition, nutrition education or equivalent education, has completed training and
holds a license from the Nevada State Board of Health.
608.5 PROVIDER RESPONSIBILITY
A. The provider will allow, upon request of proper representatives of the DHCFP, access to
all records which pertain to Medicaid recipients for regular review, audit, or utilization
review.
B. The provider will ensure services are consistent with applicable professional standards and
guidelines relating to the practice of MNT as well as state Medicaid laws and regulations
and state licensure laws and regulations.
C. The provider will ensure caseload size is within the professional standards and guidelines
related to the practice of MNT.
July 1, 2021 PHYSICIAN SERVICES Section 608 Page 3
MTL 09/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 609
Subject:
MEDICAID SERVICES MANUAL HEARINGS
609 HEARINGS
Please reference Nevada Medicaid Services Manual (MSM) Chapter 3100 for hearings procedures.
July 1, 2021 PHYSICIAN SERVICES Section 609 Page 1
ATTACHMENT A
EFFECTIVE DOS 9/1/03
POLICY #6-01 RESERVED FOR FUTURE USE Supersedes Policy News N199-06
RESERVED FOR FUTURE USE
October 1, 2015 PHYSICIAN SERVICES Attachment A Page 1
ATTACHMENT A
EFFECTIVE DOS 9/1/03
POLICY #6-02 WOUND MANAGEMENT Supersedes Policy News N199-01
A. DESCRIPTION
A wound is defined as impaired tissue integrity that may involve the epidermis, dermis, and subcutaneous
tissue, and may extend down to the underlying fascia and supporting structures. The wound may be aseptic
or infected.
B. POLICY
Wound care is a Nevada Medicaid covered benefit for recipients who have a viable healing process.
C. PRIOR AUTHORIZATION IS NOT REQUIRED
D. COVERAGE AND LIMITATIONS
1. The patient’s medical record must include a comprehensive wound history that includes date of
onset, location, depth and dimension, exudate characteristics, circulatory, neuropathy, and
nutritional assessments, current management and previous treatment regime. The provider must
culture all infected wounds prior to initiating systemic antibiotics, per Center for Disease Control
guidelines. Photographs are necessary to establish a baseline and to document the progress of the
wound, as are weekly measurements. Providers are expected to educate recipients about the disease
process, how to manage their own wound care and the importance of complying with the treatment
plan. This education should be documented in the recipient’s medical record.
2. The use of supplies during wound care treatment is considered part of the treatment. Do not bill
separately.
3. Burn Care
a. Burn care provided in the outpatient hospital setting will follow wound care guidelines
with the exception of requiring a prior authorization.
b. All diagnosis codes must be coded to the highest level of specificity.
E. COVERED CPT CODES
For a list of covered procedure and diagnosis codes, please refer to the billing manual.
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 2
ATTACHMENT A
OUTPATIENT HOSPITAL BASED EFFECTIVE DOS 9/1/03
POLICY #6-03 HYPERBARIC OXYGEN THERAPY Supersedes Policy News N199-03
A. DESCRIPTION
Hyperbaric Oxygen Therapy (HBOT) is therapy in which a recipient breathes 100% oxygen intermittently
while the pressure of the treatment chamber is increased to a point higher than sea level pressure (i.e.,>1
atm abs.). Breathing 100% oxygen at 1 atm of pressure or exposing isolated parts of the body does not
constitute HBOT; the recipient must receive the oxygen by inhalation within a pressurized chamber.
B. POLICY
1. This Nevada Medicaid benefit is covered in an outpatient hospital, with limitations, for chronic
conditions. Payment will be made where HBOT is clinically practical. HBOT is not to be a
replacement for other standard successful therapeutic measures. Treatment of acute conditions,
e.g., acute carbon monoxide intoxication, decompression illnesses, cyanide poisoning, and air or
gas embolism may be provided in an outpatient hospital.
2. PRIOR AUTHORIZATION IS REQUIRED for chronic conditions (see billing manual)
3. PRIOR AUTHORIZATION IS NOT REQUIRED for acute conditions (see billing manual)
4. Documentation supporting the reasonableness and necessity of the procedure must be in the
recipient’s medical record including recipient’s risk factors and submitted with the PA when
required.
C. COVERAGE AND LIMITATIONS
1. Wound Therapy
Approval will be restricted to requests documenting that the wound has not responded to
conventional treatments as outlined in the WOUND MANAGEMENT POLICY (6-02), and
initiated by a provider. Attach a copy of the provider’s order to the request for treatment. Maximum
numbers of treatments authorized on consecutive days are 45. Therapy is conducted once or twice
daily for a maximum of two hours each treatment.
2. HBOT must be provided and attended by an HBOT physician. Reimbursement will be limited to
therapy provided in a chamber (including the one-person unit). No payment will be made for
topical HBOT, or for other than the covered diagnosis.
3. Diabetic wounds of the lower extremities in patients who meet the following three criteria:
a. Patient has Type I or Type II diabetes and has a lower extremity wound that is due to
diabetes;
b. Patient has wound classified as Wagner grade III or higher; and
c. Patient has failed an adequate course of standard wound therapy.
D. COVERED DIAGNOSIS CODES
For a list of covered procedure and diagnosis codes, please refer to the billing manual.
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 3
ATTACHMENT A
EFFECTIVE DOS 9/1/03
POLICY #6-04 INTRATHECAL BACLOFEN (ITB) THERAPY Supersedes Policy News N199-04
A. DESCRIPTION/POLICY
FDA approved Intrathecal Baclofen (ITB) Therapy is a Nevada Medicaid covered benefit for recipients
with severe spasticity of spinal cord origin, [(e.g. Multiple Sclerosis (MS), Spinal Cord Injury (SCI)], or
spasticity of cerebral origin, [e.g., Cerebral Palsy (CP), and Brain Injury (BI)], who are unresponsive to
oral Baclofen therapy or who have Intolerable Central Nervous System (CNS) side effects.
B. PRIOR AUTHORIZATION IS REQUIRED
C. COVERAGE AND LIMITATIONS
1. Coverage of treatment will be restricted to recipients with the following indicators:
a. Spasticity due to spinal cord origin or spasticity of cerebral origin. If spasticity is result of
BI, the injury must have occurred over one year prior to be considered for ITB therapy;
b. Severe spasticity (as defined by a score of three or more on the Ashworth Scale) in the
extremities for a duration of six months or longer;
c. Recipients with increased tone that significantly interferes with movement and/or care;
d. Spasm score of two or more; documentation to include pre and post testing of strength,
degree of muscle tone, and frequency of spasm (Spasm Scale not applicable to CP
recipients as spasms are not a frequent symptom in these recipients);
e. Recipient is four years or older and has sufficient body mass to support the infusion pump;
f. Documented six-weeks or more of failed oral antispasmodic drug therapy at the maximum
dose. Recipient is refractory to oral Baclofen, or has intolerable side effects;
g. Recipient has adequate cerebrospinal fluid flow as determined by myelogram or other
studies;
h. Recipient has no known allergy to Baclofen;
i. Documentation of a favorable response to a trial dose of ITB prior to pump implantation.
If recipient requires a second and/or third trial dose of ITB, documentation needs to include
videotape of the recipient’s arm and leg range of motion to assess spasticity and muscle
tone before and after increased test doses of ITB. Recipients who do not respond to a dose
consistent with baclofen screening trial protocols are not candidates for an implanted pump
for chronic infusion therapy. Recipient must be free of infection at the time of the trial
dose;
j. Recipient, family, and physicians should agree on treatment goals. Recipient, family and
caregivers should be motivated to achieve the treatment goals and be committed to meet
the follow-up care requirements;
k. Recipient must be free of systemic infection and/or infection at the implantation site at the
time of surgery;
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 4
ATTACHMENT A
EFFECTIVE DOS 9/1/03
POLICY #6-04 INTRATHECAL BACLOFEN (ITB) THERAPY Supersedes Policy News N199-06
2. Benefit coverage includes up to three trial doses of ITB, surgical implantation of the device and
follow-up provider office visits for dose adjustments and pump refills.
3. Documentation in the recipient’s medical record should include what the expected functional
outcomes and improvements in quality of life are for the recipient post procedure, e.g., increased
independence, ease of caretaking activities, decreased pain, increased ADL’s and improved
communication. Also, document why the recipient is not a candidate for Botox injections.
4. Reimbursement for recipients with low muscle tone (often described as floppy muscles), chorea
(uncontrollable, small jerky types of movements of toes and fingers) or athetosis (involuntary
movements of face, arms or trunk) are not a Nevada Medicaid benefit.
D. COVERED CODES
For a list of covered procedure and diagnostic codes, please see the billing manual.
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 5
ATTACHMENT A
EFFECTIVE DOS 9/1/03
POLICY #6-05 RESERVED FOR FUTURE USE Supersedes Policy News N199-06
RESERVED FOR FUTURE USE
April 15, 2016 PHYSICIAN SERVICES Attachment A Page 6
ATTACHMENT A
EFFECTIVE DOS 9/1/03
POLICY #6-06 VAGUS NERVE STIMULATOR (VNS) Supersedes Policy News N199-06
A. DESCRIPTION
Vagus Nerve Stimulation (VNS) is a method for treating recipients with refractory epilepsy who are not
candidates for intracranial surgery and/or continue to be refractory following epilepsy surgery. The
programmable NeuroCybernetic Prosthesis (NCP) is surgically implanted in the upper left chest with the
leads tunneled to the vagus nerve in the left neck. An external magnet is provided to activate the generator
and deliver additional impulses when needed. The external magnet may also be used to inhibit the NCP
generator in the event of a malfunction.
B. POLICY
The Vagus Nerve Stimulator (VNS) is a covered Nevada Medicaid benefit. The benefit includes diagnostic
EEG, surgical procedure, device and medically necessary follow-up office visits for analysis and
reprogramming.
C. PRIOR AUTHORIZATION IS REQUIRED
Documentation supporting the medical necessity of the procedure must be in the recipient’s medical record
and submitted with the prior authorization when required.
D. COVERAGE AND LIMITATIONS
1. Implantation of VNS is used as an adjunctive therapy in reducing the frequency of seizures in
adults and children over age six who have seizures which are refractory to Antiepileptic Drugs
(AED). It is also indicated in recipients for whom surgery is not an option, or in whom prior surgery
has failed.
2. Coverage is restricted to those recipients with the following indicators:
a. Diagnosis of intractable epilepsy;
b. Failed antiepileptic drug (AED) therapy tried for two to four months. The medical record
should indicate changes/alterations in medications prescribed for the treatment of the
recipient’s condition. Documentation to include maintaining a constant therapeutic dose of
AED as evidenced by laboratory results per manufacturer’s recommendations;
c. Have six or more medically intractable seizures per month;
d. Have no other independent diagnosis that could explain why seizures are failing to respond
to treatment;
e. A recipient whose epileptologist/neurologist has recommended VNS implantation;
f. A surgeon experienced with implantation of the VNS;
g. The VNS will be managed by a physician familiar with the settings and protocols for use
of the device;
h. Recipients from three to six years of age must have all of the above indicators;
April 15, 2016 PHYSICIAN SERVICES Attachment A Page 7
ATTACHMENT A
EFFECTIVE DOS 9/1/03
POLICY #6-06 VAGUS NERVE STIMULATOR (VNS) Supersedes Policy News N199-08
i. Be the result of a Healthy Kids Screening (EPSDT) referral for treatment; and
j. Be supported by peer review literature, and a written recommendation for VNS
implantation and use from two Board Certified Pediatric Neurologists (other than the
treating neurologist(s).
3. Reasons for non-coverage include, but are not limited to the following diagnoses/conditions: status
epilepticus, progressive or unstable neurologic or systemic disorders, severe mental retardation,
drug abuse, gastritis, gastric/duodenal ulcers, status post bilateral or left cervical vagotomy,
unstable medical condition, pregnancy, use of investigational AED’s, bradycardia, hypersecretion
of gastric acid and/or a seizure disorder etiology more appropriately treated by other means (i.e.,
operation).
E. COVERED CODES
For a list of covered procedure and diagnosis codes, please see the billing manual.
March 1, 2015 PHYSICIAN SERVICES Attachment A Page 8
ATTACHMENT A
BARIATRIC SURGERY FOR MORBID EFFECTIVE DOS 9/1/03
POLICY #6-07 OBESITY Supersedes Policy News N199-08
A. DESCRIPTION/POLICY
1. Bariatric Surgery is a covered Nevada Medicaid benefit reserved for recipients with severe and
resistant morbid obesity in whom efforts at medically supervised weight reduction therapy have
failed and who are disabled from the complications of obesity. Morbid obesity is defined by
Nevada Medicaid as those recipients whose Body Mass Index (BMI) is 35 or greater, and who
have significant disabling comorbidity conditions which are the result of the obesity or are
aggravated by the obesity. Assessment of obesity includes BMI, waist circumference, and recipient
risk factors, including family history.
2. This benefit includes the initial work-up, the surgical procedure and routine post-surgical follow-
up care. The surgical procedure is indicated for recipients between the ages of 21 and 55 years
with morbid obesity. (Potential candidates older than age 55 will be reviewed on a case by case
basis.)
B. PRIOR AUTHORIZATION IS REQUIRED
Documentation supporting the reasonableness and necessity of bariatric surgery must be in the recipient’s
record and submitted with the PA.
C. COVERAGE AND LIMITATIONS
1. Coverage is restricted to recipients with the following indicators:
a. BMI of 35 or greater;
b. Waist circumference of more than 40 inches in men, and more than 35 inches in women;
c. Obesity related comorbidities that are disabling;
d. Strong desire for substantial weight loss;
e. Well-informed and motivated;
f. Committed to a lifestyle change; and
g. Negative history of significant psychopathology that contraindicates this surgical
procedure.
2. Documentation supporting the reasonableness and necessity of the surgery must be in the medical
record and should include evidence of participation in a medically supervised weight loss program
for a minimum of three months prior to the surgery. There must also be documentation of weight
loss therapy participation including recipient efforts at dietary therapy, physical activity, behavior
therapy, pharmacotherapy, combined therapy or any other medically supervised therapy.
3. No coverage will be provided for pregnant women, women less than six months postpartum, or
women who plan to conceive in a time frame less than 18 to 24 months post gastric bypass surgery.
October 1, 2015 PHYSICIAN SERVICES Attachment A Page 9
ATTACHMENT A
BARIATRIC SURGERY FOR MORBID EFFECTIVE DOS 9/1/03
POLICY #6-07 OBESITY Supersedes Policy News N199-08
D. COVERED CODES
For a list of covered procedure codes, please see the billing manual.
E. REFERENCES:
1. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
NetworkMLN/MLNMattersArticles/downloads/mm5013.pdf
2. http://www.cms.gov/Regulations-
andGuidance/Guidance/Manuals/downloads/ncd103c1_part2.pdf
October 1, 2015 PHYSICIAN SERVICES Attachment A Page 10
ATTACHMENT A
EFFECTIVE DOS 9/1/03
POLICY #6-08 HYALGAN AND SYNVISC INJECTIONS Supersedes Policy News N199-09
A. DESCRIPTION
Hyalgan and Synvisc are injectable drugs that are used to treat osteoarthritis of the knee. These solutions
act like an “oil” to cushion and lubricate the knee joint. Hyalgan is injected directly into the osteoarthritic
knee for a single course of treatment. Injections are administered one week apart for a total of five
injections. Synvisc is administered as a total of three intra-articular injections into the knee joint during a
three-week period. Each course of treatment must be performed by a qualified physician.
B. POLICY
1. Hyalgan and Synvisc injectables are a covered Nevada Medicaid benefit for the treatment of pain
due to osteoarthritis of the knee. Diagnosis must be supported by radiological evidence.
2. Repeat treatment is not reimbursable, as it is not medically indicated, if the first course of treatment
is not beneficial to the recipient.
C. PRIOR AUTHORIZATION IS NOT REQUIRED
D. COVERAGE AND LIMITATIONS
1. Hyalgan and Synvisc are indicated for recipients who do not obtain adequate relief from simple
pain medication and/or from exercise and physical therapy.
2. An Evaluation & Management (E&M) service will not be covered during subsequent visits for
injections unless there is a separately identifiable problem.
October 1, 2015 PHYSICIAN SERVICES Attachment A Page 11
ATTACHMENT A
EFFECTIVE DOS 9/1/03
Superseded Policy News N199-10
POLICY #6-09 END STAGE RENAL DISEASE SERVICES and New ESRD Policy
A. DESCRIPTION
Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal Nutrition (IPN) are a covered service for
hemodialysis and continuous ambulatory peritoneal dialysis (CAPD) recipients who meet all of the
requirements for Parenteral and Enteral Nutrition coverage. The recipient must have a permanently
inoperative internal body organ or function. Documentation must indicate that the impairment will be of
long and indefinite duration.
B. PRIOR AUTHORIZATION IS NOT REQUIRED
C. COVERAGE AND LIMITATIONS
1. A provider’s service furnished to dialysis recipients who are treated as outpatients, are divided into
two major categories: direct recipient care and administrative.
2. Provider’s evaluation and management-type services, “unrelated” to the dialysis procedure (not
provided during a dialysis treatment) may be billed in addition to the dialysis procedure.
3. Provider’s providing evaluation and management-type services “related” to the dialysis procedure
same day dialysis is performed, or during a dialysis treatment) are billed as included in the dialysis
procedure. Service units’ equal number of treatments.
4. Criteria for instituting IDPN/IPN:
a. Three-month average predialysis serum albumin level of <3.4 mg/dl.
b. Three-month average predialysis serum creatine of <8.0 mg/dl.
c. Three-month average predialysis serum pre-albumin level of <25 mg/dl.
d. Weight loss of 7.5% of usual body weight over three months.
e. A clinical exam consistent with moderate to severe malnutrition.
f. A dietary history of reduced food intake (protein <0.8 g/kg/day; calories <25 cal/kg/day).
g. Failed attempts at dietary and oral supplementation.
h. Eternal tube feeding contraindicted.
i. Gastrointestinal diagnosis, supported by GI consult, GI medications (Prilosec, Reglan,
Imodium, etc.).
5. Criteria for discontinuing IDPN/IPN:
a. Three-month average predialysis serum albumin level of >3.8 mg/dl.
October 1, 2015 PHYSICIAN SERVICES Attachment A Page 12
ATTACHMENT A
EFFECTIVE DOS 9/1/03
Superseded Policy News N199-10
POLICY #6-09 END STAGE RENAL DISEASE SERVICES and New ESRD Policy
b. Three-month average predialysis serum creatine of >10 mg/dl.
c. Three-month average predialysis serum pre-albumin level of >28 mg/dl.
d. A clinical exam consistent with improved nutritional status.
e. A dietary history of increased food intake (protein 1.0 g/kg/day; calories 30 cal/kg/day).
f. Absence of active inflammation or other serious condition characterized by high albumin
turnover.
g. No improvement with IDPN/IPN treatment after six months.
h. Complications or intolerance associated with IDPN/IPN treatment.
6. No coverage will be provided for situations involving temporary impairments (less than 90 days).
No coverage will be provided if recipients are noncompliant with the plan of treatment.
October 1, 2015 PHYSICIAN SERVICES Attachment A Page 13
ATTACHMENT A
DIABETIC OUTPATIENT SELF- EFFECTIVE DOS 9/1/03
POLICY #6-10 MANAGEMENT TRAINING SERVICES Supersedes Policy News N299-08
A. DESCRIPTION
1. Nevada Medicaid defines DSMT as the development of a specific treatment plan for Type I and
Type II diabetics to include blood glucose self-monitoring, diet and exercise planning, and
motivates recipients to use the skills for self-management.
2. Reimbursement will follow Medicare guidelines for initial recipient and group training sessions.
For information regarding blood glucose monitors and diabetic supplies see MSM Chapter 1300,
DME Disposable Supplies and Supplements.
3. Services must be furnished by certified programs which meet the National Diabetes Advisory
Board (NDAB) standards, and hold an Education Recognition Program (ERP) certificate from the
American Diabetes Association and/or the American Association of Diabetic Educators. Program
instructors should include at least a nurse educator and dietician with recent didactic and training
in diabetes clinical and educational issues. Certification as a diabetes educator by the National
Board of Diabetes Educators is required.
B. PRIOR AUTHORIZATION IS REQUIRED
When recipients require additional or repeat training sessions that exceed ten hours of training.
C. COVERAGE AND LIMITATIONS
1. The provider managing the recipient’s diabetic condition certifies the comprehensive plan of care
to provide the recipient with the necessary skills and knowledge in the management of their
condition, and to ensure therapy compliance. The program must be capable of offering, based on
target population need, instruction in the following content areas:
a. Diabetes review;
b. Stress and psychological adjustment;
c. Family involvement and social support;
d. Medications;
e. Monitoring blood glucose and interpretation of results;
f. Relationships between nutrition, exercise and activity, medication and glucose levels;
g. Prevention, detection and treatment of both acute and chronic diabetic complications,
including instruction related to care of feet, skin and teeth;
h. Behavioral change strategies, goal setting, risk factor reduction and problem solving;
i. Benefits, risks and management options for improvement of glucose control;
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 14
ATTACHMENT A
DIABETIC OUTPATIENT SELF- EFFECTIVE DOS 9/1/03
POLICY #6-10 MANAGEMENT TRAINING SERVICES Supersedes Policy News N299-08
j. Preconception care, pregnancy and gestational diabetes; and
k. Utilization of health care systems and community resources.
2. Indications for repeat training Prior Authorization is required for recipients whose diabetes is
poorly controlled include:
a. Hemoglobin A 1 c blood levels of 8.5 or greater;
b. Four or more serious symptomatic hypoglycemic episodes in a two-month period;
c. Two or more hospitalizations for uncontrolled diabetes in a six-month period;
d. Any ketoacidosis or hyperosmolar state;
e. Pregnancy in a previously diagnosed diabetic; or
f. Diabetics beginning initial insulin therapy.
3. No coverage will be provided for initial training which exceeds ten hours, or for repeat training,
without a prior authorization.
D. COVERED CODES
For a list of covered procedure and diagnosis codes, please refer to the billing manual.
October 1, 2015 PHYSICIAN SERVICES Attachment A Page 15
ATTACHMENT A
EFFECTIVE DATE 12/18/04
POLICY #6-11 BOTULINUM TOXIN RE-ISSUE/UPDATE 01/29/20
A. DESCRIPTION
Botulinum Toxin injections are a Nevada Medicaid covered benefit for certain spastic conditions
including, but not limited to cerebral palsy, stroke, head trauma, spinal cord injuries and multiple sclerosis.
The injections may also reduce spasticity or excessive muscular contractions to relieve pain, to assist in
posturing and ambulation, to allow better range of motion, to permit better physical therapy and/or provide
adequate perineal hygiene.
B. PRIOR AUTHORIZATION
Prior authorization is required for Botulinum Toxin. Please reference MSM Chapter 1200, Prescribed
Drugs for prior authorization criteria.
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 16
ATTACHMENT A
POLICY #6-12 RESERVED FOR FUTURE USE
RESERVED FOR FUTURE USE
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 17
ATTACHMENT A
POLICY #6-13 SCHOOL BASED HEALTH CENTER EFFECTIVE DATE 01/01/15
A. DESCRIPTION
School Based Health Centers (SBHCs) provide primary and preventive medical services to Medicaid and
Nevada Check Up recipients. SBHCs are health centers located on or near a school facility of a school
district, independent school or board of an Indian tribe or tribal organization. An SBHC operates as a
separate delivery model from School Health Services (SHS) provided through a Local Education Agency
(LEA) or State Education Agency (SEA). SHS policy is located in MSM Chapter 2800, School Health
Services.
B. POLICY
1. The center(s) will, through providers of healthcare operating within the scope of their practice
under state law, be used exclusively to provide primary and preventive health services to children
and adolescents in accordance with recommended guidelines. Each center will be organized
through the school, community and health care provider agreements, and will be administered by
a sponsoring agency.
2. Staffing and providers may include but are not limited to: Support Staff, Site Director,
Immunization Coordinator, Medical Doctor, Osteopathic Doctor, APRN, Ph.D. of Nursing,
PA/PA-C and Qualified Mental Health Professionals. Nevada Medicaid reimburses for services
that are medically necessary and performed by a qualified provider within the scope of practice as
defined by state law.
C. PRIOR AUTHORIZATION
Medical services provided by SBHCs must follow prior authorization policy for each service provided
under corresponding prior authorization rules throughout the MSMs.
D. COVERAGE AND LIMITATIONS
1. All services that are provided must be medically necessary (see MSM Chapter 100, Medicaid
Program) to be considered covered SBHC services. Medically necessary services provided by a
qualified provider practicing within their scope of work may include but are not be limited to:
a. Primary and preventive health care including medical screenings;
b. Treatment for common illnesses and minor injuries;
c. Referral and follow-up for serious illnesses and emergencies;
d. Care and consultation, as well as referral and follow-up for pregnancy, chronic diseases,
disorders, and emotional/behavioral problems;
e. Referral, preventive services and care for high risk behaviors and conditions such as drug
and alcohol abuse, violence, injuries and sexually transmitted diseases;
f. Sports physicals as part of a comprehensive well child checkup;
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 18
POLICY #6-16 SCHOOL BASED HEALTH CENTER EFFECTIVE DATE 01/01/15
ATTACHMENT A
g. Vaccinations;
h. Diagnostic and preventive dental, and referral services; and
i. Laboratory testing.
2. NON-COVERED SERVICES
Non-covered services include, but are not limited to:
a. Services that are not medically necessary;
b. Services that require prior authorization and one has not been obtained or approved; and
c. Medical services provided directly by an LEA or SEA.
E. PARENTAL CONSENT
1. A parent or guardian must sign a written consent form for a student to receive SBHC services.
Once the parent signs the written consent form and the center-specific forms, the Health Center
will provide or refer the student for any of the services that the child needs. Parents may indicate
if they do not want the child to receive a specific service by writing the name of the service in the
appropriate space on the center-specific form.
2. Although the Health Center will attempt to keep parents informed of the services their child
receives, signing the Uniform Consent gives the Health Center permission to provide medical and
behavioral health services to the child without contacting the parent each time the child visits the
Center. Except in an emergency situation, no child is treated, counseled or referred without a
consent form signed by a parent.
3. In emergencies, the Health Center will call the parent, but the Health Center is required by law to
treat the child even when the parent cannot be reached.
F. MINOR CONSENT LAWS
Providers practicing in SBHCs are governed by and must abide by the NRS Minor’s Consent for
examination and treatment.
G. THIRD PARTY LIABILITY (TPL)
SBHCs must follow TPL and other health care coverage guidelines as set forth in the MSM Chapter 100,
Medicaid Program. There are no regulatory exceptions regarding TPL for SBHCs. SBHCs must bill the
appropriate TPL and other health care coverage prior to submitting reimbursement claims to the Quality
Improvement Organization (QIO)-like vendor contracted with DHCFP.
July 1, 2021 PHYSICIAN SERVICES Attachment A Page 19
ATTACHMENT A
POLICY #6-13 SCHOOL BASED HEALTH CENTER EFFECTIVE DATE 01/01/15
H. PROVIDER RESPONSIBILITIES
1. The provider must be certified by the Division of Public and Behavioral Health as an SBHC.
2. Enroll with the QIO-like vendor for Nevada Medicaid, meeting all provider qualifications as an
SBHC.
3. Ensure the billing number and servicing number are the same.
4. Follow all billing guidelines for SBHCs.
5. Provider must work within the scope of services for each professional providing services.
October 1, 2015 PHYSICIAN SERVICES Attachment A Page 20
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
April 30, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: LYNNE FOSTER, CHIEF OF DIVISION COMPLIANCE
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 700 – RATES AND SUPPLEMENTAL REIMBURSEMENT
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 700 – Rates and Cost Containment are
being proposed to update and clarify the information. The title of the Chapter is being changed
from “Rates and Cost Containment” to “Rates and Supplemental Reimbursement.” Section 705 –
Letters of Agreement is being added.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary. Global changes were made in reference to the Medicaid
State Plan in order that it be consistent throughout the chapter.
Entities Financially Affected: All provider types are affected by the proposed changes.
Financial Impact on Local Government: No financial impact is anticipated for local government.
These changes are effective May 1, 2019.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 10/19 MTL 21/13, 16/12, 19/09, 26/07
MSM Ch 700 – Rates and Supplemental MSM Ch 700 – Rates and Supplemental
Reimbursement Reimbursement
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
700(D) INTRODUCTION Revising language from “mentally retarded” to
“Individuals with Intellectual Disabilities (ICF/IID).”
703.2(A) FEE TO Changing the language from “non-Medicare” patients to
INCREASE “all” patients. Adding new language after that to read:
Page 1 of 3
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
QUALITY OF “during the preceding month listed by the type of
NURSING CARE insurance coverage for each patient day,…”
703.2(B)(1) Changing the percent from 5.5% to 6.0% as that is the
current federal limit the program is operating under.
703.2(B)(2) Clarifying the reference by changing … “patients by the
rate in 2.a” to “patients by the rate in 703.2(B)(1).”
703.2(B)(3) Adding clarifying language when the January report is
due as this differs from other months.
703.3(B)(1) COST REPORTS Revising language from “Mentally Retarded (ICF/MR)”
to “ICF/IID.”
703.3(C)(2) Clarifying the reference by changing “any amounts due
under 3.a” to “any amounts due under 703.3(A).”
704 MEDICAID Revising language referencing the Nevada Medicaid
RATE(S) APPEAL State Plan. Clarifying “Appeals” to “Rate appeals.”
Adding language to indicate “provider-specific rates.”
Changing “procedures” to “the methodologies” and
clarifying “cannot be appealed and the policies outlined
in MSM 704 would not apply.”
Adding information clarifying who may or may not file
appeals.
704(G)(10) Adding 10. to the list that reads: “That the basis for relief
is fiscally acceptable under current and/or future budget
authority.”
704(I) Removing “The decision on the appeal shall set forth
Findings of Fact and Conclusions of Law” and adding
“The DHCFP will contact the person designated in
704(F)(1) to provide an explanation of the decision and
allow an opportunity to reconcile the dispute.”
704 (J) Clarifying the reference by changing “to the person
designated in 704.2.a” … to “to the person designated in
704(F)(1).”
704(K) Revising the language to read: “The Administrator’s
decision is considered final.”
Page 2 of 3
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
705 LETTERS OF This section is being added and provides information
AGREEMENT related to Letters of Agreement (LOA) for out-of-state
providers.
Page 3 of 3
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
RATES AND SUPPLEMENTAL REIMBURSEMENT
700 INTRODUCTION ..........................................................................................................................1
701 AUTHORITY ..................................................................................................................................1
701.1 FEE TO INCREASE QUALITY OF NURSING CARE ................................................................1
701.2 COST REPORTS .............................................................................................................................1
701.3 MEDICAID RATE(S) APPEAL .....................................................................................................1
702 ELIGIBILITY RULES FOR SUPPLEMENTAL PAYMENT PROGRAMS ...............................1
702.1 RULES OF PARTICIPATION FOR INPATIENT UPPER PAYMENT LIMIT (UPL) FOR
PRIVATE HOSPITAL SUPPLEMENTAL PAYMENT PROGRAM ..........................................1
703 POLICY ...........................................................................................................................................1
703.1 INPATIENT HOSPITAL SERVICES ............................................................................................1
703.2 FEE TO INCREASE QUALITY OF NURSING CARE ................................................................1
703.3 COST REPORTS .............................................................................................................................2
704 MEDICAID RATE(S) APPEAL .....................................................................................................1
705 LETTERS OF AGREEMENT .........................................................................................................1
705.1 SCOPE AND RESPONSIBILITY ..................................................................................................1
705.2 PROCEDURES................................................................................................................................1
705.3 PERIODIC REVIEW.......................................................................................................................2
Page 1 of 1
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 700
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
700 INTRODUCTION
The Division of Health Care Financing and Policy (DHCFP) establishes the methods and standards
for provider reimbursements for Medicaid services in accordance with the Code of Federal
Regulations (CFR), Title 42, Part 447 and in consultation with providers and a public hearings
process. The methods and standards for rate determinations are described in Nevada’s approved
State Plan under Title XIX of the Social Security Act (i.e. the Medicaid State Plan).
Providers should consult the Medicaid State Plan, Section 4.19 – Payment for Services, for
methods and standards for reimbursement. The following is a brief summary of the detail
attachments to Section 4.19:
A. Attachment 4.19-A describes methods and standards for reimbursing inpatient hospitals,
residential treatment centers, Indian Health Service and Tribal 638 Health Facilities.
B. Attachment 4.19-B describes the methods and standards for reimbursing medical services
provided by licensed professionals in various settings and those items ancillary to licensed
medical services, such as laboratory and x-ray, pharmaceuticals, dentures, prosthetic
devices, eyeglasses, medical supplies, appliances and equipment and transportation.
C. Attachment 4.19-C describes the methods and standards for reimbursing reserved beds in
various institutions excluding acute care facilities.
D. Attachment 4.19-D describes the methods and standards for long-term care facilities
including hospital-based and freestanding nursing facilities, Intermediate Care Facilities
for Individuals with Intellectual Disabilities (ICF/IID) and swing beds in hospitals.
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 700 Page 1
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 701
Subject:
MEDICAID SERVICES MANUAL AUTHORIZATION
701 AUTHORITY
701.1 FEE TO INCREASE QUALITY OF NURSING CARE
Nevada Revised Statute (NRS) 442.3755 to NRS 422.379
701.2 COST REPORTS
CFR, Title 42, Part 413-Principles of Reasonable Cost Reimbursement, Section 413.24
A. Title XIX of the Social Security Act (SSA), Medicaid State Plan, Attachment 4.19-D, Page
6, Section C.
701.3 MEDICAID RATE(S) APPEAL
The authority for provider rate(s) appeals exists under the CFR (CFR, Title 42, Chapter IV, Part
447 – Payments for Services, Section 447.253(e) – Other requirements). This section states, “The
Medicaid agency must provide an appeals or exception procedure that allows individual providers
an opportunity to submit additional evidence and receive prompt administrative review, with
respect to such issues as the agency determines appropriate, of payment rates.”
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 701 Page 1
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 702
Subject:
MEDICAID SERVICES MANUAL ELIGIBILITY RULES FOR
SUPPLEMENTAL PAYMENT
PROGRAMS
702 ELIGIBILITY RULES FOR SUPPLEMENTAL PAYMENT PROGRAMS
702.1 RULES OF PARTICIPATION FOR INPATIENT UPPER PAYMENT LIMIT (UPL) FOR
PRIVATE HOSPITAL SUPPLEMENTAL PAYMENT PROGRAM
Attachment 4.19-A, Section XV, Part B of the Medicaid State Plan authorizes Medicaid
supplemental payments to certain private hospitals affiliated with Nevada units of government
through a Low Income and Needy Care Collaboration Agreement. Participation in the program
must be consistent with federal approval of the State Plan.
In order to be eligible to provide the non-federal share of these Medicaid supplemental payments,
a unit of government must execute a certification that it will comply with the program limitations
adopted by the DHCFP in its Nevada Medicaid Supplemental Payment Program Conditions of
Participation (CoP). Each unit of government must execute this certification on a form
promulgated by the DHCFP. Each unit of government’s participation must be consistent with
federal approval of the State Plan.
In order to be eligible to receive Medicaid supplemental payments under this section of the
Medicaid State Plan, a hospital must execute a certification that it will comply with the program
limitations adopted by the DHCFP in its Nevada Medicaid Supplemental Payment Program CoP.
Each hospital must execute this certification on a form promulgated by the DHCFP. Each private
hospital’s participation must be consistent with federal approval of the State Plan.
The State Plan, CoP, certification forms and other participation requirements are available to the
public at the DHCFP’s office and on the website at: https://dhcfp.nv.gov/hcfpdata.htm.
In order to be consistent with CFR Title 42, Chapter IV, Part 447, Subpart C, Section 447.272, the
DHCFP:
A. Prohibits any cash or in-kind transfers from the private hospitals to the governmental entity
that have a direct or indirect relationship to Medicaid payments;
B. Does not allow a governmental entity to condition the amount it funds the Medicaid
program on a specified or required minimum amount of low income and needy care;
C. Does not allow a governmental entity to assign any of its contractual or statutory
obligations to a private hospital receiving payments under State Plan Amendment (SPA)
10-002C;
D. Does not allow the governmental entity to recoup funds from a hospital that has not
adequately performed under the Low Income and Needy Care Collaboration Agreement;
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 702 Page 1
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 702
Subject:
MEDICAID SERVICES MANUAL ELIGIBILITY RULES FOR
SUPPLEMENTAL PAYMENT
PROGRAMS
E. Prohibits each private hospital from returning any of the supplemental payments it receives
under SPA 10-002C to the governmental entity that provides the non-federal share of the
payments; and
F. Prohibits each governmental entity from receiving any portion of the supplemental
Medicaid payments made to the private hospitals under SPA 10-002.
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 702 Page 2
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 703
Subject:
MEDICAID SERVICES MANUAL POLICY
703 POLICY
703.1 INPATIENT HOSPITAL SERVICES
Inpatient hospital services, which have been authorized for payment at the acute level by a Quality
Improvement Organization (QIO-like vendor), as specified in the contract between the QIO-like
vendor and the DHCFP, are reimbursed by all-inclusive, prospective per diem rates by type of
admission/service. The all-inclusive prospective rates cover routine and ancillary services
furnished by the hospital, including direct patient care for professional services furnished to
inpatients by hospital-staffed physicians and practitioners. For specific rate methods and standards
for inpatient hospital services, refer to the State Plan, Section 4.19, Attachment A.
703.2 FEE TO INCREASE QUALITY OF NURSING CARE
The DHCFP established the following policy to assess and collect fees to increase the quality of
nursing care. NRS 422.3775 states: “Each nursing facility that is licensed in this State shall pay a
fee assessed by the Division to increase the quality of nursing care in this State.”
A. Reporting Requirements:
Each nursing facility shall file with the DHCFP each month a report setting forth the total
number of days of care it provided to all patients during the preceding month listed by the
type of insurance coverage for each patient day, the total gross revenue it earned as
compensation for services provided to patients during the preceding month, and any other
information required by the Division.
B. Payment of Fee:
1. The DHCFP shall annually establish a rate per non-Medicare patient day that is
equivalent to 6.0%, or a percentage not to exceed any limitation provided under
federal law or regulation, of the total annual accrual basis gross revenue for services
provided to patients of all nursing facilities licensed in this state.
2. The DHCFP shall calculate the fee owed by each nursing facility by multiplying
the total number of days of care provided to non-Medicare patients by the rate in
703.2(B)(1).
3. The monthly report and fee assessed pursuant to this section are due 30 days after
the end of the month for which the fee was assessed. The January report is due not
later than the last day of February.
C. Failure to Pay or Late Payment of Fee:
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 703 Page 1
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 703
Subject:
MEDICAID SERVICES MANUAL POLICY
1. The DHCFP may assess a penalty of one percent of the fee for each day a fee is
past due up to 10 days. The DHCFP may assess interest at the rate of 1.5% of the
fee per month or fraction thereof for any past due fee. In the event a facility has not
submitted the required monthly report, the DHCFP may estimate the fee due for
purposes of assessing penalties and interest.
2. The DHCFP may withhold past due fees, penalties and interest from a facility’s
Medicaid claims payments until such past due amounts are paid in full.
703.3 COST REPORTS
The DHCFP established the following policy to collect Medicare/Medicaid cost reports. (A
Medicare/Medicaid Cost Report is the standard Medicare Cost Report with the required Medicaid
sections completed.)
The DHCFP adopts Medicare deadlines for the Medicare/Medicaid cost reports. These
requirements are found in the CFR (CFR, Title 42, Part 413 – Principles of Reasonable Cost
Reimbursement, Section 413.24). This section states, “Due dates for cost reports. (i) Cost reports
are due on or before the last day of the fifth month following the close of the period covered by the
report. For cost reports ending on a day other than the last day of the month, cost reports are due
150 days after the last day of the cost reporting period.”
The authority to collect Medicaid Cost Reports exists under Title XIX of the SSA, Medicaid State
Plan, Attachment 4.19. Cost and other statistical information within the cost report must be
reported in compliance with allowable and non-allowable cost definitions contained in the
Medicare/Medicaid provider reimbursement manual (commonly referred to as Centers for
Medicare and Medicaid Services (CMS) Publication 15).
A. Hospital Cost Reporting Requirements:
Hospital (including hospital-based nursing facility) annual Medicare/Medicaid cost reports
are to be filed with the Medicaid program (DHCFP) following the cost report filing
deadlines adopted in 42 CFR 413.24. If a facility requests an extension from the Medicare
program, they must also request an extension from the DHCFP. Extension requests
approved by Medicare will automatically be approved by the DHCFP, once the DHCFP
receives evidence of Medicare approval from the facility.
B. Free-Standing Cost Reporting Requirements:
1. Free-standing nursing facilities and ICF/IID must complete and file an annual
Medicare/Medicaid cost report with the DHCFP.
2. Cost reports are to be received by the DHCFP by the last day of the third month
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 703 Page 2
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 703
Subject:
MEDICAID SERVICES MANUAL POLICY
following a facility’s fiscal year end. If the facility is unable to complete their cost
report within this time frame, a request for a 30-day extension can be requested
from the DHCFP prior to the original cost report due date. Reasonable extension
requests will be granted.
3. Minimum Direct Care Staffing Requirement: In the event that a nursing facility
does not incur direct care cost at least equal to 94% of the direct care median, the
DHCFP will have the option to recoup, from future payments to that provider, an
amount equal to 100% of the difference between the provider’s direct care rate and
the actual cost the provider incurred. This provision is intended to encourage
adequate direct care staffing. Any penalties collected shall accrue to the State
General Fund and shall be used to offset Medicaid expenses.
C. Failure to File or Late Filing of Cost Reports
1. Facilities failing to file a Medicare/Medicaid cost report in accordance with these
provisions may have their Medicaid payments suspended or be required to pay back
to the Medicaid program all payments received during the fiscal year period for
which they were to provide a cost report. Facilities may also be subject to an
administrative fine of up to $500 per day for each day the required cost reports are
delinquent.
2. The DHCFP may withhold any amounts due under 703.3(A) (above) from a
facility’s Medicaid claims payments until such amounts are paid in full.
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 703 Page 3
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 704
Subject:
MEDICAID SERVICES MANUAL APPEALS
704 MEDICAID RATE(S) APPEAL
The following appeal procedure applies to reimbursement rates paid to providers for providing
services under the Medicaid State Plan to Medicaid recipients enrolled in the Fee-for-Service
Medicaid program. Rate appeals are limited to individual providers requesting review of a
provider-specific rate. For example, a provider who is reimbursed under a negotiated rate or by
cost pursuant to the State Plan may seek review through the process outlined in Medicaid Services
Manual (MSM) Chapter 704.
The rate appeal process may not be used to request a rate increase for general rates. General rates
are determined by methodologies set forth in the State Plan and are not eligible for review through
the process outlined in MSM Chapter 704.
In addition to the above, appeals may not be filed by the following:
A. Providers who are reimbursed under the Medicare principles of retrospective
reimbursement described in 42 CFR 413 and further specified in CMS Publication 15;
B. Providers who are reimbursed under the Prospective Payment System (PPS) established by
cost-based reporting as required by the SSA §1902(a)(15) (42 United States Code (USC)
§1396a(a)(15)) and S.S.A. §1902(bb) (42 USC §1396a(bb));
C. Indian Health Services who are reimbursed in accordance with the most recent Federal
Register Notice; and
D. Government providers who undergo a cost reconciliation or cost settlement
reimbursement.
E. Appeals must be submitted in writing to the address below and clearly marked as a Rate
appeal.
To ensure receipt of the appeal, certified mail or other commonly accepted delivery
methods which clearly show the date of receipt are encouraged.
Appeal address: Administrator DHCFP, 1100 E. William Street, Suite 101, Carson City,
Nevada 89701.
F. The appeal must contain the following information:
1. The name, address and telephone number of the person who has authority to act on
behalf of the provider/appellant;
2. The specific rate(s) to be reviewed;
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 704 Page 1
MTL 26/07
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 704
Subject:
MEDICAID SERVICES MANUAL HEARINGS
3. The basis upon which the provider believes relief should be granted including
supporting documentation:
a. Claims documentation showing costs for Medicaid services not fully
compensated by Medicaid payments is necessary, but not sufficient to form
a basis for relief.
b. The documentation should show that payments received from Medicaid for
the appealed rate fail to compensate for costs attributable to providing
services to Medicaid patients as well as for the rates in aggregate for the
provider.
c. The documentation must show how the specific circumstances of services
provided to Medicaid recipients relative to other like-providers result in
higher costs not adequately or appropriately considered in the development
of the existing rate(s).
4. The relief requested, including the methodology used to develop the relief
requested.
Actual costs from the most recent prior year(s), or costs from part of the current
year, may be used in developing the methodology for the relief request, so long as
it is not a cost reimbursement methodology; and
5. Any other information the provider believes to be relevant to the review.
G. The Administrator, or their designee, may consider the following factors in deciding
whether to grant rate relief:
1. Whether there are circumstances related to the appellant when compared to other
providers that cause the appellant to have higher Medicaid costs in the rate category
reviewed;
2. Whether the circumstances relating to the provider are adequately considered in the
rate-setting methodology set forth in the State Plan;
3. The extent to which comparable health care services are available and accessible
for all people in the geographic area served by the appellant/provider;
4. Whether Medicaid payments are sufficient to meet Medicaid costs in the appealed
rate(s);
July 14, 2009 RATES AND COST CONTAINMENT Section 704 Page 2
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 704
Subject:
MEDICAID SERVICES MANUAL APPEALS
5. The total Medicaid payments to the provider and all Medicaid payments for the
appealed rate(s): In the case of hospitals, this includes total Medicaid costs to the
hospital for inpatient care and the hospital’s Medicaid costs for the appealed rate(s);
6. Audit review information, if any;
7. Information and data used to set the existing or appealed rate;
8. Such other information or documentation as the Administrator, or their designee,
deems relevant; and
9. That the basis for relief results in uncompensated Medicaid costs to the provider,
both in the appealed rate(s) and in aggregate Medicaid payments under the State
Plan; and
10. That the basis for relief is fiscally acceptable under current and/or future budget
authority.
H. The Administrator, or their designee, shall review the appeal and supporting documentation
and issue a written decision within 90 calendar days of receipt of a properly submitted
appeal. The Administrator, or their designee, may request any additional information from
the provider, including independent verification by an unrelated third party of the
provider’s claims. If the Administrator, or their designee, requests additional information
or verification, the period in which the Administrator, or their designee, must issue a
decision is extended to 90 calendar days from the receipt of the requested information.
I. The DHCFP will contact the person designated in 704(F)(1) to provide an explanation of
the decision and allow an opportunity to reconcile the dispute.
J. The decision will be sent in writing by certified mail, return receipt requested, to the person
designated in 704(F)(1).
K. The Administrator’s decision is considered final.
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 704 Page 3
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 705
Subject:
MEDICAID SERVICES MANUAL LETTERS OF AGREEMENT
705 LETTERS OF AGREEMENT
Pursuant to the conditions and limitations prescribed in the Medicaid State Plan, the DHCFP may
negotiate reimbursement rates for out-of-state providers to serve Nevada Medicaid recipients. The
services of these providers are often necessary to ensure access to services for Medicaid and Nevada
Check Up recipients that may not otherwise be available from in-state providers or in those
instances where a recipient is in need of emergency care while outside of the State of Nevada.
705.1 SCOPE AND RESPONSIBILITY
The following procedure will be used for all out-of-state providers requesting a provider-specific
rate. These procedures do not apply to external professional services billed outside of an inpatient
or outpatient facility setting.
These procedures are applicable primarily to out-of-state inpatient and outpatient acute, psychiatric
and specialty hospital services and other services associated with such treatment, including
transportation and physician services.
The Rate Analysis and Development (RAD) unit of the DHCFP is responsible for administering
the provision of this section. All agreements under this section are not final until they are fully
executed by the Division’s Administration.
705.2 PROCEDURES
A. Before an agreement under this section can be finalized, a provider must be enrolled as a
current Nevada Medicaid provider. The provider must submit a list of their current active
Nevada Medicaid provider numbers for which the agreement will apply.
B. If the service requires a prior authorization (PA), providers must present the PA number
when requesting a Letter of Agreement (LOA). Information regarding PAs may be found
in the MSM Chapter 100 – Medicaid Program.
C. The RAD unit will negotiate a provider-specific reimbursement agreement within the
constraints of the Medicaid State Plan and the MSM. A percentage of usual and customary
billed charges is the most common methodology, but other methods may be acceptable.
1. Negotiations will be conducted with the purpose of ensuring both fiscal
responsibility and restraint, as well as providing access to services for Nevada
Medicaid recipients.
D. Agreements may be for a single recipient or an individual provider. They are for all services
rendered by the out-of-state provider. Methodologies may vary by type of service.
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 705 Page 1
MTL 10/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 705
Subject:
MEDICAID SERVICES MANUAL LETTERS OF AGREEMENT
E. All agreements must have a reimbursement effective and expiration date. This allows for
periodic review and updates of the methodology. In the event an agreement expires without
renewal, the provider will be reimbursed on the same basis as in-state providers for the
same service(s).
1. If a PA is not required, the effective date for the LOA is the time of the request. If
a PA is required, the effective date for the LOA will be the authorized effective date
on the PA issued by the fiscal intermediary for Nevada Medicaid. A retroactive
LOA will only be provided if the service occurred over a weekend, or for
emergencies, and must be approved by the DHCFP Administrator.
F. All agreements must be consistent with the capabilities of the Medicaid Management
Information System (MMIS), which is used for processing billing claims.
G. The LOA template, as approved by the DHCFP, will be used to confirm the reimbursement
agreement with the provider. The LOA may only be executed using the template approved
by the DHCFP. Reproduced templates will not be accepted.
H. Copies of the fully executed agreement will be sent to the provider, the fiscal intermediary
and the appropriate DHCFP Chiefs.
I. When submitting claims, the provider must include a copy of the LOA to ensure
reimbursement will be at the provider-specific rate.
705.3 PERIODIC REVIEW
Agreements may be reviewed by the DHCFP as necessary to ensure compliance with Nevada
Medicaid policy.
At any time, the out-of-state provider may request a review of the provider-specific rate for the
LOA.
May 1, 2019 RATES AND SUPPLEMENTAL REIMBURSEMENT Section 705 Page 2
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
July 26, 2018
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: LYNNE FOSTER, CHIEF OF DIVISION COMPLIANCE/Lynne Foster/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 800 – LABORATORY SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 800 – are proposed to update language,
definitions and limitations for drug screening and testing. Presumptive drug screens are limited to
one per day with a maximum of 20 tests per 12-rolling months. Only three definitive drug screens
are permitted per recipient per 12-rolling months. Should more than three be needed, a prior
authorization is required.
Entities Financially Affected: Hospital, Outpatient (Provider Type (PT) 12), Special Clinics (PT
17), Physician/Osteopath (PT 20), Certified Registered Nurse Practitioner, Nurse (PT 24),
Laboratory – Pathology/Clinic (PT 43), School Based Services (PT 60), Nurse Midwife (PT 74),
and Physician’s Assistant (PT 77).
Financial Impact on Local Government: Unknown at this time.
These changes are effective August 1, 2018.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 11/18 MTL 15/14
MSM Chapter 800 – Laboratory Services MSM Chapter 800 – Laboratory Services
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
803.1A.1.p.1 Coverage and Added language to clarify the requirements of the
limitations presence of a drug or drug class for when to conduct a
drug screen.
803.1.A.1.p.3 Coverage and Added language to clarify structures of screening of
limitations drugs including presumptive and definitive. This includes
the maximum number of 20 presumptive and the
Page 1 of 2
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
maximum number of three definitive drugs screens that
can be performed in a 12-month rolling period.
803.1.A.1.p.4 Coverage and Added language that standing orders for presumptive
limitations drug screens may be utilized.
803.1.A.1.p.5 Coverage and Added language that procedure codes should only be
limitations reported with a quantity of one per episode of care.
803.1.A.1.p.6 Coverage and Added language that testing for the same drug with a
limitations blood and urine specimen simultaneously is not covered.
803.1.A.1.p.7 Coverage and Added language that drugs screens not meeting medical
limitations necessity are not covered.
803.1.A.1.p.8 Coverage and Added language that routine drug screens are not covered
limitations unless used in conjunction with an extended course of
treatment for substance abuse disorders.
803.1.A.1.p.9 Coverage and Added language that drug confirmation tests are not
limitations eligible to be separately reported under any procedure
code, unlisted or otherwise.
Page 2 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
LABORATORY SERVICES
800 INTRODUCTION ...........................................................................................................................1
801 AUTHORITY ..................................................................................................................................1
802 RESERVED .....................................................................................................................................1
803 POLICY ...........................................................................................................................................1
803.1A COVERAGE AND LIMITATIONS ...............................................................................................1
803.1B PROVIDER RESPONSIBILITY.....................................................................................................5
803.1C PRIOR AUTHORIZATION ............................................................................................................7
804 HEARINGS .....................................................................................................................................1
ATTACHMENT A
08-01 BRCA1 / BRCA2 GENE ANALYSIS……………………………………………………………1
08-02 ONCOTYPE DX™ BREAST CANCER ASSAY………………………………………………..1
MTL 15/14
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 800
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
800 LABORATORY SERVICES
INTRODUCTION
The Nevada Medicaid Laboratory Services program is designed to provide laboratory services
under a Clinical Laboratory Improvement Amendment of 1988 (CLIA) certified provider. These
services include microbiology, serology, immunohematology, cytology, histology, chemical,
hematology, biophysical, toxicology or other methods of “in-vitro” examination of tissues,
secretions, excretions or other human body parts. Clinical laboratory services are furnished
primarily in three distinct settings: independent clinical laboratories, physician office laboratories
and hospital-based laboratories. Such services shall maintain a high standard of quality and shall
be provided within the limitations and exclusions specified within this chapter.
All providers participating in the Medicaid Program must deliver services in accordance with the
rules and regulations of the Medicaid Program.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), with the exception of those listed in the NCU Manual Chapter 1000.
November 1, 2014 LABORATORY SERVICES Section 800 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 801
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
801 AUTHORITY
The Centers for Medicare and Medicaid Services (CMS) mandate that necessary and essential
laboratory services be available for all Nevada Medicaid recipients. Laboratory services for
children are provided under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
program per the Social Security Act (SSA) of 1905 (a)(3)(1)(B)(iv)(r)(5). The Nevada EPSDT
program provides children with services additional to those available to adult recipients.
Laboratory services are available through the Medicaid Program according to the:
Code of Federal Regulations (CFR):
• 42 CFR 493 Laboratory Requirements
• 42 CFR 410.32 Diagnostic X-Ray and Laboratory Tests
• 42 CFR 440.30 Other Laboratory and X-Ray Services
• 42 CFR 441.17 Laboratory Services
Nevada Revised Statute (NRS) Chapter 652 (Medical Laboratories)
Medicaid State Plan Attachment 1.2-B, 101.9.C and Attachment 4.19-B.3.
Other authorities regarding laboratory services available through the Medicaid Program include:
Social Security Act:
• Section 1902(a)(9)(C) (State Plans for Medical Assistance)
• Section 1905(a)(3), Section 1905(r)(1)(B)(iv) and Section 1905(r)(5) (EPSDT, Provision
of Laboratory Services)
42 CFR 482.27 (Conditions of Participation for Hospitals, Laboratory Services)
NRS:
• NRS 442.600- 442.660 (Serologic or rapid test Human Immunodeficiency Virus (HIV))
• NRS 442.010 (Serologic testing for syphilis in the first and third trimester of pregnancy)
November 1, 2014 LABORATORY SERVICES Section 801 Page 1
MTL 15/14
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 802
Subject:
MEDICAID SERVICES MANUAL RESERVED
802 RESERVED
November 1, 2014 LABORATORY SERVICES Section 802 Page 1
MTL 15/14
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 803
Subject:
MEDICAID SERVICES MANUAL POLICY
803 POLICY
803.1 Nevada Medicaid and NCU reimburse for medically necessary, diagnosis related, covered
laboratory services provided to all eligible recipients.
Nevada Medicaid and NCU provide outpatient clinical laboratory services through one or more
independent clinical laboratories, physician office laboratories, clinics and hospital-based
laboratories.
803.1A COVERAGE AND LIMITATIONS
1. Covered Services:
a. Except for specific laboratory tests identified under non-covered services, the
Division of Health Care Financing and Policy (DHCFP) reimburses organ or disease
oriented panels, therapeutic drug assays, evocative/suppression testing, clinical
pathology consultations, urinalysis, chemistry, hematology and coagulation,
immunology, tissue typing, transfusion medicine, microbiology, cytopathology,
cytogenic, surgical pathology, total transcutaneous bilirubin and tests specified
under, “Other Procedures” in the most recent version of Current Procedural
Terminology (CPT). Reference the Nevada Medicaid and NCU billing guidelines
for Provider Type 43, Laboratory, Pathology/Clinical, for covered CPT codes.
b. Follow-up testing performed by either the discharging hospital laboratory and/or the
newborn’s physician for newborns discharged with a hyperbilirubinemia diagnosis.
c. Ova and parasite testing for medically appropriate diagnosis.
d. An arterial blood drawing fee for Arterial Blood Gases (ABG) performed by
physicians and/or respiratory therapists.
e. Specialized or unique testing which cannot be performed within the State and
catchment area laboratories referred to a reference laboratory. Reference Section
803.1C.2 regarding prior authorization requirements.
f. Genotype and Phenotype assay testing for recipients:
1. With an acute (new or recent) HIV diagnosis upon entry into HIV care and/or
prior to the initiation of antiretroviral therapy;
2. Presenting with documented virologic failure after initiation of antiretroviral
therapy; or
November 1, 2014 LABORATORY SERVICES Section 803 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 803
Subject:
MEDICAID SERVICES MANUAL POLICY
3. Demonstrating documented suboptimal suppression of viral load after
initiation of antiretroviral therapy.
g. One venipuncture specimen collection fee per patient, per date of service,
specifically when the specimen is sent directly from a physician’s office laboratory
or clinic to an independent clinical laboratory for testing.
h. Laboratory tests associated with the EPSDT (Healthy Kids Program) screening
examination referenced in Medicaid Services Manual (MSM) Chapter 1500. The
associated costs of the hematocrit and urine “dip stick” with the exception of
metabolic screening (e.g. Phenylketonuria (PKU)) and sickle cell screening fees, are
included as part of the fee for EPSDT.
i. Metabolic screening (e.g. PKU) tests are referred to the Nevada State Public Health
Laboratory.
j. Sickle cell screens are referred to an independent clinical laboratory.
k. Serological or rapid-test HIV testing during the first and/or third trimester of
pregnancy or during childbirth performed in accordance with NRS 442.600 –
442.660.
l. An HIV rapid test for newborns (including infants in foster care) when the mother
has not been tested for HIV prior to or during the delivery or if the mother’s HIV
status is unknown postpartum.
m. Serologic testing for syphilis in the first and third trimester of pregnancy in
accordance with NRS 442.010.
n. Semen analysis, motility and count following a vasectomy procedure, not including
Huhner test, is limited to the CPT code that is specified in the DHCFP’s/Quality
Improvement Organization (QIO)-like vendor billing manual.
o. HIV tropism testing, not meeting criteria specified in Section 803.1A.2.m.
p. Drug Screening and Testing
1. Drugs or drug classes for which screening is performed should only reflect
those likely to be present based on the recipient’s medical history, current
clinical presentation or risk potential for abuse and diversion.
2. Each drug or drug class being tested for must be indicated by the referring
physician in a written order and reflected in the patient’s medical record.
August 1, 2018 LABORATORY SERVICES Section 803 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 803
Subject:
MEDICAID SERVICES MANUAL POLICY
This information must be patient-specific and accurately reflect the need for
each test and must include the specific drugs being screened including
recipient diagnosis.
3. Current coding for testing of drugs relies on a structure of screening (known
as presumptive screening) and may be followed by quantitative
measurements (known as definitive testing) that identifies the specific drug
or drugs and quantity in the recipient.
a. Only one presumptive test performed by direct observation or
instrument assisted direct observation or instrument chemistry
analyzers may be billed per recipient per day within a maximum of
20 presumptive test per 12-rolling months.
1. If the recipient should require more than 20 presumptive
tests per 12-rolling month, a prior authorization is required.
b. Only three definitive drug tests are permitted per recipient per 12-
rolling months.
1. If the recipient requires more than three definitive tests per
12-rolling month, a prior authorization is required, meeting
medical necessity.
2. Definitive testing is only covered to confirm an unexpected
result or identify drugs or metabolites that cannot be detected
on a presumptive drug screen.
3. Definitive testing should be based on the recipient’s
presentation and history and only include what is needed for
safe pain management.
4. Standing orders for presumptive drug screens may be utilized, but must be
individualized for each member, signed and dated by the treating
practitioner and updated every 30 days. Standing orders are not permitted
for definitive drug screens.
5. Procedure codes should be reported with a quantity of one per episode of
care, regardless of the number of collection/testing items used, the number
of procedures and/or the drug classes screened.
6. Testing for the same drug with a blood and urine specimen simultaneously
is not covered.
August 1, 2018 LABORATORY SERVICES Section 803 Page 3
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 803
Subject:
MEDICAID SERVICES MANUAL POLICY
7. Drug screening for pre-employment or employment purposes, medicolegal
and/or court ordered that do not meet medical necessity and/or drug
screenings for participation in school or military are not covered.
8. Routine drug screening is not covered unless used in conjunction with an
extended course of treatment for substance use disorders. Specific intervals,
at which recipient test should be performed, based on their individual needs,
must be documented in the member’s medical record with their treatment
plan.
9. Drug confirmation tests are not eligible to be separately reported under any
procedure code, unlisted or otherwise.
2. Non-Covered Services
Laboratory tests listed in the most recent, annually updated CPT publication which are not
benefits include:
a. Post mortem examination codes.
b. Reproductive medicine procedures, except as indicated in Section 803.1.A.1.m.
c. Handling/conveyance fees (e.g. urine, stool cultures, pap smears).
d. Medicaid and NCU Managed Care recipients (laboratory tests are the sole
responsibility of the managed care provider).
e. Those services deemed inappropriate to a probable diagnosis are not covered.
Services deemed inappropriate will be reviewed for possible recoupments.
f. All unlisted laboratory codes except for the unlisted microbiology code used to bill
phenotype assay tropism testing only.
g. Routine venipuncture by a provider testing the laboratory specimen or referring the
laboratory specimen to an affiliate laboratory.
h. Collection of a capillary blood specimen (e.g. finger, heel or ear stick) when it is
part of or integral to the test procedure (e.g. a bleeding or clotting time).
i. Physician services related to deviation from standard blood banking procedures (e.g.
use of outdated blood or Rh incompatible units).
August 1, 2018 LABORATORY SERVICES Section 803 Page 4
MTL 23/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 803
Subject:
MEDICAID SERVICES MANUAL POLICY
j. Microdissection by laser capture.
k. Caffeine halothane contracture test.
l. Routine use (e.g. serial testing) of genotype and/or phenotype testing in individuals
without virologic failure or suboptimal viral response or with viral loads maintained
at an undetectable level on a current medication regime.
m. HIV tropism test:
1. Subsequent to a prior mixed or dual tropism test result; or
2. Testing performed more than twice in a recipient’s lifetime.
n. Blood typing for paternity testing.
o. Gene expression profiling, except when it is medically necessary as a prognostic
assay to identify recipients diagnosed with breast cancer who are likely to respond
to systemic chemotherapy when utilizing Oncotype DX TM, as defined in Policy
Attachment #08-02.
p. Molecular testing except for BRCA1/BRCA2 testing services for:
1. Individuals without a personal history of breast and/or ovarian cancers,
considered to be high risk as defined in Policy Attachment #08-01 or as
otherwise defined by the US Preventive Services Task Force;
2. Women with a personal history of breast and/or ovarian cancer with a
personal history of breast cancer as defined in Policy Attachment #08-01 or
as otherwise defined by the National Comprehensive Cancer Network
(NCCN) Clinical Practice Guidelines; or
3. Men with a personal history of breast cancer as defined in Policy Attachment
#08-01 or as otherwise defined by the NCCN Clinical Practice Guidelines.
803.1B PROVIDER RESPONSIBILITY
Providers must:
1. Verify recipients Medicaid eligibility and program benefit. Medicaid Fee-for-Service
(FFS) will not reimburse for laboratory procedures performed for Medicaid or NCU
recipients in managed care. Managed care plans may have their own authorization
requirements. See MSM Chapter 3600.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 803
Subject:
MEDICAID SERVICES MANUAL POLICY
2. Have appropriate state licensure or registration from the state where the laboratory is
located, as applicable.
3. Have current and appropriate CLIA certification for the level of laboratory tests performed.
4. Except in the case of provision of emergency laboratory services, have a valid Provider
Contract with the Nevada DHCFP and Nevada Medicaid enrollment number or be an
affiliate of an in-state laboratory that has a valid Medicaid enrollment number.
An out-of-state laboratory providing covered, emergency medical laboratory services to a
Medicaid or NCU recipient is exempt from the enrollment process for these services as
long as the provider is enrolled as a Medicaid provider and is licensed to provide the
laboratory service in the provider’s home state.
5. Be in compliance with all applicable federal, state and local laboratory requirements.
6. Be in compliance with all Nevada MSM policies.
7. Be in compliance with claim and billing requirements specified in MSM Chapter 100, the
QIO-like vendor/Medicaid and NCU billing manual, and the most recent version of the
CPT and the Healthcare Common Procedure Coding System manuals.
8. Include on all claims the highest level of code specificity in accordance with the most
current International Classification of Diseases, Clinical Modification manual related to
the laboratory test performed. If a diagnosis or narrative diagnosis is not submitted by the
prescribing practitioner, a laboratory must request this information from the physician/
practitioner who ordered the service.
9. Specify the current CLIA number of the laboratory performing the test on all claims, except
when billing for CLIA exempt tests.
10. Only bill for laboratory services that the laboratory is currently licensed/registered and
certified to perform.
11. Ensure each recipient’s laboratory record contains the following information:
a. Identification number of the specimen;
b. Name or any other means of confidentially identifying the person from whom the
specimen was taken;
c. Name of the prescriber and, if applicable, the referring laboratory that submitted
the specimen;
November 9, 2016 LABORATORY SERVICES Section 803 Page 6
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 803
Subject:
MEDICAID SERVICES MANUAL POLICY
d. Date the specimen was collected by the prescriber or laboratory;
e. Date the specimen was received in the laboratory;
f. Condition of unsatisfactory specimens when received (e.g. broken, leaked,
hemolyzed or turbid);
g. Test performed;
h. Date the test was performed;
i. Results of the test and the date of reporting; and
j. Name and address of the laboratory where any specimen is referred, if applicable.
12. Ensure that there is a written report on file for laboratory and pathology services that have
a professional component requiring physician interpretation, whether or not "with
interpretation and report" is stated in the code description of the service provided.
13. Maintain a quality-control program and make results of proficiency testing programs
available to Nevada Medicaid or the QIO-like vendor upon request.
803.1C PRIOR AUTHORIZATION
The ordering physician must obtain prior authorization for the following services, except for
Medicare/Medicaid dual eligible recipients who are still eligible for Medicare benefits:
1. Genotype and phenotype assay testing for recipients with chronic HIV infection prior to
initiation of highly active antiretroviral therapy.
2. Laboratory tests referred by a physician office laboratory directly to an out of state
laboratory.
November 1, 2014 LABORATORY SERVICES Section 803 Page 7
MTL 15/14
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 804
Subject:
MEDICAID SERVICES MANUAL HEARINGS
804 HEARINGS
Reference Nevada MSM Chapters 100 and 3100 for the Medicaid Hearings and Grievance process.
November 1, 2014 LABORATORY SERVICES Section 804 Page 1
EFFECTIVE DATE
POLICY # 08-01 BRCA1 / BRCA2 GENE ANALYSIS August 1, 2014
DESCRIPTION
Breast Cancer gene 1 (BRCA1) and Breast Cancer gene 2 (BRCA2) are human genes that belong to a class of
genes known as tumor suppressors. Mutation of these genes has been linked to hereditary breast and ovarian
cancer. A woman's risk of developing breast and/or ovarian cancer is greatly increased if she inherits a deleterious
BRCA1 or BRCA2 mutation. Men with these mutations also have an increased risk of breast cancer.
POLICY
BRCA1/BRCA2 testing services for individuals without a personal history of breast and/or ovarian cancer should
be provided to high risk individuals as defined below or as otherwise defined by the US Preventive Services Task
Force (USPSTF).
BRCA1/BRCA2 testing services for women with a personal history of breast and/or ovarian cancer and for men
with a personal history of breast cancer should be provided as defined below or as otherwise defined by the NCCN
Clinical Practice Guidelines.
Genetic counseling must precede genetic testing for hereditary cancer.
If the mutation in the family is known, only the test for that mutation is covered. For example, if a mutation for
BRCA1 has been identified in a family, a single site mutation analysis for that mutation is covered, while a full
sequence BRCA1 and BRCA2 analyses is not. An exception to this can be considered if a Certified Genetic
Counselor presents sufficient justifiable need.
If the individual is of Ashkenazi Jewish descent, test the three common mutations first. Then if negative, consider
comprehensive ("Reflex") testing based on assessment of individual and family history as if the individual is of
non-Ashkenazi Jewish descent.
PRIOR AUTHORIZATION: YES NO
COVERAGE AND LIMITATIONS:
Frequency is limited to once in a lifetime.
BRCA1/BRCA2 gene analysis is covered for individuals meeting the following criteria:
1. For individuals without diagnosis of breast or ovarian cancer:
a. Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 years or
younger;
b. A combination of three or more first- or second-degree relatives with breast cancer regardless of
age at diagnosis;
c. A combination of both breast and ovarian cancer among first- or second-degree relatives;
d. A first-degree with bilateral breast cancer;
November 1, 2014 LABORATORY SERVICES Attachment A Page 1
EFFECTIVE DATE
POLICY # 08-01 BRCA1 / BRCA2 GENE ANALYSIS August 1, 2014
e. A combination of two or more first- or second-degree relatives with ovarian cancer, regardless of
age at diagnosis;
f. A first or second-degree relative with both breast and ovarian cancer at any age;
g. History of breast cancer in a male relative; or
h. For women of Ashkenazi Jewish descent, any first-degree relative (or two second-degree relatives
on the same side of the family) with breast or ovarian cancer.
2. A family history of breast or ovarian cancer that includes a relative with a known deleterious BRCA
mutation; or
3. A personal history of breast cancer plus one or more of the following:
a. Diagnosed at age ≤ 45 years;
b. Diagnosed at age ≤ 50 years with ≥ 1 close blood relative with breast cancer diagnosed at any age
or with a limited family history;
c. Two breast primaries when first breast cancer occurred at age ≤ 50 years;
d. Diagnosed at age ≤ 60 years with a triple negative breast cancer;
e. Diagnosed at age ≤ 50 years with a limited family history;
f. Diagnosed at any age, with ≥ 1 close blood relative with breast cancer diagnosed ≤ 50 years;
g. Diagnosed at any age with ≥ 2 close blood relatives with breast cancer at any age;
h. Diagnosed at any age with ≥ 1 close blood relative with epithelial ovarian cancer;
i. Diagnosed at any age with ≥ 2 close blood relatives with pancreatic cancer or aggressive prostate
cancer (Gleason Score ≥ 7) at any age;
j. Close male blood relative with breast cancer; or
k. For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi Jewish)
no additional family history may be required.
4. Personal history of epithelial ovarian cancer; or
5. Personal history of male breast cancer; or
6. Personal history of pancreatic cancer or aggressive prostate cancer (Gleason Score ≥ 7) at any age with ≥
2 close blood relatives with breast and/or ovarian and/or pancreatic cancer or aggressive prostate cancer
(Gleason Score ≥ 7) at any age.
November 1, 2014 LABORATORY SERVICES Attachment A Page 2
EFFECTIVE DATE
POLICY # 08-01 BRCA1 / BRCA2 GENE ANALYSIS November 9, 2016
REFERENCES:
1. The NCCN Clinical Practice Guidelines in Oncology Breast Cancer (Version 3.2013). 2013
National Comprehensive Cancer Network, Inc. Available at:
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Accessed August 20, 2013.
2. US Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast
and ovarian cancer susceptibility recommendation statement. Available at:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/brca-related-
cancer-risk-assessment-genetic-counseling-and-genetic-testing.
Accessed August 10, 2016.
November 9, 2016 LABORATORY SERVICES Attachment A Page 3
EFFECTIVE DATE
POLICY # 08-02 ONCOTYPE DX TM BREAST CANCER ASSAY November 9, 2016
DESCRIPTION
Oncotype DXTM predicts the 10-year risk of distant recurrence and the likelihood of chemotherapy benefit in
women with ER-positive, HER2-negative, early stage invasive breast cancer. The application of gene expression
profiling using Oncotype DX TM is employed to identify patients who are predicted to obtain the most therapeutic
benefit from adjuvant Tamoxifen and may not require adjuvant chemotherapy. The Oncotype DX TM uses reverse
transcription polymerase chain reaction (RT-PCR) to determine the expression of a panel of 21 genes isolated
from formalin-fixed, paraffin-embedded tissue (FPET).
POLICY
The Oncotype DXTM is considered medically necessary for eligible participants with diagnosed breast cancer as a
prognostic assay to identify who is most likely to respond to systemic chemotherapy. The assay aids in identifying
patients who are predicted to obtain the most therapeutic benefit from adjuvant Tamoxifen and may not require
adjuvant chemotherapy.
PRIOR AUTHORIZATION: YES NO
COVERAGE AND LIMITATIONS:
Oncotype DX TM breast cancer assay is covered for individuals meeting the following criteria:
1. Patient has new diagnosed early stage (Stage 1 or Stage 2) breast cancer; and
2. The patient’s breast cancer meets all of the following criteria:
a. Unilateral non-fixed; and
b. Estrogen-receptor (ER) positive OR progesterone-receptor (PR) positive; and
c. Node-negative (isolated tumor cells and/or micrometastases [less than or equal to 2mm in size] i.e.
pNO(i+) and/or pN1(mi), are not considered positive for the purpose of this guideline) or has 1-3
involved ipsilateral axillary lymph nodes; and
d. Human epidermal growth factor receptor 2 (HER2)-negative; and
e. Tumor size is >.5 cm.
3. The Gene expression profile is ordered by the physician who will administer the hormonal and
chemotherapy, usually the oncologist, or the test is ordered by the treating surgeon after discussing the
patient’s clinical situation with the oncologist.
4. The assay is ordered within six months following diagnosis.
5. The results will be used to aid in making the decision regarding chemotherapy:
a. The recipient must be a candidate for chemotherapy or be treated with adjuvant endocrine therapy,
e.g. Tamoxifen.
November 9, 2016 LABORATORY SERVICES Attachment A Page 1
EFFECTIVE DATE
POLICY # 08-02 ONCOTYPE DX TM BREAST CANCER ASSAY November 9, 2016
Frequency is limited to once in a lifetime.
1. May be billed more than once for the same recipient if the provider can prove that the recipient has a new
secondary primary breast cancer that meets the criteria listed.
REFERENCES
CMS local coverage determination (LCD) Gene expression profiling panel for use in the management of breast
cancer treatment available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=33586&ver=6&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&C
ptHcpcsCode=81519&bc=gAAAABAAAAAAAA%3d%3d&
November 9, 2016 LABORATORY SERVICES Attachment A Page 2
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
December 27, 2018
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: LYNNE FOSTER, CHIEF OF DIVISION COMPLIANCE /Lynne Foster/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 900 – PRIVATE DUTY NURSING
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 900 – Private Duty Nursing (PDN) are
being proposed to ensure compliance with federal requirements. Language restricting the provision
of services solely to the recipient’s place of residence has been removed. Language now allows
PDN to be provided in the recipient’s home or any setting where normal life activities occur.
Medical necessity for the PDN program was clarified and language was updated accordingly for
clarity and readability. Service limitations and prior authorization (PA) requirements for all PDN
services have also been added. Hours authorized will be the number of hours that are medically
necessary to support the skilled interventions required. The timeframe for ongoing authorizations
was changed. The chapter now requires ongoing authorizations be submitted at least 10 days prior
to the end of the authorization period, versus 15 days, to align with Chapter 1400 – Home Health
Agencies ongoing authorization timeframe.
PDN definitions have been moved to the MSM Addendum. MSM Addendum Sections C and I are
being proposed to revise language regarding the definition of Concurrent Care and add language
regarding the definition of Immediate Relative.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: Providers of skilled nursing services in the community setting,
including, but not limited to Home Health Agencies and Private Duty Nursing (Provider Type (PT)
29).
Financial Impact on Local Government: No financial impact is anticipated for local government.
These changes are effective December 28, 2018.
Page 1 of 5
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 21/18 MTL 10/03, 22/07, 22/08
MSM Chapter 900 – Private Duty Nursing MSM Chapter 900 – Private Duty Nursing
Background and Explanation of Policy Changes,
Manual Section Title Clarifications and Updates
Section
900 INTRODUCTION Language was updated and/or reworded for improved
readability and clarity.
901 AUTHORITY Added new language “any setting where normal life
activities occur.” to align with federal requirements.
902 DEFINITIONS Deleted this section. Added reference to MSM
Addendum.
903.1 POLICY STATEMENT Clarified language for PDN program. Added language
to define “continuous,” “complex” and “substantial.”
Added new language, PDN is not intended for 24-
hour care.
903.1A(1) PROGRAM Deleted Subsection (b) regarding “legally responsible
ELIGIBILTY adult providing care” and clarified language in
CRITERIA Subsection (c) to align with federal requirements.
903.1A(2) COVERED SERVICES “Tracheotomy” was replaced with “tracheostomy” for
accurate medical terminology. Replaced “to remain at
home” with “prevent institutionalization.” Language
was updated and/or reworded for improved
readability and clarity.
903.1A(3) MEDICAL CRITERIA Section renamed “MEDICAL NECESSITY.” Deleted
Skilled Nursing Need Categories within section.
Examples of “skilled nursing interventions” updated
for accurate medical terminology. Defined “BID” as
twice per day for clarity. Added language for “Non-
invasive” ventilation. “Decision Guide” section
deleted. Language was updated and/or reworded for
improved readability and clarity.
903.1A(4) NON-COVERED Added new language regarding “non-skilled
SERVICES interventions which are custodial in nature” and
included examples. New “Legally Responsible
Individual (LRI)” was added to align with other MSM
policy definitions. Language was updated and/or
reworded for improved readability and clarity.
Page 2 of 5
Background and Explanation of Policy Changes,
Manual Section Title Clarifications and Updates
Section
903.1B PROVIDER Language added to state provider compliance with all
RESPONSIBILITIES Chapter 900 language, MSM Chapter 100 and any and
all state and federal regulations. Added Social Security
Act reference. Added new language “any setting
where normal life activities occur.” to align with
federal requirements. “Termination of Services”
section updated for clarity and readability regarding
“Immediate Termination” and “Advanced
Termination” of services. Throughout the section
“patient” is replaced with “recipient” where
appropriate and language was updated or reworded for
clarity.
903.1C RECIPIENT Language was updated and/or reworded for improved
RESONPNSIBILITIES readability and clarity.
903.1D AUTHORIZATION Section renamed “AUTHORIZATION PROCESS.”
PROCESS AND Clarifying language added for authorized hours for
REIMBURSEMENTS recipients with new tracheostomy. Service hours may
be increased to 84 hours per week. Clarifying
language added for authorized hours for recipients
with a new ventilator. Service hours may be increased
to 112 hours per week for an eight week interval.
Language added to section for Early and Periodic
Screening, Diagnostic and Treatment (EPSDT)
services, reference to MSM Chapter 1500 for
authorization process.
Third Party Liability language deleted as it is
duplicative to previous section earlier in Chapter.
Section 903.1D(d) deleted, as holiday hour
reimbursement is no longer applicable. Durable
Medical Equipment changed to Durable Medical
Equipment Prosthetics, Orthotics and Supplies
(DMEPOS), reference to MSM Chapter 1300 for
DMEPOS policy and provider billing guide for clarity
added. Section 903.1D(e) “REIMBURSEMENT”
moved to end section of the chapter and renumbered.
Ongoing authorization timeline changed from 15 days
to 10 days for consistency with processing
timeframes. Clarifying language added to “RETRO
AUTHORIZATIONS” regarding services provided
while Prior Authorization (PA) requests are
“pending.”
Page 3 of 5
Background and Explanation of Policy Changes,
Manual Section Title Clarifications and Updates
Section
Ongoing authorization language clarified. Language
added to authorization process and ongoing
authorizations PDN acuity grid must be completed.
PDN acuity grid is used to determine if PDN services
are medically necessary and to authorize the number
of hours required. For ongoing authorization of hours
for recipients with a new tracheostomy or ventilator,
clinical documentation must be submitted.
903.2A COVERAGE AND Section renamed to “24 HOUR CARE COVERAGE
LIMIATIONS AND LIMITATIONS” for clarity.
903.2B PROVIDER Section renamed to “24 HOUR CARE PROVIDER
RESPONSILBITIES RESPONSIBLITIES” for clarity.
903.2C RECIPIENT Section renamed to “24 HOUR CARE RECIPIENT
RESPONSIBILITES RESPONSIBLITIES” for clarity.
903.2D AUTHORIZATION Section renamed to “24 HOUR CARE
PROCESS AUTHORIZATION PROCESS” for clarity.
903.3 CONCURRENT CARE “Multiple” replaced with “up to three” for more
concise definition.
903.3A PROVIDER Section renamed to “CONCURRENT CARE
RESPONSIBILITIES PROVIDER RESPONSIBILITIES” for clarity.
903.4 OUT-OF-STATE Language added to section Out-of-State Services in
SERVICES which a PA is required by the QIO-like vendor.
903.4A COVERAGE AND Section renamed to “OUT-OF-STATE COVERAGE
LIMITATIONS AND LIMITATIONS.” Language added regarding
service limitation of 30 days and ongoing
authorizations after the initial out-of-state
authorization period must be prior authorized by the
QIO-like vendor. Language from MSM 100 added to
section to define locality for clarity.
903.4B PROVIDER Section renamed to “OUT-OF STATE PROVIDER
RESPONSIBILITIES RESPONSIBLITIES” for clarity.
903.4C RECIPIENT Section renamed to “RECIPIENT
RESPONSBILITIES RESPONSIBLITIES FOR OUT-OF-STATE
SERVICES” for clarity.
Page 4 of 5
Background and Explanation of Policy Changes,
Manual Section Title Clarifications and Updates
Section
903.5A COVERAGE AND Section renamed to “CRISIS OVERRIDE
LIMITATIONS COVERAGE AND LIMITATIONS” for clarity.
903.5B PROVIDER Section renamed to “CRISIS OVERRIDE
RESPONSIBLITIES PROVIDER RESPONSIBLITIES” for clarity.
Reference to previous chapter section corrected.
904 RATES AND Previously in Section 903.1(e), now a new stand-
REIMBURSEMENT alone section which refers to billing guide and
reimbursement code table for specific billing codes
and reimbursements.
905 HEARINGS Manual section renumbered.
906 REFERENCES AND Section deleted.
CROSS REFERENCES
Page 5 of 5
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
PRIVATE DUTY NURSING
900 INTRODUCTION ...................................................................................................... 1
901 AUTHORITY ............................................................................................................. 1
902 DEFINITIONS ............................................................................................................ 1
903 POLICY ...................................................................................................................... 1
903.1 POLICY STATEMENT ............................................................................................. 1
903.1A COVERAGE AND LIMITATIONS .......................................................................... 1
903.1B PROVIDER RESPONSIBILITIES ............................................................................ 4
903.1C RECIPIENT'S RESPONSIBILITIES ....................................................................... 10
903.1D AUTHORIZATION PROCESS ............................................................................... 13
903.2 24 HOUR CARE....................................................................................................... 16
903.2A 24-HOUR COVERAGE AND LIMITATIONS ....................................................... 16
903.2B 24-HOUR PROVIDER RESPONSIBILITIES ......................................................... 16
903.2C 24-HOUR CARE RECIPIENT RESPONSIBILITIES ............................................. 16
903.2D 24-HOUR CARE AUTHORIZATION PROCESS .................................................. 17
903.3 CONCURRENT CARE ............................................................................................ 17
903.3A CONCURRENT CARE PROVIDER RESPONSIBILITIES ................................... 17
903.4 OUT-OF-STATE SERVICES .................................................................................. 17
903.4A OUT-OF-STATE COVERAGE AND LIMITATIONS ........................................... 17
903.4B OUT-OF-STATE PROVIDER RESPONSIBILITIES ............................................. 18
903.4C RECIPIENT RESPONSIBILITIES FOR OUT-OF-STATE SERVICES ................ 18
903.5 CRISIS OVERRIDE ................................................................................................. 19
903.5A CRISIS OVERRIDE COVERAGE AND LIMITATIONS ...................................... 19
903.5B CRISIS OVERRIDE PROVIDER RESPONSIBILITIES ........................................ 19
904 RATES AND REIMBURSEMENT ........................................................................... 1
905 HEARINGS ................................................................................................................ 1
MTL 21/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 900
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
900 INTRODUCTION PRIVATE DUTY NURSING
Private duty nursing (PDN) is an optional benefit offered under the Nevada Medicaid State Plan.
PDN provides more individual and continuous care than is available from a visiting nurse for
recipients who meet specified criteria and require more than four continuous hours of skilled
nursing (SN) care per day. The intent of private duty nursing is to assist recipients with complex
direct skilled nursing care, to develop caregiver competencies through training and education and
to optimize recipient health status and outcomes. PDN may be authorized for recipients needing
both a medical device to compensate for the loss of a vital body function and substantial, complex
and continuous SN care to prevent institutionalization.
PDN services may be provided, within program limitations, to a recipient in his/her home or in
settings outside the home wherever normal life activities take place. Services are authorized based
on medical necessity, program criteria, utilization control measures and the availability of the state
resources to meet recipient needs.
All Medicaid policies and requirements are the same for Nevada Check Up, except for areas where
Medicaid and Nevada Check Up policies differ as documented in Medicaid Services Manual
(MSM) Chapter 3700.
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Subject:
MEDICAID SERVICES MANUAL AUTHORITY
901 AUTHORITY
Social Security Act (SSA) Sections 1814(a)(2)(c), 1835(a)(2)(a) and 1905(a)(8).
42 CFR 440.80 PDN services.
PDN services mean nursing services for recipients who require more individual and continuous
care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital
or skilled nursing facility. These services are provided:
A. By a registered nurse or a licensed practical nurse;
B. Under the direction of the recipient’s physician; and
C. At the State’s option, to a recipient in one or more of the following locations:
1. In the recipient’s home or any setting where normal life activities occur;
2. A hospital; or
3. A nursing facility
Nevada Medicaid has opted to provide PDN in the recipient’s home or any setting where normal
life activities take place.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 902
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
902 DEFINITIONS
Program definitions can be found in the MSM Addendum.
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Section:
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Subject:
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903 POLICY
903.1 POLICY STATEMENT
The PDN benefit reimburses medically necessary and appropriate hourly nursing services by a
registered nurse (RN) or licensed practical nurse (LPN) under the supervision of an RN. PDN
services are not intended to provide 24-hour care. PDN may be authorized for recipients needing
both a medical device to compensate for the loss of a vital body function and substantial, complex
and continuous skilled nursing care to prevent institutionalization.
For purposes of the chapter, “Continuous” means nursing assessments requiring skilled
interventions to be performed at least every two to three hours during the Medicaid-covered PDN
shift. The recipient’s medical condition(s) and necessary skilled interventions must justify a shift
of at least four continuous hours. “Complex” means multifaceted needs requiring SN interventions.
Observation in the event an intervention is required is not considered complex skilled nursing and
shall not be covered as medically necessary PDN services. “Substantial” means there is a need for
interrelated nursing assessments and interventions. Interventions that do not require assessment or
judgment by a licensed nurse are not considered substantial.
Service hours are determined based on medical necessity and are not related to diagnoses of mental
illness (MI) or intellectual disability (ID).
903.1A COVERAGE AND LIMITATIONS
1. PROGRAM ELIGIBILITY CRITERIA
a. The recipient has ongoing Medicaid eligibility for services;
b. The services have been determined to meet the medical criteria for private duty
nursing; and
c. The service can be safely provided in the home or setting where normal life
activities take place.
2. COVERED SERVICES
a. PDN service may be authorized for recipients who need more continuous SN care
than can be provided in an intermittent skilled nurse visit through a home health
agency and whose care exceeds the scope of service that can be provided by a home
health aide or personal care attendant (PCA).
b. PDN services may be approved for up to 84 hours per week for new tracheostomy
recipients for the initial eight-week authorization the period immediately following
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discharge from the hospital.
c. PDN services may be approved for up to 112 hours per week for new ventilator
dependent recipients for the initial eight-week authorization period immediately
following discharge from the hospital.
d. PDN services may be approved for recipients who are chronically ill who require
extensive SN care to prevent institutionalization.
3. MEDICAL NECESSITY
PDN is considered medically necessary when a recipient requires the services of a licensed
RN or an LPN under the supervision of an RN to perform SN interventions to maintain or
improve the recipient’s health status. SN refers to assessments, judgments, intervention
and evaluation of interventions which require the education, training and experience of a
licensed nurse to complete. Services must be based on an assessment and supporting
documentation that describes the complexity and intensity of the recipient’s care and the
frequency of SN interventions. Services must be provided under the direction of a
physician and according to a signed plan of care.
Different SN intervention refers to distinct tasks that affect different body systems and
require separate SN knowledge. For example, care for a tracheostomy and care for total
parenteral nutrition (TPN) would be considered two different SN tasks. Related SN
interventions are tasks that are an intrinsic component of the SN task. For example,
suctioning is an integral part of tracheostomy care and would be considered one SN task.
a. Some examples of typical “SN interventions” include, but are not limited to, the
following:
1. Ventilator care.
2. Tracheostomy with related suctioning and dressing changes.
3. Non-invasive ventilation (NIV), i.e. CPAP or BiPAP, may be considered
SN interventions in the management of both acute and chronic respiratory
failure for recipients who are clinically unstable, and when the NIV is new.
Or within 60 days of the start of CPAP or BiPAP, and stability with use is
not yet established. Once NIV has been established for 60 days, if recipient
is clinically stable, then NIV is no longer considered a skilled nursing
intervention. CPAP or BiPAP for indications other than acute and chronic
respiratory failure is not considered a skilled nursing intervention.
4. TPN.
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5. Peritoneal dialysis.
6. Enteral feedings, and administration of medication, are considered a SN
task when associated with complex medical problems or with medical
fragility of the recipient.
7. Complex medication administration – six or more prescription medications
on different frequency schedules or four or more medications requiring
close monitoring of dosage and side effects.
8. Continuous oxygen administration, with a pulse oximeter and a documented
need for observation and adjustments in the rate of oxygen administration.
9. Multiple sterile complex dressing change required at least twice per day.
The dressing change must be separate from other SN interventions such as
changing a tracheostomy site dressing when associated with tracheostomy
care.
Additional skilled interventions not listed here may be considered in determining
the intensity of SN needed.
4. NON-COVERED SERVICES
The following services are not covered benefits under the PDN program and are therefore
not reimbursable:
a. Services provided to recipients that are ineligible for Medicaid.
b. Non-skilled nursing interventions which are custodial in nature. Some examples of
typical “non-skilled nursing interventions” include, but are not limited to, the
following:
1. Administration of nebulized medications
2. Application and removal of orthotic braces
3. Application of chest vest and use of cough assist device(s)
While a PDN may perform such tasks, there must be an additional need for
interventions that do require the assessment and/or judgment of a licensed nurse.
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c. Services provided by a legally responsible individual (LRI) or immediate family
member. No reimbursement is made for services provided by an immediate relative
or LRI.
d. Services provided to a recipient who is a resident in a hospital, skilled nursing
facility including a nursing facility for the mentally ill (NF/MI) or intermediate care
facility for the Individuals with Intellectual Disabilities (ICF/IID) or at institution
for the treatment of mental health or chemical addiction.
e. Services rendered at school sites responsible for providing “school-based health
service” pursuant to IDEA 34 Code of Federal Regulations (CFR)§300.24.
f. Services provided to someone other than the intended recipient.
g. Services that Nevada Medicaid determines could reasonably be performed by the
recipient.
h. Services provided without authorization.
i. Services that are not on the approved plan of care (POC).
j. Service requests that exceed program limits.
k. Respite care.
l. Companion Care, baby-sitting, supervision or social visitation.
m. Homemaker services.
n. Medical Social Services (MSS).
o. Duplicative services, such as personal care services (PCS) that are provided during
private duty nursing hours.
p. Travel time to and from the recipient’s residence.
q. Transportation of the recipient by the private duty nurse.
903.1B PROVIDER RESPONSIBILITIES
The provider shall furnish qualified RNs and/or LPNs, under the supervision of a registered nurse
to assist eligible Medicaid recipients with complex skilled nursing tasks as identified in the
physician’s written POC. Services are to be provided as specified in this Chapter and must meet
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the conditions of participation as stated in MSM Chapter 100. The provider must comply with all
local, state and federal regulations, and applicable statutes, including but not limited to Federal
Law Section 1905(a)(8) of the SSA.
1. PROVIDER QUALIFICATIONS
The provider must be enrolled as a Medicare certified Home Health Agency (HHA),
licensed and authorized by State and Federal Laws to provide health care in the home.
2. MEDICAID ELIGIBILITY
The provider must verify, each month, continued Medicaid eligibility for each recipient.
This can be accomplished by viewing the recipient’s Medicaid Identification card,
contacting the eligibility staff at the welfare office hot line or utilizing the electronic
verification system (EVS). Verification of Medicaid eligibility is the sole responsibility of
the provider agency.
3. PHYSICIAN ORDER AND PLAN OF CARE
The provider must provide PDN services initiated by a physician’s order and designated in
the POC which is documented on a CMS 485. The POC is a written set of medical orders
signed by the physician which certify the specific HHA services that will be provided, the
frequency of the services and the projected time frame necessary to provide such services.
The POC is reviewed by the physician every 60 days. A new POC is required when there
is a change in the recipient’s condition, change in orders following hospitalization and/or
change in the ordering physician.
4. PRIOR AUTHORIZATION
The provider must obtain prior authorization for all PDN services prior to the start of care.
Refer to the authorization process 903.1D.
5. THIRD PARTY LIABILITY (TPL)
The provider must determine, on admission, the primary payor source. If Medicaid is not
the primary payor, the provider must bill the third-party payor before billing Medicaid. The
provider must also inform the recipient orally and in writing of the following:
a. The extent to which payment may be expected from third-party payors; and
b. The charges for services that will not be covered by third-party payors; and
c. The charges that the recipient may have to pay.
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6. PLACE OF SERVICE
The provider must provide PDN service in the recipient’s place of residence or in any
setting where normal life activities take place. School sites are excluded as a matter of
special education law (IDEA 34 CFR§300.24).
7. CASE INITIATION
A referral from physicians, discharge planners or recipient triggers the process for PDN
hours.
The provider should make an initial visit to the recipient’s home or to the hospital to
complete an evaluation to determine if the recipient is appropriate for PDN hours and if
they can accept the case. During this visit the provider must:
a. Complete a nursing assessment, using a CMS Outcome and Assessment
Information Set (OASIS) form for recipients age 21 or older or age-appropriate
evaluation;
b. Complete a Nevada Medicaid PDN prior authorization (PA) form and physician’s
POC using the CMS 485 Form; and
c. Establish the safety of the recipient during the provision of services.
If the provider determines the recipient is not appropriate for PDN services or they cannot
accept the case, the provider must contact the Nevada Medicaid District Office Care
Coordinator and inform them of the reason the service cannot be delivered.
If the provider is able to initiate service, all required documents should be submitted to the
Quality Improvement Organization (QIO)-like vendor.
8. CONFIDENTIALITY
The provider must ensure the confidentiality of recipient records and other information,
such as the health, social, domestic and financial circumstances learned in providing
services to recipients.
The provider shall not release information related to recipients without written consent
from the recipient or the recipient’s legal representative, except as required by law.
Providers meeting the definition of a “covered entity” as defined in the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Regulations (45 CFR 160) must
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Subject:
MEDICAID SERVICES MANUAL POLICY
comply with the applicable Privacy Regulations contained in 45 CFR 160, 162 and 164 for
recipient health information.
9. NOTIFICATION OF SUSPECTED ABUSE/NEGLECT
The Division expects that all Medicaid providers are in compliance with all laws relating
to incidences of abuse, neglect or exploitation.
a. CHILD ABUSE
State law requires that certain persons employed in certain capacities must make a
report to a child protective services agency or law enforcement agency
immediately, but in no event later than 24 hours after there is reason to suspect a
child has been abused or neglected.
For minors under the age of 18, the Division of Child and Family Services or the
appropriate county agency accepts reports of suspected abuse.
Refer to Nevada Revised Statutes (NRS) 432B regarding child abuse or neglect.
b. ELDER ABUSE
For adults aged 60 and over, the Aging and Disability Service Division accepts
reports of suspected abuse, neglect or self-neglect, exploitation or isolation.
Refer to NRS 200.5091 regarding elder abuse or neglect.
c. OTHER AGE GROUPS
For all other individuals, contact social services and/or law enforcement agencies.
10. RECIPIENT RIGHTS
The governing body of the provider agency has an obligation to protect and promote the
exercise of the recipient rights. A recipient has the right to exercise his/her rights as a
recipient of the provider. A recipient’s family or guardian may exercise a recipient’s rights
when a recipient has been judged incompetent. The recipient has the right to be notified in
writing of his rights and obligations before treatment is begun. HHAs must provide each
recipient and family with a written copy of the bill of rights. A signed, dated copy of the
recipient’s bill of rights will be included in the patient’s medical record. Refer to recipient
rights later in this chapter.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 903
Subject:
MEDICAID SERVICES MANUAL POLICY
11. ADVANCE DIRECTIVES
The provider must provide the recipient or parent/legal guardian with information
regarding their rights to make decisions about their health care, including the right to
execute a living will or grant a power of attorney to another individual, per 42 CFR
489.102, Patient Self Determination Act (Advance Directives).
HHA’s must also:
a. Provide written information to the recipient(s) at the onset of service concerning an
individual’s right under Nevada state law, NRS 449, to make decisions concerning
medical care, including the right to accept or refuse medical or surgical treatment
and the right to formulate Advance Directives;
b. Inform recipients about the agency’s policy on implementing Advance Directives.
c. Document in the individual’s medical record whether or not the individual has
executed an Advance Directive.
d. Ensure compliance with the requirements of NRS 449 regarding Advance
Directives at agencies of the provider or organization.
e. Provide (individually or with others) education to staff and the community on issues
concerning Advance Directives.
f. Not discriminate against a recipient based on whether he or she has executed an
Advance Directive.
12. NON-DISCRIMINATION
The provider must act in accordance with federal rules and regulations and may not
discriminate unlawfully against recipients based on race, color, national origin, sex,
religion, age, disability or handicap (including AIDS or AIDS-related conditions).
13. COMPLAINT RESOLUTION
The provider must respond to all complaints in a reasonable and prompt manner. The
provider must perform recipient/provider problem solving and complaint resolution.
a. The provider must maintain records that identify the complaint, the date received
and the outcome.
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b. The provider must submit documentation regarding the complaint to Nevada
Medicaid Central Office (NMCO) immediately upon request.
14. TERMINATION OF SERVICES
a. IMMEDIATE TERMINATION
The provider may terminate PDN services immediately for the following reasons:
1. The recipient or other persons in the household subjects the skilled nurse to
physical or verbal abuse, sexual harassment and/or exposure to the use of
illegal substances, illegal situations or threats of physical harm.
2. The recipient is ineligible for Medicaid.
3. The recipient requests termination of services.
4. The place of service is considered unsafe for the provision of PDN services;
5. The recipient is admitted to an acute hospital setting or other institutional
setting.
b. ADVANCE NOTICE TERMINATION
The provider must provide at least five calendar days advance written notice to
recipients when PDN services are terminated for the following reasons:
1. The recipient or caregiver refuses to comply with the physician’s POC.
2. The recipient or caregiver is non-cooperative in the establishment or
delivery of services.
3. The recipient no longer meets the criteria for PDN services.
4. The recipient refuses service of a skilled nurse based solely or partly on the
race, religion, sex, marital status, color, age, disability or national origin.
5. The provider is no longer able to provide services as authorized (i.e. no
qualified staff).
Note: A provider’s inability to provide services for a specific recipient does not
constitute termination or denial from Nevada Medicaid’s PDN program. The
recipient may choose another provider.
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Note: The nurse provider must comply with Nevada Administrative Code (NAC)
632 (the Nurse Practice Act) regarding patient abandonment.
c. NOTIFICATION REQUIREMENTS
The provider must notify the recipient and all other appropriate individuals and
agencies when services are to be terminated. The QIO-like vendor should be
notified by telephone within two working days. The provider should submit written
documentation within five working days.
The provider will send a written notice which advises the QIO-like vendor of an
effective date of the action of the termination of service, the basis for the action and
intervention/resolution attempted prior to terminating services.
15. RECORDS
The provider must maintain medical records which fully disclose the extent and nature of
the service provided to the recipient and which supports fees or payments made. Medical
and financial records and all other records provided must be maintained for an interval of
not less than six years. Following HIPAA Privacy Regulations contained in 45 CFR 160
and 164, the provider must make records available upon request to the Division.
903.1C RECIPIENT’S RESPONSIBILITIES
The recipient or personal representative shall:
1. Provide the HHA with a valid Medicaid card at the start of service and each month
thereafter.
2. Provide the HHA with accurate and current medical information, including diagnosis,
attending physician, medication regime, etc.
3. Notify the HHA of all third-party insurance information, including the name of other third-
party insurance, such as Medicare, TRICARE, Workman’s Compensation or any changes
in insurance coverage.
4. Inform the HHA of any other home care benefit that he/she is receiving through state plan
services, such as PCS, intermittent HHA skilled nursing or therapy services. Services
provided through another agency or program such as respite, case management or
participation in a Waiver program should also be identified.
5. Have a primary LRI, who accepts responsibility for the individual’s health, safety and
welfare. The LRI must be responsible for the majority of daily care in a 24-hour interval.
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6. Have an identified alternate LRI or a backup plan to be utilized if the primary LRI and/or
the provider are unable to provide services. The PDN nurse provider is not an alternate
caregiver with legal authority.
7. Have written emergency plans in place. The caregiver/parent should inform the provider
of an alternate caregiver and/or with a plan that indicates his/her wishes if the responsible
caregiver became ill or disabled and is unavailable to provide care for any other.
8. Cooperate in establishing the need for and the delivery of services.
9. Have necessary backup utilities and communication systems available for technology
dependent recipients.
10. Comply with the delivery of services as outlined in the POC.
11. Sign the PDN visit forms to document the hours and the services that were provided.
12. Notify the provider when scheduled visits cannot be kept or services are no longer required.
13. Notify the provider of unusual occurrences of complaints regarding the delivery of services
and of dissatisfaction with specific staff.
14. Give the provider agency a copy of an Advance Directive, if applicable.
15. Not request the provider agency staff to work more hours than authorized or to change the
days/hours approved.
16. Not request the provider agency staff to provide care to non-recipients or to provide service
not on the POC (babysitting, housekeeping tasks, etc.).
17. Not subject the provider or Division staff to physical and/or verbal abuse, sexual
harassment, exposure to the use of illegal substances, illegal situations or threats of physical
harm.
18. Not refuse service of a provider based solely or partly on the provider’s race, religion, sex,
marital status, color, age, disability and/or national origin.
RECIPIENT RIGHTS
Every Medicaid recipient, their LRI, legal guardian or authorized representative is entitled to
receive a statement of “Recipient Rights” from their provider. The recipient should review and
sign this document. The recipient’s rights should include the following:
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1. A recipient has the right to courteous and respectful treatment, privacy and freedom from
abuse and neglect.
2. A recipient has the right to be free from discrimination because of race, religion, sex,
marital status, color, age, disability, national origin, sexual orientation and/or diagnosis.
3. A recipient has the right to have his property treated with respect.
4. A recipient has the right to confidentiality regarding information about his/her health,
social and financial circumstances and about what takes place in his home.
5. A recipient has the right to access information in his own record upon written request.
6. A recipient has the right to voice grievances regarding treatment or care that is or fails to
be furnished, or regarding the lack of respect for property by anyone who is furnishing
services on behalf of the HHA and must not be subjected to discrimination or reprisal for
doing so.
7. The recipient has the right to be informed of the provider’s right to refuse admission to, or
discharge any recipient whose environment, refusal of treatment or other factors prevent
the HHA from providing safe care.
8. The recipient has the right to be informed of all services offered by the agency prior to or
upon admission to the agency.
9. The recipient has the right to be informed of his condition in order to make decisions
regarding his home health care.
10. The recipient has the right to be advised, in advance, of the services that will be provided
and frequency of such services.
11. The recipient has the right to be advised, in advance, of any change in the plan of care
before the change is made.
12. The recipient has the right to participate in the development of the plan of care, treatment
and discharge planning.
13. The recipient has the right to refuse services or treatment.
14. The recipient has the right to request a Fair Hearing when disagreeing with Nevada
Medicaid’s action to deny, terminate, reduce or suspend service.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 903
Subject:
MEDICAID SERVICES MANUAL POLICY
903.1D AUTHORIZATION PROCESS
1. PRIOR AUTHORIZATION
PDN services must be prior authorized by the Nevada Medicaid QIO-like vendor, except
for mileage and initial assessments. The provider must submit all required PDN PA forms
to the QIO-like vendor.
The QIO-like vendor will review the request and supporting documentation for medical
necessity. The PDN PA form and supporting documentation will be used to determine
medical necessity and to qualify and quantify the appropriate number of PDN hours. Hours
authorized will be the number of hours that are medically necessary to support the skilled
interventions required. The QIO-like vendor will issue an authorization number for the
approved PDN service hours. Service hours cannot be initiated until the QIO-like vendor
has issued an authorization number. Hours authorized will be the number of hours that are
medically necessary to support the skilled interventions required. The PDN acuity grid is
used to determine if PDN services are medically necessary and to authorize the number of
hours required. The PDN acuity grid must be completed in its entirety, including all
signatures. Incomplete or unsigned forms will result in PA denial. All forms and
documentation must be submitted together. Failure to complete all sections of PDN acuity
grid or failure to provide all medical documentation to support the prior authorization
request may result in the number of PDN hours not being appropriately authorized.
New tracheostomy recipients may receive up to 84 hours per week, for the initial eight-
week authorization period immediately following discharge from the hospital.
New ventilator dependent recipients up to 112 hours per week, for the initial eight-week
authorization period immediately following discharge from the hospital.
A Medicaid recipient under 21 years of age may be eligible for additional authorized PDN
hours under Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Refer to
MSM Chapter 1500 Healthy Kids Program for EPSDT authorization process.
If a recipient does not meet medical necessity criteria for PDN, the PA will be denied. If
the request is for more hours than can be authorized according to program criteria, a Notice
of Decision (NOD) will be issued by the QIO-like vendor.
PDN services requested for a recipient enrolled in a Managed Care Organization (MCO)
must be prior authorized by the MCO. The MCO has sole responsibility for all decisions
related to the PDN service for MCO recipients.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
a. INITIAL EVALUATION VISIT
The initial evaluation visit does not require a PA from Nevada Medicaid or their
QIO-like vendor. During the visit the skilled nurse evaluator must complete a
nursing assessment using an OASIS or age appropriate tool. The nurse must
complete a Nevada Medicaid PDN PA form.
b. DISPOSABLE MEDICAL SUPPLIES
Disposable medical supplies require a PA request at the time of request for HHA
services and are to be listed on the Home Health Prior Authorization Form. Wound
care supplies will be authorized for the HHA for an initial ten-day period only.
Supplies will be authorized only for the specific procedure or treatment requested.
Refer to MSM Chapter 1300 regarding Durable Medical Equipment, Prosthetics,
Orthotics and Supplies (DMEPOS) policy and the provider billing guide.
c. MILEAGE
Actual mileage is reimbursed one way from the HHA/PDN office to the recipient’s
residence. Actual mileage should be listed on the PA request form to establish a
baseline for reimbursement.
2. ONGOING AUTHORIZATIONS
Requests for continuing PDN services must be submitted to the QIO-like vendor at a
minimum of 10 working days but no more than 30 days prior to the expiration date of the
existing authorization. The completed request must be submitted to the QIO-like vendor
along with a current nurse assessment and PDN assessment form. The QIO-like vendor
will review for appropriate number of hours based on program criteria and program
limitations. Hours authorized will be the number of hours that are medically necessary to
support the skilled interventions required. Hours may be reduced after the initial
authorization period based on a comprehensive review of the clinical documentation. The
PDN acuity grid is used to determine if PDN services are medically necessary and to
authorize the number of hours required. The PDN acuity grid must be completed in its
entirety, including all signatures. Incomplete or unsigned forms will result in prior
authorization denial. All forms and documentation must be submitted together. Failure to
complete all sections of PDN acuity grid or failure to provide all medical documentation
to support the PA request may result in the number of PDN hours not being appropriately
authorized.
An ongoing authorization request for 84 hours per week, after the initial eight-week
authorization period immediately following discharge from the hospital for a new
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Subject:
MEDICAID SERVICES MANUAL POLICY
tracheostomy, must include clinical documentation to support the continued need for 84
hours. If such clinical documentation is not included in the request, hours may be reduced.
An ongoing authorization request for 112 hours per week, after the initial eight-week
authorization period immediately following discharge from the hospital for a new
ventilator, must include clinical documentation to support the continued need for 112
hours. If such clinical documentation is not included in the request, hours may be reduced.
If a recipient does not meet medical necessity criteria for PDN, the PA will be denied. If
the request is for more hours than can be authorized according to program criteria, a Notice
of Decision (NOD) will be issued by the QIO-like vendor.
PDN services may be authorized for a maximum of six months.
3. ADDITIONAL AUTHORIZATIONS
a. School Break
During “planned breaks” of at least five consecutive school days (e.g. track break,
summer vacation), additional hours may be authorized within program limitations.
A separate authorization request should be submitted for the specific number of
hours requested beyond those already authorized.
b. Change in Condition/Situation
A new authorization must be requested when the recipient has a change of condition
or situation that requires either a reduction in PDN hours or an increase in PDN
hours. A completed prior authorization request (PAR) must be submitted to the
QIO-like vendor along with documentation supporting medical necessity and
program criteria.
4. RETRO AUTHORIZATIONS
a. A request for authorization of services provided to pending recipients may be made
retroactively, once Medicaid eligibility has been established. Medicaid may
authorize services retroactively for covered services within limitations of program
criteria. The PAR must include the date of determination of eligibility. Please note,
if the PA request is pending and services are provided, the provider is assuming
responsibility for PDN costs if the PA request is denied. A PA only approves
existence of medical necessity, not recipient eligibility.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 903
Subject:
MEDICAID SERVICES MANUAL POLICY
903.2 24-HOUR CARE
In the event an LRI is absent due to a medical need of the LRI, parent/guardian or authorized
representative, a Medicaid recipient under 21 years of age may be eligible to receive 24-hour care
at home through an EPSDT referral. Twenty-four-hour care must be prior authorized.
903.2A 24-HOUR COVERAGE AND LIMITATIONS
1. Twenty-four-hour care is limited to five days per calendar year;
2. No other legally responsible adult or caregiver is available to provide care;
3. Twenty-four-hour day care is medically necessary and placement in a facility would be
detrimental to the recipient’s health;
903.2B 24-HOUR PROVIDER RESPONSIBILITIES
1. The provider is responsible for requesting documentation that the primary caregiver or
family member is absent due to a medical need.
2. The provider must submit an EPSDT screening by a physician provider that the 24-hour
care is medically necessary and placement in a facility is detrimental to the recipient’s
health.
3. The provider needs to secure an authorization for disclosure from the LRI, parent/guardian
or authorized representative to provide documentation of absence due to a medical need.
Such information will be released to Nevada Medicaid or their designee for determination
of eligibility for this benefit.
All other policies found in Section 903.1B, Provider Responsibilities, of this chapter shall apply.
903.2C 24-HOUR CARE RECIPIENT RESPONSIBILITIES
1. The LRI must provide supporting documentation of the absence of the primary caregiver
due to medical need.
2. The LRI must pursue the availability of alternate caregivers to provide care during the
interval before requesting 24-hour care.
3. All other policies found in Section 903.1C, Recipient Responsibilities, of this chapter shall
apply.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
903.2D 24-HOUR CARE AUTHORIZATION PROCESS
1. The provider may request a verbal authorization of the QIO-like vendor if the need for such
service was unanticipated. A written request, along with supporting information should be
submitted as soon as possible thereafter, but no later than three working days after the
verbal request.
2. The provider agency must submit a PAR along with the EPSDT screening referral and
supporting documentation of the absence of a primary caregiver to the QIO-like vendor
prior to the provision of 24-hour coverage, if the need for such service was anticipated.
903.3 CONCURRENT CARE
Concurrent care allows for the provision of PDN service by a single nurse to more than one
recipient simultaneously. A single nurse may provide care for up to three recipients if care can be
provided safely. Concurrent care allows for authorized nursing hours to be collectively used for
the multiple recipients. Concurrent care allows for optimum utilization of limited skilled nurse
resources while providing safe skilled nursing care to Nevada Medicaid recipients. Concurrent
care must be prior authorized.
903.3A CONCURRENT CARE PROVIDER RESPONSIBILITIES
1. The provider shall evaluate and determine the safety of settings for the provision of
concurrent care.
2. The provider shall adjust requests for PDN hours when concurrent care is provided.
All policies found in Section 903.1 of this chapter shall apply.
903.4 OUT-OF-STATE SERVICES
PDN services are allowed out-of-state for Medicaid recipients absent from the state per (42 CFR
431.52). A PA is required for out-of-state services by the QIO-like vendor. Payment for services
furnished in another state are reimbursed to the same extent that Nevada would pay for service
provided within Nevada’s boundaries. Out-of-state PDN services are reimbursed at the rural rate.
903.4A OUT-OF-STATE COVERAGE AND LIMITATIONS
In addition to the policies described in Section 903.1A of this chapter, the following apply for out-
of-state. The authorization timeframe for out-of-state services is limited to no more than a 30-day
interval. For ongoing authorizations after the initial 30-day period the out-of-state provider must
contact the QIO-like vendor.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 903
Subject:
MEDICAID SERVICES MANUAL POLICY
Out-of-state services may be authorized when:
1. There is a medical emergency and the recipient’s health would be endangered if he were
required to return to the State of Nevada to obtain medical services;
2. The recipient travels to another state because the Division finds the required medical
services are not available in Nevada;
3. The Division determines that it is general practice for recipients in a particular locality to
use medical services in another state (e.g., Nevada counties that border other State lines);
a. Nevada residents living near state lines or borders may be geographically closer to
out-of-state providers than in-state providers for both primary and specialty care.
In such cases, covered medically necessary services may be routinely provided by
out-of-state providers in what the Division of Health Care Financing and Policy
(DHCFP) refers to as the “primary catchment areas.” Such services are treated the
same as those provided within the state borders for purposes of authorization and
transportation. Refer to the MSM 100 billing manual for catchment areas.
b. The same services that are covered within the state of Nevada are available for
payment for any qualified provider, in the catchment area, who is or will be enrolled
with the plan.
c. Nevada Medicaid does not pay for medical services rendered by health care
providers outside the United States.
4. The recipient is on personal business. Nevada Medicaid may reimburse for these services;
however, they will be limited to service hours currently authorized.
903.4B OUT-OF-STATE PROVIDER RESPONSIBILITIES
1. The out-of-state provider must contact provider enrollment at the Nevada Medicaid Central
Office (NMCO) to become enrolled as a Nevada Medicaid HHA provider.
2. The out-of-state provider must comply with all provisions identified in Section 903.1B.
903.4C RECIPIENT RESPONSIBILITIES FOR OUT-OF-STATE SERVICES
1. The recipient or their personal representative should contact HHA providers in the
geographic out-of-state region in which they wish service to be provided, to determine the
availability of Nevada Medicaid PDN service providers.
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Subject:
MEDICAID SERVICES MANUAL POLICY
2. The recipient should notify the out-of-state provider who is not a Nevada Medicaid
provider who is interested in becoming a provider to contact provider enrollment at
NMCO.
The recipient must comply with all the provisions identified in Section 903.1C of this chapter.
903.5 CRISIS OVERRIDE
The PDN benefit allows, in rare circumstances, a short-term increase of nursing hours beyond
standard limits in a crisis. A crisis is one that is generally unpredictable and puts the patient at risk
of institutionalization without the provision of additional hours.
903.5A CRISIS OVERRIDE COVERAGE AND LIMITATIONS
1. Additional services may be covered up to 20% above program limits.
2. Additional services are limited to one, 60-day interval in a three-year period (calendar
years).
903.5B CRISIS OVERRIDE PROVIDER RESPONSIBILITIES
The provider must contact the QIO-like vendor with information regarding the crisis situation and
need for additional hours.
All other policies as discussed in Section 903.1B.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 904
Subject:
MEDICAID SERVICES MANUAL RATES AND REIMBURSEMENT
904 RATES AND REIMBURSEMENT
Refer to the provider billing guide for instructions and the reimbursement code table for specific
billing codes.
December 28, 2018 PRIVATE DUTY NURSING Section 904 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 905
Subject:
MEDICAID SERVICES MANUAL HEARINGS
905 HEARINGS
Please reference Nevada MSM Chapter 3100 for the Medicaid Hearing process.
December 28, 2018 PRIVATE DUTY NURSING Section 905 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
February 23, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, HIPAA PRIVACY AND CIVIL RIGHTS OFFICER
/Jessica Kemmerer/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1000 – DENTAL
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1000 – Dental are being proposed to update the
American Dental Association’s (ADA) Dental Claim Form required for all prior authorization requests,
claims, adjustments, and voids. Currently, the ADA 2012 version is required. The Division of Health Care
Financing and Policy (DHCFP) proposes to allow the continued use of the ADA Dental Claim Form version
2012 and allow newer versions of this form. Additionally, the DHCFP is proposing to remove a duplication
of congenitally missing teeth, listed as part of the Medically Necessary Orthodontic Automatic Qualifying
Conditions.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and re-
arranging of sections was necessary.
Entities Financially Affected: This proposed change affects all Medicaid enrolled Provider Type (PT 22) –
Dentists, all specialties.
Financial Impact on Local Government: None.
These changes are effective February 24, 2021.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 05/21 MTL 14/20
MSM Chapter 1000 – Dental MSM Chapter 1000 – Dental
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1003.8(A)(2)(a) Orthodontics Coverage Removed duplicate medically necessary orthodontic
and Limitations automatic qualifying condition “a. Congenitally missing
teeth (excluding third molars) of at least one tooth per
quadrant.”
Page 1 of 2
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1003.8(D)(1) Authorization Process Removed duplicate medically necessary orthodontic
automatic qualifying condition “a. Congenitally missing
teeth (excluding third molars) of at least one tooth per
quadrant.”
1005.2 Forms Clarified 2012 or newer version of ADA dental claim form
required is for all prior authorization requests, claims,
adjustments, and voids.
Page 2 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
DENTAL
1000 INTRODUCTION ...........................................................................................................................1
1001 AUTHORITY ..................................................................................................................................1
1002 RESERVED.....................................................................................................................................1
1003 NEVADA MEDICAID POLICY ....................................................................................................1
1003.1 DIAGNOSTIC AND PREVENTIVE SERVICES (D0100 - D1999) .............................................1
1003.2 RESTORATIVE DENTISTRY SERVICES (D2000 - D2999) ......................................................2
1003.3 ENDODONTIC SERVICES (D3000 - D3999) ...............................................................................3
1003.4 PERIODONTIC SERVICES (D4000 - D4999) ..............................................................................3
1003.5 PROSTHODONTIC SERVICES (D5000 - D6999)........................................................................4
1003.6 DENTURE IDENTIFICATION EMBEDDING .............................................................................9
1003.7 ORAL SURGERY (D7000 - D7999) ............................................................................................10
1003.8 ORTHODONTICS (D8000 - D8999) ............................................................................................10
1003.9 ADJUNCTIVE GENERAL SERVICES (D9000 -D9999) ...........................................................19
1003.10 PERSONS 21 YEARS OF AGE AND OLDER............................................................................19
1003.11 SERVICES NOT COVERED BY MEDICAID ............................................................................20
1003.12 PHARMACY SERVICES .............................................................................................................21
1003.13 RESIDENTS OF INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH
INTELLECTUAL DISABILITIES (ICF/IID) ...............................................................................22
1003.14 PROVIDERS OUTSIDE NEVADA .............................................................................................22
1003.15 PAYMENT OF NON-COVERED SERVICES ............................................................................23
1003.16 SERVICES PROVIDED IN NURSING FACILITIES .................................................................23
1003.17 HOSPITAL/SURGICAL CENTERS ............................................................................................24
1003.18 MAXILLOFACIAL SURGERY AND OTHER PHYSICIAN SERVICES .................................26
1003.19 CONDITIONS FOR PARTICIPATION .......................................................................................27
1003.20 IMPROPER BILLING PRACTICE ..............................................................................................27
1004 HEARINGS .....................................................................................................................................1
1005 REFERENCES AND CROSS REFERENCES/FORMS ................................................................1
1005.1 CONTACTS ....................................................................................................................................1
1005.2 FORMS ............................................................................................................................................2
1005.3 DENTAL PERIODICITY SCHEDULE..........................................................................................2
1
MTL 14/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1000
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
1000 DENTAL
INTRODUCTION
The Nevada Medicaid Dental Services Program is designed to provide dental care under the
supervision of a licensed provider. Dental services provided shall maintain a high standard of
quality and shall be provided within the coverage and limitation guidelines outlined in this Chapter
and the Quality Improvement Organization-Like (QIO-Like) Vendor’s Billing Guide. All
Medicaid policies and requirements are the same for Nevada Check Up members, unless otherwise
specified in the Nevada Check Up Manual Chapter 1000.
Dentists, dental hygienists, public health endorsed dental hygienists and dental therapists
participating in Nevada Medicaid shall provide services in accordance with the rules and
regulations of the Nevada Medicaid program. Dental care provided in the Nevada Medicaid
program must meet prevailing professional standards for the community-at-large. Any dental
provider who undertakes dental treatment as covered by Nevada Medicaid must be qualified by
training and experience in accordance with the Nevada State Board of Dental Examiners rules and
regulations.
All materials and therapeutic agents used or prescribed must meet the minimum specifications of
the American Dental Association (ADA). All dental services, including without limitation,
examinations, radiographs, restorative and surgical treatment, as well as record keeping are to be
provided in accordance with current ADA guidelines and the ADA Code of Ethics, and are to be
coded according to the definitions and descriptions in the current ADA Code on Dental Procedures
and Nomenclature (CDT Code) manual. All dental services must conform to the statutes,
regulations and rules governing the practice of dentistry in the state in which the treatment takes
place.
Nevada Medicaid provides dental services for most Medicaid-eligible individuals under the age of
21 as a mandated service, a required component of the Early and Periodic Screening, Diagnosis
and Treatment (EPSDT) benefit. For Medicaid-eligible adults age 21 years and older, dental
services are an optional service as identified in this chapter and the Billing Guide documents
located at www.medicaid.nv.gov in Provider Type (PT) 22 Dentist.
Individuals under Age 21
Through the EPSDT benefits, individuals under the age of 21 receive comprehensive dental care
such as periodic and routine dental services needed for restoration of teeth, prevention of oral
disease and maintenance of dental health. The EPSDT program assures children receive the full
range of necessary dental services, including orthodontia when medically necessary and pre-
approved by the Nevada Medicaid QIO-like vendor.
Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing Guide) reflects
prior authorization requirements, covered CDT codes and service limitations. Prior authorization
April 1, 2020 DENTAL Section 1000 Page 1
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Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
(PA) is not required for most services covered under EPSDT, except when seeking medically
necessary services that are outside of what is covered in the benefit schedule. For example, a PA
request needs to be submitted for a child who needs cleanings every three months rather than the
six months allowed by current service limitations.
The EPSDT screening provider may refer children for dental services. However, such a referral is
not necessary if the parent otherwise elects to contact a Medicaid dental provider. The local
Medicaid District Office can direct the parent/guardian to local dental providers.
Individuals age 21 and older
Dental services for Medicaid-eligible adults who qualify for full Medicaid benefits receive
emergency extractions, palliative care and may also be eligible to receive prosthetic care
(dentures/partials) under certain guidelines and limitations as detailed in Section 1003.5 of this
chapter.
Pregnancy Related Services
Nevada Medicaid offers expanded dental services in addition to the adult dental services covered
for Medicaid-eligible pregnant women. These expanded pregnancy related services require a PA.
In order to reduce the risk of premature birth due to periodontal disease, pregnant women will be
allowed dental prophylaxes, fluoride varnish and certain periodontal and restorative services
during pregnancy. Refer to Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT
22 Billing Guide) for covered CDT codes, services limitations and PA requirements. Providers are
expected to refer to the American Dental Association for current clinical recommendations,
guidelines and contraindications for treatment of pregnant women, including the use of silver
diamine fluoride. Medical providers and/or Managed Care Organizations should provide a dental
referral when it is discovered that a recipient is pregnant. Dental providers should attach a copy of
the referral or provide a statement of pregnancy in the comment section of the ADA claim form
for any PA requests for pregnancy related dental services. Pregnancy related dental services are
discontinued on the date of delivery or termination of pregnancy, except services that were
authorized but not completed prior to the end of the pregnancy. An approved PA request for
pregnancy related dental services will be authorized from the date the request was received through
the expected delivery date, unless a shorter timeframe is requested by the provider. Services
authorized are honored through the time authorized on the prior authorization request, regardless
of whether the services have been started or not. Example: a pregnant woman is authorized for one
prophylaxis for the period of April 1st through September 30th. She gives birth on August 1st. The
woman has until September 30th to receive her prophylaxis.
April 1, 2020 DENTAL Section 1000 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1001
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
1001 AUTHORITY
Nevada Revised Statute (NRS) 631 – Dentistry and Dental Hygiene.
The State Plan of Nevada describes the amount, duration and scope of dental care and services
provided to the categorically needy in Attachments 3.1-A 10 and 3.1-A 12b.
The Centers for Medicare and Medicaid Services (CMS) state that necessary and essential dental
services are mandatory for all eligible Medicaid children under the Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) under the Social Security Act (SSA) 1905(r)(3). The Nevada
EPSDT program provides children with services that are in addition to those available to adult
recipients as cited in the Code of Federal Regulations (CFR) Title 42 Section 441.56.
February 3, 2017 DENTAL Section 1001 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL RESERVED
1002 RESERVED
August 1, 2015 DENTAL Section 1002 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1003
Subject:
MEDICAID SERVICES MANUAL POLICY
1003 NEVADA MEDICAID POLICY
Dentists, public health endorsed dental hygienists and dental therapists enrolled with Nevada
Medicaid are able to bill for services provided to Medicaid eligible recipients.
Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing Guide)
document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov in PT 22 Dentist
Billing Guide for a list of CDT codes detailing prior authorization requirements and service
limitations.
1003.1 DIAGNOSTIC AND PREVENTIVE SERVICES (D0100 – D1999)
The branch of dentistry used to identify and prevent dental disorders and disease.
The United States Preventive Services Task Force (USPSTF) is an independent, volunteer panel
of national experts in prevention and evidence-based medicine. Nevada Medicaid lists these
recommendations in Medicaid Services Manual (MSM) Chapter 600, Attachment A.
The USPSTF recommends application of fluoride varnish to primary teeth of all infants and
children starting at the age of primary tooth eruption, and oral fluoride supplementation starting at
six months of age for children whose water supply is fluoride deficient.
Nevada Medicaid promotes oral health by providing coverage for routine, periodic oral
examinations and preventive treatment, fluoride treatment and sealant application for children, in
accordance with the recommendations of the American Dental Association (ADA) and the
American Academy of Pediatric Dentists (AAPD) for the prevention of tooth decay and the
promotion of good oral health. Medicaid’s coverage for preventive services, for children, is guided
by the recommendations of the ADA and AAPD. Periodic dental examinations and routine
preventive treatment should begin with eruption of the first tooth and before the first birthday, and
should continue every six months or as recommended by the dentist. The examination includes
assessment of pathology and injuries, growth and development and caries risk assessment.
Anticipatory guidance/counseling should be an integral part of each dental visit. Counseling on
oral hygiene, nutrition/dietary practices, injury prevention and non-nutritive oral habits should be
included.
Nevada Medicaid authorizes payment of diagnostic and preventive dental services for qualified
recipients.
A. COVERAGE AND LIMITATIONS
Coverage is limited to EPSDT for persons less than 21 years of age. Coverage for persons
over 21 years of age is limited to diagnostic services needed for emergency extractions or
palliative care.
April 1, 2020 DENTAL Section 1003 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for
a list of covered CDT codes, prior authorization requirements and service limitations.
1003.2 RESTORATIVE DENTISTRY SERVICES (D2000 – D2999)
The branch of dentistry used to restore the integrity of the teeth through the use of fillings or
crowns.
Nevada Medicaid authorizes payment of restorative dentistry for qualified recipients.
A. COVERAGE AND LIMITATIONS
Restorative services are covered under EPSDT for persons less than 21 years of age.
For recipients age 21 years and older, with a PA, Nevada Medicaid reimburses for certain
fillings and crowns on teeth that are an abutment (anchor) tooth for that partial denture.
The ADA defines an abutment tooth as “a tooth used as a support for a prosthesis” (i.e.
partial denture). Nevada Medicaid also reimburses for palliative treatment for persons 21
years of age and older. Pregnancy related services and coverage are listed in the Nevada
Medicaid Dental Benefit Schedule (Attachment A of the PT 22 Billing Guide) found in the
QIO-like vendor’s web portal at www.medicaid.nv.gov.
Fillings are limited to the use of amalgam or tooth colored restorations.
Tooth preparation, acid etching, all adhesives (including bonding agents) liners and bases,
polishing and curing and occlusal adjustment of either the restored tooth or the opposing
tooth, is part of the amalgam restoration and must be included in the fee for the restoration.
If pins are used, they should be reported under the appropriate code.
Tooth colored restorations refers to a broad category of materials including, but not limited
to, self-curing composite, light-cured composite and glass ionomers. Tooth preparation,
acid etching, adhesives, bonding agents, liners, bases and curing are included as part of the
resin based composite restoration. If pins are used, they should be reported under the
appropriate code.
The ADA defines an Indirect Pulp Cap as a nearly exposed pulp that is covered with a
protective dressing to protect the pulp from additional injury and to promote healing. If the
pulp is exposed and the provider attempts to cover it in the hopes of avoiding further injury
to the nerve, that would be a Direct Pulp Cap (D3110). Placing a protective covering under
a deep filling to help avoid sensitivity or pulpal irritation is not a billable service and is
included in the restoration as a “liner.”
Crowns are limited to stainless steel and composite resin repairs.
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Reference the Nevada Medicaid Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for a list
of covered CDT codes, prior authorization requirements and service limitations.
1003.3 ENDODONTIC SERVICES (D3000 – D3999)
The branch of dentistry specializing in disease or injury that affects the root tips or nerves in the
teeth through the use of root canals.
Nevada Medicaid authorizes payment of endodontics for qualified recipients.
A. COVERAGE AND LIMITATIONS
Restorative services are covered under EPSDT for persons less than 21 years of age.
Reference the Nevada Medicaid Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov.
1003.4 PERIODONTIC SERVICES (D4000 – D4999)
The branch of dentistry used to treat and prevent disease affecting supporting bones, ligaments and
gums of the teeth.
Nevada Medicaid authorizes payment of periodontics for qualified recipients.
A. COVERAGE AND LIMITATIONS
1. Periodontic services are covered under EPSDT for persons less than 21 years of
age. Periodontal services for persons less than 21 years of age are limited to either
four quadrants of scaling and root planing every two years with a maximum of four
periodontal maintenance treatments annually or a maximum of two dental
prophylaxis treatments annually.
2. Medicaid carefully monitors for the appropriate use of the codes for periodontal
scaling and root planing. These codes are generally limited to recipients who are at
least 14 years old. Providers' in-office records must verify x-rays, periodontal
charting and diagnoses documenting the need for these procedures.
3. Periodontal scaling and root planing for pregnant recipients is a covered service
that requires a PA. Due to the risk of pregnancy gingivitis, Medicaid will cover a
second cleaning during pregnancy as well as 100% coverage of the treatment of
inflamed gums around wisdom teeth during pregnancy. Medical providers and/or
Managed Care Organizations should provide a dental referral when a recipient
becomes pregnant. Dental providers should attach a copy of the referral or provide
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a statement of pregnancy in the comment section of the ADA claim form to any PA
requests for pregnancy related dental services. Pregnancy related dental services
are discontinued on the date of delivery or termination of pregnancy, except for
services that were authorized but not completed prior to the end of the pregnancy.
4. Palliative treatment is covered for persons 21 years of age and older.
Medicaid also monitors for the appropriate use of the code for full mouth debridement.
This code is typically reserved for severe cases in which the licensed dental provider is
unable to complete an oral evaluation because the tooth surfaces are covered by thick
deposits of plaque and calculus. The full mouth debridement involves gross removal of the
prominent plaque and calculus deposits, making it possible for a licensed dental provider
to inspect the oral cavity for signs of decay, infection or gum disease. CDT Code D4355 is
a preliminary treatment that should be completed before the exam and should not occur on
the same day.
Reference the Nevada Medicaid Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for a list
of covered CDT codes, prior authorization requirements and service limitations.
1003.5 PROSTHODONTICS SERVICES (D5000 – D6999)
The branch of dentistry used to replace missing teeth or restore oral structure through the use of
partials, dentures, etc.
Nevada Medicaid provides payment benefits of certain prosthodontics for qualified recipients.
Emergency prosthetic repair refers to dental prosthetics that are rendered completely
unserviceable. Loose dentures or dentures with broken/missing teeth do not meet the intent of the
definition unless irritation is present and sufficiently documented. The dentist's in-office records
must substantiate the emergency for the purposes of Medicaid post-payment utilization review and
control.
A. COVERAGE AND LIMITATIONS
1. Partial dentures and full dentures may be provided when medically necessary to
prevent the progression of weight loss and promote adequate mastication. Medicaid
limits reimbursement of services to one new full or partial denture per five years.
Given reasonable care and maintenance, prostheses should last five years.
Education given by the dentist on the proper care of the prostheses is expected and
included in the purchase of any prosthetic service.
2. Medicaid will pay for necessary emergency x-rays required to diagnose Medicaid
covered removable prostheses. No PA is necessary for the initial comprehensive
examination and x-rays. The dentist's office records must substantiate the
recipient's medical necessity (e.g., x-ray evidence, reported significant loss of
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weight, sore and bleeding gums, painful mastication, etc.). Payment for the
examination and x-rays may be withdrawn if post-payment reviews of in-office
records do not substantiate the medical necessity. Payment for dentures or partials
includes any adjustments or relines necessary for six months after the date of
delivery.
3. A person qualifies for a partial denture if four or more teeth in sequence are missing
unilaterally, or four or more teeth are missing that would cause the person to have
difficulty with mastication.
A benefit when replacing permanent teeth is due to a lack of posterior balanced
occlusion. Lack of posterior balanced occlusion is defined as follows:
a. five posterior permanent teeth are missing, (excluding 3rd molars); or
b. all four 1st and 2nd permanent molars are missing; or
c. the 1st and 2nd permanent molars and a premolar are missing on the same
side.
Third molars are not considered in the qualification for dentures. Teeth anterior to
the third molars (including second molars) are considered in qualification for
dentures. For example, a partial would be appropriate for someone missing teeth
numbers 2, 3, 4 and 5 because these are four missing teeth in sequence. A partial
would be appropriate for someone missing teeth numbers 18, 19, 20 and 28 or 29
because the person would be expected to have difficulty with mastication. A partial
would not be appropriate for someone missing teeth numbers 19, 20 and 31 because
there are not enough teeth missing for significant difficulty with mastication.
4. Third molars are not replaceable as missing teeth nor are they considered in the
qualification for payment of partial dentures. Second molars are replaceable as
missing teeth with missing posteriors in the same quadrant as explained in the above
examples. A flipper may be used as a temporary replacement for employment
purposes when an anterior tooth is extracted. For healing purposes, a flipper may
be used temporarily when the partial for an anterior tooth will not be available for
greater than three months.
5. A person may also qualify for a partial when missing any one of the six upper or
lower anterior teeth (6, 7, 8, 9, 10, 11, 22, 23, 24, 25, 26 or 27) when necessary for
employment. A supportive written Division of Welfare and Supportive Services
(DWSS), New Employees of Nevada (NEON) report meets the employment
verification requirement. The NEON report must be maintained in the recipient’s
dental record for retrospective review.
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6. Requests to override the 5-year limitation on full and partial dentures will require a
PA and will only be considered for the following exceptional circumstances:
a. Dentures were stolen (requires a copy of the police report). Also under
consideration is if the theft is a repeatedly occurring event. The recipient
must exercise reasonable care in maintaining the denture.
b. Dentures were lost in a house fire (requires a copy of the fire report or other
notification documenting the fire such as a newspaper article).
c. Dentures were lost in a natural disaster (requires a copy of documentation
from Federal Emergency Management Agency (FEMA), the American Red
Cross or any other documentation indicating that the recipient’s residence
was in the area affected by the natural disaster).
d. Dentures no longer fit due to a significant medical condition. Requires
documentation regarding the supporting medical condition, such as a letter
from the recipient’s physician/surgeon supporting the medical need, and a
letter from the dentist stating that the existing denture cannot be made
functional by adjusting or relining it and that new dentures will be
functional. Providers and recipients cannot expect to receive approval for
replacement prosthesis without adequate justification and documentation.
e. Dentures could not be made functional by the issuing dentist. Requires a
letter from the recipient’s new dentist and the recipient. The dentist stating
that the existing denture cannot be made functional by adjusting or relining
it, the medical necessity for the new denture and that the new denture will
be functional. The recipient stating that they returned to the issuing dentist
requesting the denture be made functional and the issuing dentist was unable
to comply (see Section 1003.5.8). Providers and recipients cannot expect to
receive approval for replacement prosthesis without adequate justification
and documentation.
Process to request an override based on the above exceptional circumstances
requires PA. The provider must submit the following in the PA request:
f. A properly completed ADA claim form clearly marked “Request for
Denture Override”.
g. Copies of current radiographs when requesting an override for a partial
denture to a full denture.
h. Any supporting documentation listed in this section, as applicable.
i. A cover letter that clearly describes the circumstances of the case.
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j. These requests must be submitted electronically through Medicaid’s QIO-
like vendor’s web portal.
7. Medicaid will pay for a maximum of one emergency denture reline and/or
adjustment not more often than once every six months, with a maximum of six
relines or adjustments every five years, beginning six months after the date of
partial/denture purchase Denture/partial relines and adjustments required within the
first six months are considered prepaid with Medicaid’s payment for the prosthetic.
No prior approval is required for relines or adjustments. The provider’s in-office
records must substantially document the medical emergency need. Dentists should
search the recipient’s service history in the provider portal or call or write to the
fiscal agent to ensure the reline is not being done within six months of the date of
the last reline or new denture purchase. A claim submitted for a reline or adjustment
sooner than six months since the last payment for a reline or adjustment will deny
for payment. Post payment review will be done to assure that medical necessity of
the service has been substantially documented.
8. If the recipient is unable to wear the denture, the recipient must schedule an
appointment with the issuing dentist to have the denture/partial made functional.
Factors which would cause the denture to not be functional would include improper
fit, sore or bleeding gums and painful mastication. If the issuing dentist is unable
to make the denture functional, resulting in the recipient requiring services from
another dentist, a full or partial recoupment of payment may occur less the cost of
the laboratory services. When the issuing dentist receives a recoupment notice the
dentist must provide a copy of the invoice detailing the laboratory charges so that
it may be deducted from the recoupment amount. The requirements in Section
1003.6 are applicable if a dentist requests a new denture within a five year period.
B. PROVIDER RESPONSIBILITY
1. New dentures or partials (or their replacements every five years) must be evaluated
for medical necessity. Medicaid will pay for one comprehensive examination per
36 rolling months (Code D0150) in connection with new dentures or denture
replacements only. Dentists may bill the comprehensive examination charge at the
time of the comprehensive exam. Dentists may bill up to two additional exams
(D0140) for subsequent denture appointments. The claim for the prosthetic should
not be submitted to Nevada Medicaid prior to the delivery date.
2. Keep diagnosable, panoramic or full mouth x-rays as part of the dentist’s record for
all removable prosthetics. The x-rays and dentists office notes must substantiate all
missing teeth.
3. The recipient must sign and date a delivery receipt to verify that the
dentures/partials were received and are accepted and/or acceptable. The date of the
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signature on the delivery receipt must be the date the dentures/partials were
received by the recipient. The delivery receipt must include the recipient’s name,
quantity, detailed description of the time(s) delivered and the date and time of
delivery and be maintained in the recipient’s dental record. The delivery receipt is
a required attachment when submitting the claim for reimbursement through the
QIO-like vendor’s web portal. Claims cannot be submitted prior to the date of
delivery.
C. AUTHORIZATION REQUIREMENTS
1. PA is required for partials and/or full dentures for all recipients residing in Nursing
Facilities or receiving Hospice services. Reference Nevada Medicaid’s Dental
Benefit Schedule (Attachment A of the PT 22 Billing Guide) document located in
the QIO-like vendor’s web portal at www.medicaid.nv.gov for a list of covered
CDT codes, prior authorization requirements and service limitations.
2. Requests for partials and/or full dentures for all recipients residing in Nursing
facilities or receiving Hospice services must explain the significance of the medical
need. PA requests must include:
a. One letter each from the recipient’s primary care physician and dentist
documenting the recipient’s medical need for the service in considering
his/her total medical condition.
b. The below information must be included in the prior authorization request.
The information can be contained within the letter signed by the attending
physician, in a separate letter from the facility’s social worker or other
appropriate staff, included as documentation from chart notes, etc., or
provided in a combination. Include:
1. Current weight compared to the previous year (to determine whether
there has been fluctuation); and
2. Type of diet; and
3. Diagnosis; and
4. Mental status relating to the recipient’s ability to understand the use
and care of the partials and/or full dentures. If the recipient is unable
to care for the dentures, include details on who will care for them.
Any other factors relating to conditions that hinder effective
functioning, including but not limited to, impaired mastication,
muscular dysfunction, ability to swallow and reason for poor
nutrition. When documenting reason for poor nutrition, specify
whether this is related to dental structures or related to the recipient’s
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physical or medical condition, and whether the poor nutrition will
be improved with dentures.
3. No PA is required for partials and/or full dentures for all other recipients. Post
payment review will be completed at the discretion of the DHCFP with recoupment
of payment for any partials or full dentures not meeting the above policy for
qualification of coverage.
1003.6 DENTURE IDENTIFICATION EMBEDDING
Nevada Medicaid provides payment of denture identification embedding for qualified recipients.
A. COVERAGE AND LIMITATIONS
Any removable prosthetic appliance paid for by the Nevada Medicaid program must have
permanent identification labeling embedded in it as defined in NRS 631.375. All artificial
teeth, dentures or other removable dental appliances, at the time they are manufactured or
sent to a laboratory for repair, must be identified with the name or social security number
of the owner by:
1. Embedding the name or number in the material of the appliance;
2. Adding the name or number with an adhesive; or
3. Making the appliance in any manner consistent with advances in technology and
approved by the Board.
B. PROVIDER RESPONSIBILITY
Medicaid requires embedding of the recipient’s first initial, last name or the last four digits
of the social security number for complete dentures, partial dentures with acrylic saddles
and when relining unmarked appliances. In cases of insufficient room, you may reduce the
person’s name and identifiers to the first and second initials or the last four digits of the
social security number.
Code D5899 and descriptor “ID Embedding” must be completed by delivery unless the
prosthetics already show such markings and the provider so states.
C. AUTHORIZATION REQUIREMENTS
Nevada Medicaid does not require PA for ID embedding.
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1003.7 ORAL AND MAXILLOFACIAL SURGERY (D7000 – D7999)
The branch of dentistry using surgery to treat disorders/diseases of the mouth.
Nevada Medicaid authorizes payment of oral surgery for qualified recipients.
A. COVERAGE AND LIMITATIONS
1. Services are covered under EPSDT for persons less than 21 years of age. For
pregnant women and persons 21 years of age and older, services are covered as
emergency care or palliative treatment.
2. Tooth extraction coverage is limited to cases involving symptomatic teeth with
clinical symptoms and/or signs of pathology, including acute or chronic pain,
inflammation, infection or peri-radicular radiographic evidence of defect.
3. Elective tooth extractions are not covered by Medicaid. “Elective Tooth
Extraction” is the extraction of asymptomatic teeth, that is, teeth without symptoms
and/or signs of pathology. It includes the extraction of other asymptomatic teeth
without clinical evidence of pathology, including third molars (tooth numbers 1,
16, 17 and 32). The exception is extractions that are deemed medically necessary
as part of a prior authorized orthodontic treatment plan.
B. AUTHORIZATION REQUIREMENTS
No PA is necessary for most oral and maxillofacial surgery services under EPSDT and for
persons 21 years of age and older if the service is considered an emergency extraction or
palliative care.
Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing Guide)
document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for a list of
covered CDT codes, prior authorization requirements and service limitations.
1003.8 ORTHODONTICS (D8000 – D8999)
The branch of dentistry used to correct malocclusions (the "bite") of the mouth and restore it to
proper alignment and function.
Nevada Medicaid authorizes payment for orthodontics for qualified recipients under 21 years of
age when certain conditions are met that confirm medical necessity.
Diagnostic Code D0350 is considered to be an “Orthodontia” service only code when required for
Orthodontia treatment prior authorization. Nevada Medicaid reimburses for D0350 to
Orthodontists only, unless prior authorization is received through EPSDT.
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A. COVERAGE AND LIMITATIONS
1. Nevada Medicaid excludes orthodontic work, except that which is authorized by
Medicaid’s QIO-like vendor as medically necessary Nevada Medicaid has adopted
the automatic qualifying conditions list developed by the American Association of
Orthodontists’ (AAO) Committee on Medically Necessary Orthodontic Care. If a
recipient under age 21 does not meet the criteria for any of the AAO’s automatic
qualifying conditions, but the orthodontist finds there is a medical need for
orthodontic work as defined under Section 1003.8.D.2, services can be requested
under EPSDT.
2. Medically Necessary Orthodontic Automatic Qualifying Conditions are deemed
medically necessary and are qualified for reimbursement when it is part of a case
involving treatment of cranio-facial anomalies, malocclusions caused by trauma or
a severe malocclusion or cranio-facial disharmony that include, but are not limited
to:
a. Overjet equal to or greater than 9 millimeters.
b. Reverse overjet equal to or greater than 3.5 millimeters.
c. Anterior and/or posterior crossbite of three or more teeth per arch.
d. Lateral or anterior open bite equal to or greater than 2 millimeters; of four
or more teeth per arch.
e. Impinging overbite with evidence of occlusal contact into the opposing soft
tissue.
f. Impactions where eruption is impeded but extraction is not indicated
(excluding third molars).
g. Jaws and/or dentition which are profoundly affected by a congenital or
developmental disorder (craniofacial anomalies), trauma or pathology.
h. Two or more congenitally missing teeth (excluding third molars) of at least
one tooth per quadrant.
i. Crowding or spacing of 10 millimeters or more, in either the maxillary or
mandibular arch (excluding third molars).
Note: For conditions not listed above, providers may request orthodontic treatment
under the EPSDT “Healthy Kids Exception” by demonstrating medical need as
defined in Section 1003.8(D)(2).
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3. Prior to the Orthodontist requesting a PA for Orthodontic services, the following
criteria must be met:
a. the recipient must have received dental services by a referring dentist on at
least two occasions, on separate days; and
b. missed no more than 30 percent of any scheduled appointments, for any
reason on all Client Treatment History forms submitted.
c. The referring provider must provide the applicable dental appointment
history and not submit more than two years of dental appointment history.
When a recipient is unable to attend dental appointments for any reason, the
treatment plan could be jeopardized or caused to extend beyond the anticipated time
to complete the treatment, for which the Orthodontist is not reimbursed.
4. Orthodontia treatment is limited to once per a recipient’s lifetime for limited
transitional treatment (Dental Codes D8010, D8020 and D8040), and once per
lifetime for comprehensive orthodontic treatment (Dental Codes D8080 and
D8090). If treatment is discontinued for any reason, including the recipient’s non-
compliance, Medicaid will not authorize a second orthodontia treatment.
5. Medicaid reimburses for orthodontia services only to those providers enrolled with
Nevada Medicaid with the orthodontia specialty (PT 22 with Specialty Code 079).
B. PROVIDER RESPONSIBILITY
1. Only Dentists with a specialty of Orthodontia: PT 22 with the Specialty Code 079
will be reimbursed for orthodontic services. Payment for orthodontia covers the
length of treatment.
2. A copy of the Client Treatment History form must be completed by the recipient’s
treating general or pediatric dentist and is to be in the orthodontic PA request. The
treating orthodontist must complete a new Client Treatment History form when
requesting a PA for a second phase of orthodontic treatment.
3. Medicaid shall deny any orthodontic prior authorization requests when the attached
Client Treatment History form report does not show the recipient has a good history
of keeping dental appointments. “Good history “is defined as: missing no more than
30 % of scheduled appointments for any reason within a 24 month period or not
complying with dental care treatment plans, as evidenced by active carious lesions,
acute gingivitis, acute periodontitis, poor oral hygiene or other unresolved dental
factors that could result in poor orthodontic case success.
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4. Prior to the Orthodontist requesting a PA for Orthodontic services, the following
criteria must be met:
a. the recipient must have received dental services by a referring dentist on at
least two occasions, on separate days; and
b. missed no more than 30% of any scheduled appointments, for any reason
on all Client Treatment History forms submitted.
c. The referring provider must provide the applicable dental appointment
history and not submit more than two years of dental appointment history.
When a recipient is unable to attend dental appointments for any reason, the
treatment plan could be jeopardized, or could cause the treatment plan to extend
beyond the anticipated time to complete the treatment, for which the Orthodontist
is not reimbursed.
5. Coordination with Ancillary Dentists: The orthodontist and any ancillary dentists
must coordinate with each other to assure Medicaid will pay for the ancillary dental
services. For example, the orthodontist’s proposed treatment plan should show
he/she will be referring the child for extractions or other services. The ancillary
dentist need not obtain separate approval for his/her services.
a. Additionally, the treating orthodontist must coordinate with the recipient’s
general dentist, or provide in their own orthodontic practice, routine
cleanings and examinations according to the AAPD periodicity schedule.
6. A recipient may select a new Orthodontist if the recipient becomes dissatisfied with
the original Orthodontist or must geographically move before completion of the
treatment plan. When a recipient changes providers during active treatment, the
provider must comply with the following:
a. Acceptance of reimbursement by the Orthodontist is considered their
agreement to prorate and forward any unused portion of the reimbursement
to a Nevada Medicaid contracted Orthodontist, selected by the recipient, to
complete the treatment.
b. The originating provider must not release Medicaid funds to anyone other
than another Medicaid orthodontic provider who agrees to use the funds to
complete the approved treatment plan. No additional funds will be allocated
or approved to the new Orthodontist for the completion of the treatment.
Without such an agreement, the originating provider must return the unused
fund (see Section 8 below) to the Medicaid fiscal agent at the address listed
in Section 1005.1 of this chapter.
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c. Medicaid payment for orthodontic services includes the removal of any
banding and providing retainers at no additional cost to the recipient. The
Orthodontist accepts this responsibility as part of providing Medicaid
services.
7. Circumstances in which an Orthodontist may discontinue treatment:
a. Due to the recipients’ poor oral hygiene compliance, when identified and
documented by the Orthodontist; and/or
b. The recipient fails to contact the Orthodontist’s office within a four-month
period; and/or
c. The recipient has not kept at least one appointment within a six-month
period.
8. When treatment is discontinued due to any of the reasons listed above, the provider
must refund any unused portion of the reimbursement to the Medicaid Fiscal Agent
(address listed in Section 1005.1 of this chapter). The provider must contact the
Fiscal Agent to request a balance of the remaining funds which should be refunded.
The refund amount will be based on the approved treatment plan, the services
already rendered and the residual amount that will be refunded to the Fiscal Agent.
Any refunded unused funds are not available to be used for further or future
orthodontic treatment for that recipient.
9. The Orthodontist may not bill the recipient or Medicaid for additional charges on
broken bands, or other necessary services, even if the recipient’s poor compliance
or carelessness caused the need for additional services.
10. Providers must maintain a detailed, comprehensive, legible dental record of all
orthodontia treatment and care. Legible electronic dental records are acceptable.
C. RECIPIENT’S RESPONSIBILITIES
1. Prior to the Orthodontist requesting a PA for Orthodontic services, the following
criteria must be met:
a. the recipient must have received dental services by a referring dentist on at
least two occasions, on separate days; and
b. missed no more than 30% of any scheduled appointments, for any reason.
c. The recipient’s referring provider must provide the applicable dental
appointment history and not submit more than two years of dental
appointment history.
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2. The recipient is responsible for maintaining good oral hygiene on a regular basis,
as instructed by the Orthodontist and/or dentist, to maintain the orthodontia
treatment plan or orthodontic appliances received.
3. The recipient is responsible to attend all scheduled and follow-up appointments as
scheduled as part of the treatment plan.
4. The recipient is responsible for contacting the Orthodontic provider immediately
when they are going to miss any scheduled appointments, change providers, or
when they have a change in their eligibility status, or when they are moving out of
the area.
D. AUTHORIZATION PROCESS
1. Requests for orthodontic treatment must be prior authorized. The PA request must
include a completed Orthodontic Medical Necessity (OMN) form. To qualify for
authorization, the form must explain the significance of at least one of the following
Medically Necessary Orthodontic Automatic Qualifying Conditions, in the OMN
form (form found at www.medicaid.nv.gov) or medical need under an EPSDT
“Healthy Kids” exception. Clinical documentation must be submitted that
substantiates and validates the condition(s) with diagnostic panoramic radiographs,
diagnostic photos or photographs of diagnostic models with the automatic
qualifying condition.
Medically necessary Orthodontics are deemed necessary and qualified when it is
part of a case involving treatment of cranio-facial anomalies, malocclusions caused
as a result of trauma or a severe malocclusion or cranio-facial disharmony that
includes, but not limited to:
a. Overjet equal to or greater than 9 millimeters.
b. Reverse overjet equal to or greater than 3.5 millimeters.
c. Anterior and/or posterior crossbite of three or more teeth per arch.
d. Lateral or anterior open bite equal to or greater than 2 millimeters; of four
or more teeth per arch.
e. Impinging overbite with evidence of occlusal contact into the opposing soft
tissue.
f. Impactions where eruption is impeded but extraction is not indicated
(excluding third molars).
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g. Jaws and/or dentition which are profoundly affected by a congenital or
developmental disorder (craniofacial anomalies), trauma or pathology.
h. Two or more congenitally missing teeth (excluding third molars) of at least
one tooth per quadrant.
i. Crowding or spacing of 10 millimeters or more, in either the maxillary or
mandibular arch (excluding third molars).
Note: For conditions not listed above, providers may request orthodontic treatment
under the EPSDT “Healthy Kids Exception” by demonstrating “Medical Need.”
2. The automatic qualifying conditions specified by the AAO have been determined
to be medically necessary. Requests for orthodontia under an ESPDT exception
must demonstrate a functional impairment indicative of medical necessity. The PA
request must explain the significance of one or more of the following considerations
of “medical need.”
a. Functional factors relating to conditions that hinder effective functioning,
including, but not limited to, impaired mastication and muscular
dysfunction.
b. Factors related to the degree of deformity and malformation which produce
a psychological need for the procedure. The PA request must include
documentation from a Qualified Mental Health Practitioner (QMHP) acting
within the scope of their practice that verifies the psychological need; the
documentation must be based on objective evidence and reviewed by the
QIO-like vendor.
c. The recipient's overall medical need for the service in light of his/her total
medical condition. For example, an orthodontia need which might be slight
in an otherwise healthy child may become quite severe for a child suffering
from complicating ailments such as cerebral palsy or epilepsy. A functional
impairment must be demonstrated.
d. The medical appropriateness of an orthodontic treatment plan as opposed to
other available dental treatment. Appropriate consideration may be given,
for example, to a child's inability to understand and follow a treatment plan
where failure to follow the plan would result in medical complications of
the child's condition.
Medicaid does not authorize orthodontic treatment based on the possibility of risk of a
future condition, ease of hygiene or aesthetic improvement.
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3. PA requests must be submitted on an American Dental Association (ADA) claim
form.
The following documents are required to be attached with the prior authorization
request to the QIO-like vendor:
a. Orthodontic Medical Necessity (OMN) Form.
b. Client Treatment History Form.
c. A copy of the oral examination record(s), including diagnostic photographs
or photos of diagnostic models demonstrating measurements and a copy of
a panoramic x-ray. Diagnostic photographs and/or photographs of
diagnostic models and panoramic x-rays must be of sufficient quality to
confirm the diagnosis and must include any other documentation or
measurements as required in the Orthodontic Medical Necessity Form, to
confirm the diagnosis.
d. The provider must submit the appropriate level of documentation to support
the diagnosis. Providers are encouraged to use the recommendations for
diagnostic records encompassed in the most current edition of the American
Association of Orthodontists “Clinical Practice Guidelines for Orthodontics
and Dentofacial Orthopedics” which includes the recommendations for the
use of panoramic radiographs, cephalometric radiographs and Intraoral and
Extraoral photographs to confirm a diagnosis.
e. If the request is submitted under one of the AAO automatic qualifiers,
include a treatment plan, principal diagnosis and any significant associated
diagnoses, and prognosis.
If the request is submitted as an EPSDT exception, include the following:
1. Principal diagnosis and any significant associated diagnoses.
2. Prognosis.
3. Date of onset of the illness or condition and etiology if known.
4. Clinical significance or functional impairment caused by the illness
or condition.
5. Specific services to be rendered by each discipline and anticipated
time for achievement of treatment goals.
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6. Therapeutic goals to be achieved by each discipline and anticipated
time for achievement of the therapeutic goals.
7. A description of previous services that were provided to address the
illness/condition and the result of the prior care.
8. Treatment plan.
f. Any other documentation that may be required to substantiate the prior
authorization decision.
The Orthodontic Medical Necessity Form and the Client Treatment History Form
are located on the QIO-like vendor’s web portal at www.medicaid.nv.gov.
4. Medicaid’s QIO-like vendor will accept PA requests ONLY from those providers
with a specialty in Orthodontia (PT 22 with Specialty Code 079).
a. Orthodontists must use one of the codes for “limited” or “comprehensive”
orthodontic treatment for claims and PA requests.
b. Medicaid will deny an extension of orthodontic treatment if the results are
poor or the recipient has failed to keep appointments or comply with
treatment.
c. PA requests submitted must show all proposed orthodontic procedures and
list the following at a minimum: initial banding, months of treatment
including retention treatments and any retainers. Medicaid expects the
provider to render unlisted but necessary treatment components at no
additional charge. The provider's usual and customary charge must show
for each service. Stating a total fee for all services is not acceptable.
d. The QIO-like vendor may require the Orthodontists to shorten their
treatment plan after reviewing the submitted PA materials and
documentation.
5. The QIO-like vendor inputs the disposition for the requested orthodontic service
directly into the current system. No forms are submitted for signature for indication
of approved reimbursement amount. The fiscal agent does not return denied
orthodontic requests to providers.
6. When the provider completes the initial banding, he/she must enter the date of
service and the usual and customary charges amount on the claim form and return
it to the fiscal agent. The fiscal agent will make payment for the total specified on
the approved treatment plan.
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MEDICAID SERVICES MANUAL POLICY
E. OUT – OF STATE ORTHODONTIA
Nevada Medicaid will not pay for the continuation of orthodontic treatment if the recipient
started their treatment with an out-of-state provider. Nevada Medicaid will pay for the
removal of the orthodontic appliance(s) under EPSDT. The new, Nevada orthodontist can
then submit a PA request following the NV Medicaid criteria detailed in Section 1003.8(D).
Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for
a list of covered CDT codes, prior authorization requirements and service limitations.
1003.9 ADJUNCTIVE GENERAL SERVICES (D9000 – D9999)
The branch of dentistry for unclassified treatment including palliative care and anesthesia.
Nevada Medicaid authorizes payment of adjunctive general services for qualified recipients under
21 years of age and for emergency care, palliative care and anesthesia for persons 21 years of age
and older.
A. COVERAGE AND LIMITATIONS
Services are covered under EPSDT for persons less than 21 years of age; palliative care is
covered for persons 21 years of age and older.
For dental codes related to General or IV anesthesia, the provider must show the actual
beginning and end times in the recipient’s dental record. Anesthesia time begins when the
provider administering the anesthetic agent initiates the appropriate anesthesia and
monitoring protocol and ends when the provider is no longer in constant attendance (i.e.,
when the recipient can be safely placed under postoperative supervision).
B. AUTHORIZATION REQUIREMENTS
No PA is necessary for most services under EPSDT. Persons 21 years of age and older
require PA unless the service is for emergency extractions or palliative care.
Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for
a list of covered CDT codes, prior authorization requirements and service limitations.
1003.10 PERSONS 21 YEARS OF AGE AND OLDER
Nevada Medicaid authorizes payment for qualified persons 21 years of age and older for partials,
dentures, emergency extractions and palliative care only.
A. COVERAGE AND LIMITATIONS
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Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for
a list of covered CDT codes, prior authorization requirements and service limitations.
B. PROVIDER RESPONSIBILITY
1. Providers must keep all substantiating x-rays on file for a minimum of six years
following the date of service. Providers must keep the x-rays, related charting and
other case documentation easily available to Medicaid reviewers during this period.
2. The Medicaid program considers emergency extractions a program benefit without
prior or post approval. This includes the use of in-office sedation or anesthesia. The
program does not cover extractions for cosmetic purposes. Dentists need not
routinely submit substantiating x-rays to the Medicaid fiscal agent. However,
Medicaid will periodically request copies of x-rays substantiating third molar
extractions (teeth 1, 16, 17 and 32 for adults and children) related to tissue
impaction, partial and full bony and surgical versus simple extractions. The dentists
on-file x-rays must reveal sufficient bone and root complications for difficult
surgical removal procedures.
3. For treatment necessary to avoid life-threatening health complications, providers
perform services necessary to prevent life-threatening deterioration of a person’s
physical health without PA even though the services do not immediately qualify as
Medicaid covered emergency services. The dentist must certify the services were
medically necessary due to health complicating conditions such as HIV, AIDS,
cancer, bone marrow transplantation or post kidney transplant. The dentist’s
certification must be part of a note explaining why the treatment was necessary to
avoid life-threatening problems. For example, the dentist may explain successful
cancer treatment or organ transplantation depended on extractions or treatment of
caries to protect the recipient’s compromised immune system from the stress of oral
infection.
C. AUTHORIZATION REQUIREMENTS
No authorization is needed if the service is for emergency extraction or palliative care.
Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for
a list of covered CDT codes, prior authorization requirements and service limitations.
1003.11 SERVICES NOT COVERED BY MEDICAID
A. COVERAGE AND LIMITATIONS
Nevada Medicaid does not cover the following services:
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1. Cosmetic services.
2. Routine and preventive dental care, such as periodic prophylaxis, sealants, silver
diamine fluoride application, restoration of incipient or minor decay, treatment of
sensitivity to hot and cold or other minor pain is not covered for persons 21 years
of age and older. (Prophylaxes and restorative dental services under pregnancy
related services require PA and are reviewed on an individual basis).
3. Crowns are not allowed for persons 21 years of age and older, except where
required on an anchor or abutment tooth for a partial denture. Gold crowns are not
a covered benefit for any age.
4. For persons 21 years of age and older, Temporal Mandibular Disease (TMD)
services are not covered by Nevada Medicaid except for adult emergency services.
5. No show appointments or charges for missed appointments are not allowed.
Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing Guide)
document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for a list of
covered CDT codes, prior authorization requirements and service limitations.
1003.12 PHARMACY SERVICES
Nevada Medicaid authorizes payment of pharmacy services for qualified recipients.
A. COVERAGE AND LIMITATIONS
Fluoride supplements are covered only for recipients less than 21 years old.
B. PROVIDER RESPONSIBILITY
At this time, PA is not required for preventative medicaments like fluoride supplements
when prescribed by a dentist; however, it is recommended that prescribers check current
policy for any changes made.
The recipient must present the prescription with a Nevada Medicaid card to a Medicaid
participating pharmacy provider. Providers must verify eligibility prior to service.
C. AUTHORIZATION PROCESS
These guidelines do not change any Medicaid policy regarding non-covered medications
or medications which always require PA.
The Nevada Medicaid Preferred Drug List (PDL), PA requirements and quantity limits are
available on the www.medicaid.nv.gov website.
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Refer to the pharmacy policy located in MSM Chapter 1200 Prescribed Drugs.
1003.13 RESIDENTS OF INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH
INTELLECTUAL DISABILITIES (ICF/IID)
Nevada Medicaid authorizes payment for Medicaid covered services provided in an ICF/IID to
full Medicaid-eligible recipients.
All dental services provided to recipients in an ICF/IID are administered under the same policy
coverage and limitations provided throughout this dental chapter. Reference Nevada Medicaid’s
Dental Benefit Schedule (Attachment A of the PT 22 Billing Guide) document located in the QIO-
like vendor’s web portal at www.medicaid.nv.gov for a list of covered CDT codes, prior
authorization requirements and service limitations.
A. COVERAGE AND LIMITATIONS
Under Federal regulations (CFR 483.460(e-h), the ICF/IID is required to provide or make
arrangements for comprehensive dental diagnostic and treatment services for their
residents.
B. PROVIDER RESPONSIBILITY
For dental services beyond the Medicaid covered benefit, the dentist must establish a
relationship with the ICF/IID facility staff to assure verification of the recipient’s ICF/IID
residency, and payment source for dental services prior to service.
1003.14 PROVIDERS OUTSIDE NEVADA
Nevada Medicaid authorizes payment for out-of-state providers under Medicaid guidelines.
A. COVERAGE AND LIMITATIONS
Out-of-state providers are subject to the coverage and limitations of dental services under
Nevada Medicaid.
B. PROVIDER RESPONSIBILITY
Out-of-state providers are subject to all Medicaid rules and guidelines.
C. AUTHORIZATION REQUIREMENTS
Out-of-state providers must use the same PA process as in-state dental providers.
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1003.15 PAYMENT OF NON-COVERED SERVICES
A. COVERAGE AND LIMITATIONS
Nevada Medicaid does not authorize payment for non-covered services.
B. PROVIDER RESPONSIBILITY
Dental providers must inform the recipient of his/her financial responsibility before
rendering any uncovered service. Consider this done when the recipient or a responsible
designee signs a written document acknowledging acceptance of financial responsibility
for each specific itemized service. The signed document must state, “I understand Medicaid
will not cover the above itemized service cost(s). I agree to pay for the services.”
If Medicaid covers a procedure, the provider cannot charge the recipient for the balance
after Medicaid’s payment. Also, providers cannot charge Medicaid for one covered service
and provide a different service. For example, since Medicaid does not cover restorations
or prosthetics made of gold, Medicaid’s payment on a covered restoration or prosthesis
cannot be used to offset one made of gold. The recipient would need to pay the complete
charge for the gold restoration or prosthesis, or the recipient must accept the Medicaid
benefit service only.
C. RECIPIENT RESPONSIBILITY
Services exceeding program limitations are not considered Medicaid benefits. These
services are the financial responsibility of the recipient. For persons less than 21 years of
age, medically necessary services that are outside of what is covered in the benefit schedule
can be requested with a PA as an EPSDT exception. For example, a PA request needs to
be submitted for a child who needs cleanings every three months rather than the six months
allowed by current service limitations.
D. AUTHORIZATION REQUIREMENTS
Nevada Medicaid does not authorize payment for non-covered services.
1003.16 SERVICES PROVIDED IN NURSING FACILITIES
Nevada Medicaid authorizes payment for services provided in nursing facilities to qualified
recipients eligible with full Medicaid benefits.
A. COVERAGE AND LIMITATIONS
All dental services provided to recipients in a nursing facility are administered under the
same policy coverage and limitations provided throughout this Dental Chapter.
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B. PROVIDER RESPONSIBILITY
Medicaid advises dentists to confirm the recipient’s eligibility through the Eligibility
Verification System (EVS) for the month the service will be provided and retain a copy
prior to service. Medicaid advises dentists to develop procedures with nursing facility staff
to screen for ineligible recipients. Medicaid recommends dentists become users of EVS by
making arrangements with Medicaid’s QIO-like vendor.
C. NURSING FACILITY RESPONSIBILITY
Nursing facility staff must screen for Medicaid eligibility.
D. AUTHORIZATION REQUIREMENTS
PA is required for partials and/or full dentures for all recipients residing in nursing facilities
or receiving Hospice services. See Section 1003.5.C.
1003.17 HOSPITAL/SURGICAL CENTERS
A. COVERAGE AND LIMITATIONS
Nevada Medicaid authorizes payment for certain dental services in hospital or surgical
centers for qualified recipients with PA unless it is an emergency.
B. AUTHORIZATION REQUIREMENTS
1. Inpatient Hospital Setting: Prior authorization for inpatient hospitalization for a
dental procedure is necessary for Medicaid reimbursement.
a. If PA is required for the dental procedure (CDT code), the dental consultant
must obtain prior authorization. Reference Nevada Medicaid’s Dental
Benefit Schedule (Attachment A of the PT 22 Billing Guide) document
located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for a
list of covered CDT codes, prior authorization requirements and service
limitations.
b. PA must be obtained from Medicaid’s QIO-like vendor or the Managed
Care Organization (MCO) to certify the necessity for the recipient to be
hospitalized for the performance of the inpatient dental procedure. The
certification must be done before or on the date of the admission.
The provider must write, “Hospital Admission” at the top of the
Examination and Treatment Plan box of the claim form.
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MEDICAID SERVICES MANUAL POLICY
2. Outpatient/Surgical Center Setting: Prior authorization for dental procedures
performed in an outpatient/surgical center setting may require prior authorization.
a. For Medicaid recipients of all ages: If PA is required for the dental
procedure (CDT code), the dentist rendering the service must obtain prior
authorization. Reference Nevada Medicaid’s Dental Benefit Schedule
(Attachment A of the PT 22 Billing Guide) document located in the QIO-
like vendor’s web portal at www.medicaid.nv.gov for a list of covered CDT
codes, prior authorization requirements and service limitations.
b. For Medicaid recipients ages five and below, prior authorization is required
for the outpatient facility. The authorization request must include a narrative
signed by the provider with the clinical rationale for the dental procedure to
be completed in an outpatient setting. The narrative must detail the clinical
reason, including medical necessity, that the recipient is unable to have the
services completed in the office.
c. For Medicaid recipients ages 6 to 20, specific authorization is not required
for the anesthesiologist and/or outpatient facility. Procedures done as
outpatient services for recipients less than 21 years of age in a hospital or
surgical center must be identified. The provider must write “Outpatient
Facility Services” at the top of the Examination and Treatment Plan box of
the claim form.
d. For Medicaid recipients 21 years of age and older, the outpatient facility
services must be prior authorized. The authorization request must include a
narrative signed by the provider with the clinical rationale for the dental
procedure to be completed in an outpatient setting. The narrative must detail
the clinical reason that the recipient is unable to have the services completed
in the office.
e. All dentists providing surgical center services to Medicaid recipients must
retain in-office copies of x-rays, intra-oral preoperative photographs (when
necessary) and documentation necessary to substantiate service need. The
substantiating evidence must be retained and remain readily available for
no less than six years. Medicaid holds the provider responsible for assuring
the evidence is sufficient for the Medicaid agency’s post utilization
review/control purposes.
f. In situations where the dentist believes his treatment plan to have weak
support from x-rays, intra-oral photographs, etc., the dentist should submit
the evidence with a request for PA. Without PA, Medicaid will reclaim
payment for the services if post service review findings do not support the
dentist’s treatment plan and medical necessity.
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Subject:
MEDICAID SERVICES MANUAL POLICY
g. Medicaid does not reimburse providers for travel and hospital call related
costs for services done in an outpatient surgical center.
1003.18 MAXILLOFACIAL SURGERY AND OTHER PHYSICIAN SERVICES
Nevada Medicaid authorizes payment for maxillofacial surgery and other physician services for
qualified recipients.
A. COVERAGE AND LIMITATIONS
Temporomandibular Disorders (TMDs) encompasses a variety of conditions. For
recipients less than 21 years of age, TMD services may be provided by a dentist or medical
doctor under EPSDT. Coverage for the medical management of TMD related disease for
recipients will be limited to appropriate current TMD related diagnosis codes.
Adult dental services continue to be restricted to palliative treatment, emergency
extractions and dentures/partials.
Reference Nevada Medicaid’s Dental Benefit Schedule (Attachment A of the PT 22 Billing
Guide) document located in the QIO-like vendor’s web portal at www.medicaid.nv.gov for
a list of covered CDT codes, prior authorization requirements and service limitations.
B. PROVIDER RESPONSIBILITY
Program utilization control requires that each type of provider (dentist, physician,
pharmacist, etc.) be delineated with the use of a specific PT number. For example, dentists
are a PT 22 while physicians are a PT 20. Providers also have the option to choose a
specialty type. For example, a PT 22 can choose a specialty type of Maxillofacial Surgery
(Specialty 170) or Oral Surgery (Specialty 080). All dental related services must be
billed/requested with the most appropriate dental code found on the QIO-like vendor's web
portal at www.medicaid.nv.gov. For certain oral and maxillofacial surgery procedures,
when an appropriate dental code is not available, a CPT Code may be used if Medicaid
allows the code to be billed by a PT 22, Specialty 080 and/or 170. Providers are encouraged
to check the www.medicaid.nv.gov website or contact the QIO-like vendor to confirm
ability to bill for specific CPT codes.
The CPT Code for fluoride varnish application which can be administered by PT 17, 20,
24 and 77 should be billed on a CMS 1500 form using the most appropriate and available
ICD diagnosis code.
C. AUTHORIZATION REQUIREMENTS
See B. Provider Responsibility.
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1003.19 CONDITIONS FOR PARTICIPATION
All dental providers must have a current license issued by the Nevada State Board of Dental
Examiners to practice dentistry. Dental specialists must be dental specialties that are recognized
and approved by the American Dental Association and the Nevada State Board of Dental
Examiners and be enrolled as a Nevada Medicaid provider. Out of state dentists must meet the
licensing requirements of the state in which they practice and be enrolled as a Nevada Medicaid
provider.
Dental services may also be performed in a clinic setting as long as the care is furnished by or
under the direction of a dentist. The clinic must have a dental administrator and all professional
staff, dentists, hygienists, public endorsed hygienists, dental therapists, etc. must have a current
Nevada license and/or certification from the appropriate state licensing board.
1003.20 IMPROPER BILLING PRACTICE
Providers must bill only for the dates when services were actually provided, in accordance with
this MSM Chapter and the PT 22 Billing Guide.
Any provider found by the State or its agent(s) to have engaged in improper billing practices,
without limitations, may be subject to sanctions including recoupment, denial or termination from
participation in Nevada Medicaid.
The findings and conclusions of any investigation or audit by the DHCFP shall not be construed
as prohibiting any criminal or civil investigations, actions or other claims for relief that may be
available to any party under applicable federal, state or local laws.
Improper billing practices may include but are not limited to:
A. Submitting claims for unauthorized procedures or treatments.
B. Submitting claims for services not provided.
C. Submitting false or exaggerated claim of the level of functional impairment or medical
necessity to secure approval for treatment and reimbursement.
D. Submitting claims for treatment or procedures without documentation to support the
claims.
E. Submitting claims for unnecessary procedures or treatments that are in excess of amount,
scope and duration necessary to reasonably achieve its purpose.
F. Submitting claims for dental services provided by unqualified personnel.
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Any Dental provider who improperly bills the DHCFP for services rendered is subject to all
administrative and corrective sanctions and recoupment in accordance with MSM Chapter 3300 –
Program Integrity. All Medicaid overpayments are subject to recoupment.
Any such action taken against a dental provider by the DHCFP has no bearing on any criminal
liability of the provider.
February 3, 2017 DENTAL Section 1003 Page 28
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Section:
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Subject:
MEDICAID SERVICES MANUAL HEARINGS
1004 HEARINGS
Please reference Nevada MSM Chapter 3100 for the Medicaid Hearing process.
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Subject:
MEDICAID SERVICES MANUAL REFERENCES AND CROSS
REFERENCES/FORMS
1005 REFERENCES AND CROSS REFERENCES/FORMS
Other sources which may impact the provision of Dental services include, but are not limited to
the following:
Chapter 100: Medicaid Program
Chapter 200: Hospital Services
Chapter 300: Radiology Services
Chapter 500: Nursing Facilities
Chapter 600: Physician Services
Chapter 1200: Prescribed Drugs
Chapter 1500: Healthy Kids Program (EPSDT)
Chapter 1600: Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)
Chapter 2100: Home and Community-Based Services Waiver for Individuals with Intellectual
Disabilities
Chapter 3100: Hearings
Chapter 3300: Program Integrity
1005.1 CONTACTS
A. Nevada Medicaid Provider Enrollment
Division of Health Care Financing and Policy
1100 East William Street
Carson City, NV 89701
(775) 684-3705
https://dhcfp.nv.gov
B. DXC Technology
Customer Services Center
(For claim inquiries and general information)
(877) 638-3472
www.medicaid.nv.gov
C. Prior Authorization for Dental
(800) 525-2395 (Phone)
April 1, 2020 DENTAL Section 1005 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL REFERENCES AND CROSS
REFERENCES/FORMS
1005.2 FORMS
A. The ADA Dental Claim Form 2012 or newer version is required for all prior authorization
requests, claims, adjustments and voids.
1005.3 DENTAL PERIODICITY SCHEDULE
The recommended periodicity schedule can be found at http://www.aapd.org/.
February 24, 2021 DENTAL Section 1005 Page 2
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
July 26, 2017
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL LYNNE
FROM: FOSTER, CHIEF OF DIVISION COMPLIANCE /Lynn Foster/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES CHAPTER 1100,
OCULAR SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1100 – Ocular Services are being
proposed to add new language clarifying ocular prosthetic services.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: Optometrist (Provider Type (PT) 25) and Durable Medical
Equipment (PT 33).
Financial Impact on Local Government: None.
These changes are effective July 27, 2017.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 17/17 MTL 24/15
OCULAR SERVICES OCULAR SERVICES
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1103.1A(5) Ocular Prosthetic Add new language clarifying ocular prosthetic services.
Services
Page 1 of 1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
OCULAR SERVICES
1100 INTRODUCTION ...............................................................................................................................1
1101 AUTHORITY ......................................................................................................................................1
1102 RESERVED .........................................................................................................................................1
1103 POLICY ..............................................................................................................................................1
1103.1 OCULAR SERVICES .........................................................................................................................1
1103.1A COVERAGE AND LIMITATIONS ...................................................................................................1
1103.1B PROVIDER RESPONSIBILITY.........................................................................................................6
1103.1C RECIPIENT RESPONSIBILITY ........................................................................................................6
1104 HEARINGS .........................................................................................................................................1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1100
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
1100 INTRODUCTION
The Nevada Medicaid Ocular program reimburses for medically necessary ocular services to
eligible Medicaid recipients under the care of the prescribing practitioner. Such services shall
maintain a high standard of quality and shall be provided within the limitations and exclusions
described in this chapter.
All providers participating in the Medicaid program must offer services in accordance with the
rules and regulations of the Medicaid program. Conditions of participation are available from
Provider Support Services at Nevada Medicaid.
Ocular services are an optional benefit within the Nevada Medicaid Program.
All Medicaid policies and requirements (such as prior authorizations, etc.) are the same for Nevada
Check Up (NCU), with the exception of areas where Medicaid and NCU policies differ. For further
clarification, please refer to the NCU Manual, Chapter 1000.
October 1, 2015 OCULAR SERVICES Section 1100 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1101
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
1101 AUTHORITY
The citation denoting the amount, duration and scope of services are found in 42 Code of Federal
Regulation (CFR) Part 440.200, and Sections 1902(a), 1902(e), 1905(a), 1905(p), 1915, 1920 and
1925 of the Social Security Act (SSA). CFR 440.225 and 441.30. Nevada State Plan Section 3.1,
Pages 19, 216 and 27.
The State Legislature sets forth standards of practice for licensed professionals in the Nevada
Revised Statutes (NRS) for the following Specialists:
• Physicians: NRS Chapter 630.375
• Optometry: NRS Chapter 636
• Dispensing Opticians: NRS Chapter 637
October 1, 2015 OCULAR SERVICES Section 1101 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1102
Subject:
MEDICAID SERVICES MANUAL RESERVED
1102 RESERVED
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1103
Subject:
MEDICAID SERVICES MANUAL POLICY
1103 POLICY
1103.1 OCULAR SERVICES
1103.1A COVERAGE AND LIMITATIONS
Medicaid will reimburse for routine comprehensive ophthalmological examinations and/or
refractive examinations of the eyes and glasses with a prescription for and provision of corrective
eyeglasses to eligible Medicaid recipients of all ages once every 12 months. Any exceptions
require prior authorizations.
1. HEALTHY KIDS (EPSDT)
a. Nevada Medicaid provides for vision screenings as referred by any appropriate
health, developmental or educational professional after a Healthy Kids Screening
Exam. Optometrists and ophthalmologists may perform such exams without prior
authorization upon request or identification of medical need. "Medical Need" may
be identified as any ophthalmological examination performed to diagnose, treat or
follow any ophthalmological condition that has been identified during the Healthy
Kids examination.
b. Glasses may be provided at any interval without prior authorization for Early and
Periodic Screening, Diagnosis and Treatment (EPSDT) recipients, as long as there is
a change in refractive status from the most recent exam, or for broken or lost glasses.
Physician records must reflect this change and the records must be available for
review for the time mandated by the federal government. Recipients enrolled in a
Managed Care plan are mandated to access Healthy Kids EPSDT ocular services
through their Managed Care provider.
2. EXAMINATIONS
a. Refractive examinations performed by an optometrist or ophthalmologist are covered
for Medicaid recipients of all ages once every 12 months. Any exceptions require
prior authorization.
b. Ocular examinations performed by an optometrist for medical conditions within the
scope of their license do not require a prior authorization.
c. Ocular examinations performed by an ophthalmologist for medical conditions do not
require prior authorization and are considered a regular physician visit. Current
limitations are based on medical necessity.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1103
Subject:
MEDICAID SERVICES MANUAL POLICY
d. Following cataract surgery, if the recipient is Medicare eligible and requires
eyeglasses, the provider must bill Medicare first and attach the Medicare Explanation
of Benefits (EOB) to the claim for co-insurance and deductible.
3. LENSES
Lenses are covered for recipients of all ages. No prior authorization is needed for recipients
under 21. For recipients over 21, a prior authorization is required if the 12-month limitation
is exceeded.
a. COVERED
The following are covered for Nevada Medicaid recipients of all ages as noted:
1. A change in refractive error must exceed plus or minus 0.5 diopter or 10
degrees in axis deviation in order to qualify within the 12-month limitation;
2. Lens material may be tempered glass tillyer grade or equivalent or standard
plastic, at recipient’s option;
3. Ultra-lightweight plastics, e.g., Lite Style and polycarbonate-style, are
covered when they are medically necessary to avoid very heavy glasses
which would hurt the bridge of the nose. The acceptable means for avoiding
severe imbalance of the weight of the glasses are up to +7 diopters in
children;
4. Polycarbonate lenses are covered under EPSDT when medically necessary;
5. Safety lenses when the recipient has vision in only one eye;
6. A single plano or balance lens is handled as if it were a corrective lens and so
called “half glasses” are handled as if they were standard size corrective
lenses;
7. Slab-off lenses, Prisms, Aspheric, Lenticular lenses;
8. “Executive” bifocals may be covered for children with: esotropia, and
esophoria, accommodation, oculomotor dysfunction such as tracking and
saccadic problems. Prior authorization is not required when using one of the
above medical diagnoses;
9. Filters: PLS 40 filters when prescribed for patients with the following
diagnoses: macular degeneration, retinitis pigmentosa, rod/cone dystrophy or
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1103
Subject:
MEDICAID SERVICES MANUAL POLICY
achromastopia. In all these cases, the best uncorrected vision must test better
than 20/200;
10. UV filters when prescribed following cataract surgery;
11. Bifocals and trifocals are reimbursable for a combination of any of the
conditions at near or far point, including but not limited to: estropia,
esophoria, cataracts, glaucoma, accommodative dysfunctions, nystogmus,
stigmatism, myopia, presbyopia;
12. Double segment lenses required for employment which must be prior
authorized;
13. Therapeutic contact lenses when prescribed for treatment of a medical
condition;
14. Tints are covered when medically necessary;
15. Low vision aides such as telescopic lenses, magnifying glasses, bioptic
systems and special inserts in regular lenses which must be prior authorized;
16. Scratch-proof coatings for plastic lenses are covered for EPSDT recipients.
b. NON-COVERED
The following are not covered:
1. Sunglasses and cosmetic lenses.
2. Contact lenses are disallowed UNLESS their use is:
a. The only means to bring vision to the minimum criteria required to
avoid legal blindness; or
b. Medically indicated following cataract surgery; or
c. The necessary means for avoiding very heavy glasses which would
hurt the bridge of the nose (e.g., where the correction is 9+ diopters
in each eye). The necessary means for avoiding severe imbalance
of the weight of glasses is where one eye is corrected to 9+ diopters
and the other eye is 3+; or
d. Required when the recipient has a diagnosis of Keratoconus.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
3. Replacement of lenses, unless the patient has a significant change in
refractive status.
4. Blended and progressive multi-focal lenses, “transitional lenses.”
5. Faceted lenses.
6. “Additional” Cost of an Extended Repair Replacement (ERR) warranty.
4. FRAMES
a. COVERED
1. Existing frames must be used whenever possible. If new frames are
necessary, they may be metal or plastic, at the patient's option, up to
Medicaid’s allowable cost.
2. Providers must stock a variety of frames to enable the recipient to choose a
frame at no cost to them, if they so choose.
b. NON-COVERED
The following are not covered:
1. Frames with ornamentation.
2. Eyeglass frames which attach to or act as a holder for hearing aid(s).
5. OCULAR PROSTHETIC SERVICES
a. Ocular prosthesis is covered when medically necessary, allowing one per eye, per 60
months (five years).
b. Ocular prosthesis requires prior authorization. Please reference Medicaid Services
Manual (MSM) Chapter 1300, Durable Medical Equipment (DME), for prior
authorization guidelines.
c. A physician or optometrist must submit a referral for an ocular prosthesis, and the
referral must be maintained in the recipient’s medical record.
d. Necessity for the procedure must include:
1. explanation of medical necessity for the prosthetic eye;
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Section:
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Subject:
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2. prior prosthetic eye history, if applicable; and
3. description and justification other than a pre-cast prosthesis.
e. For replacement of a prosthetic eye or sclera cover shell, one of the following
justifications must be included:
1. accommodation for changes resulting from orbital development;
2. as necessary to prevent a significant disability;
3. when prior prosthesis was lost or destroyed due to circumstances beyond the
recipient’s control; or
4. when the prior prosthesis can no longer be rehabilitated.
f. Polishing/resurfacing of an ocular prosthesis is covered once each 12 months, per
eye without prior authorization. If medical necessity exceeds limitations, a prior
authorization is required.
g. If there is one paid claim historically for the same eye, right or left, medical
necessity for a second claim within the 60-month period must include one of the
following conditions:
1. socket growth or contracture;
2. lagophthalmos;
3. ptosis;
4. lower lid laxity;
5. entropion;
6. ectropion;
7. implant exposure; or
8. other conditions that can be improved or minimized with appropriate
prosthetic modification.
h. Fabrication and fitting of an ocular conformer must include:
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Section:
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Subject:
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1. a written prescription by a physician or optometrist, and the prescription
must be retained in the recipient’s medical record;
2. medical necessity for the recipient; and
3. documentation of post-surgical use to prevent closure and/or adhesions
between the orbit and eyelid during the healing process.
i. The recipient is responsible for general care and maintenance of the eye socket and
prosthesis, as directed by the provider.
6. VISION THERAPY
Vision therapy is a covered Medicaid benefit and must be prior authorized by the QIO-like
vendor.
1103.1B PROVIDER RESPONSIBILITY
1. Providers must confirm the recipient’s eligibility by reviewing the current Medicaid card
before providing services, or access eligibility via the Electronic Verification of Eligibility
(EVE) system.
2. It is the provider’s responsibility to ask the recipient if there is additional visual coverage
through third party payers.
1103.1C RECIPIENT RESPONSIBILITY
Services requested by the recipient but for which Medicaid makes no payment are the responsibility
of, and may be billed to, the recipient. Nevada Medicaid recipients are only responsible for payment
of services not covered by Medicaid, such as eyeglass extras. Prior to service, the recipient must be
informed in writing and agree in writing he/she will be responsible for payment.
1. The recipient is responsible for presenting a valid Medicaid card to the examiner and/or
optician.
2. The recipient is responsible for presenting any form or identification necessary to utilize
other health insurance coverage.
3. If the recipient selects a frame with a wholesale cost greater than the Medicaid allowable,
they will be responsible for the additional amount. The recipient’s agreement to make
payment must be in writing. A copy of the agreement must be retained in the recipient’s
chart. The Nevada Medicaid Surveillance and Utilization Review Unit (SUR) conducts a
regular review of claims history to monitor this.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1103
Subject:
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4. If the recipient selects a lens option not covered by Medicaid, he/she is then responsible for
payment only of the non-covered options. Medicaid pays the lens cost minus the cost of
options. Non-covered options must be listed separately on the invoice. Claims will be
returned to providers for correction.
5. If the recipient chooses an ERR warranty which is not covered by Medicaid's payment,
he/she is responsible for warranty payment.
6. The recipient is responsible for making and keeping appointments with the doctor.
7. The recipient is responsible for contacting the provider of the eyeglasses (if different from
the examiner) for fitting and delivery.
8. The recipient is responsible for picking up the eyeglasses and returning for any necessary
adjustments within the time allotted for such adjustments. (Medicaid will not pay for office
visits for adjustments. The provider is expected to make reasonable adjustments and repair,
without charge).
9. UNCLAIMED EYEGLASSES
The recipient has 15 days to claim eyeglasses reimbursed by Nevada Medicaid. If after 15
days, the item is still held by the provider:
a. The provider shall notify the appropriate district office.
b. The caseworker attempts to contact the recipient and make arrangements to claim the
eyeglasses.
If the caseworker is unable to contact the recipient or the recipient refuses to claim
the eyeglasses, the worker advises the Nevada Medicaid Office (NMO) and notifies
the provider the item will not be picked up, NMO then notifies Utilization Control
for a possible restriction of the recipient's medical services.
c. Following notification the item will remain unclaimed, provider may submit a bill in
the normal fashion to the Nevada Medicaid fiscal agent.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1104
Subject:
MEDICAID SERVICES MANUAL HEARINGS
1104 HEARINGS
Please reference MSM Chapter 3100, for Medicaid Recipient Hearings process.
October 1, 2015 OCULAR SERVICES Section 1104 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
August 31, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, HIPAA PRIVACY AND CIVIL RIGHTS
OFFICER /Jessica Kemmerer/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1200 – PRESCRIBED DRUGS
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1200 – Prescribed Drugs are being
proposed to reflect recommendations approved on April 22, 2021, by the Drug Use Review (DUR)
Board. The proposed changes include the addition of new prior authorization criteria for Nurtec®
ODT (rimegepant) within the Anti-Migraine Medication section; addition of new prior
authorization for Kesimpta®(ofatumumab) within the Multiple Sclerosis (MS) Agents section;
revisions to the existing Anti-Hepatitis Agents prior authorization criteria as well as the removal
of discontinued products, Daklinza® (daclatasvir), Olysio® (simeprevir), Technivie® (ombitasvir
/ paritaprevir / ritonavir) and Viekira® XR (dasabuvir / ombitasvir / paritaprevir / ritonavir);
revisions to the existing Hereditary Angioedema Agents prior authorization criteria; formatting
changes to the existing Platelet Inhibitors section; addition of new prior authorization criteria for
Xywav® (calcium / magnesium / potassium / sodium oxybates) within the Narcolepsy Agents
section and revisions to the existing prior authorization for Valtoco® (diazepam nasal spray)
within the Anticonvulsants section. In addition, Division of Health Care Financing and Policy
(DHCFP) is proposing revisions to section 1203.1E to reflect the intent Assembly Bill (AB) 178
from the 81st (2021) Nevada Legislative Session which allows DHCFP to waive the early refills
requirement for a non-controlled substance prescription in areas for which an emergency or
disaster has been declared.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: No entities are anticipated to be financially affected.
Financial Impact on Local Government: No known financial impact on local government.
These changes are effective September 7, 2021.
Page 1 of 2
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 13/21 MTL 18/17
MSM Chapter 1200 - Prescribed Drugs MSM Chapter 1200 - Prescribed Drugs
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
1203.1E Early Refills Added language to reflect the intent of AB 178 from
the 81st (2021) Nevada Legislative Session which
allows DHCFP to waive early refills requirement for
non-controlled substance prescriptions in areas for
which an emergency or disaster has been declared.
Appendix A Anti-Migraine Updated last reviewed date. Added new prior
Section S Medications authorization criteria for Nurtec® ODT. Updated web
links throughout section.
Appendix A Multiple Sclerosis Update last reviewed date. Updated general prior
Section CC (MS) Agents authorization to reflect prior authorization for
Kesimpta®. Updated web links throughout section.
Appendix A Anti-Hepatitis Updated last reviewed date. Removed existing prior
Section HH Agents authorization criteria for Daklinza®, Olysio®,
Technivie® and Viekira XR® as these products have
been discontinued. Updated existing prior
authorization criteria for Viekira®.
Appendix A Hereditary Updated last reviewed date. Updated clinical criteria
Section JJ Angioedema Agents for Cinryze® to include Haegarda®, Orladeyo® and
Takhzyro®. Updated prior authorization criteria for
Firazyr® and Ruconest® and off label use Cynryze®.
Updated prior authorization criteria for Kalbitor® and
Berinert®. Updated formatting and web links
throughout section.
Appendix A Platelet Inhibitors Updated last reviewed date. Updated formatting and
Section NN web links throughout section.
Appendix A Narcolepsy Agents Updated last reviewed date. Added new prior
Section AAA authorization criteria for Xywav®. Updated web
links throughout section.
Appendix A Anticonvulsants Updated last reviewed date. Updated current
Section BBBB Valtoco® prior authorization criteria. Updated web
links.
Page 2 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
PRESCRIBED DRUGS
1200 INTRODUCTION ................................................................................................................................ 1
1201 AUTHORITY ....................................................................................................................................... 1
1202 RESERVED .......................................................................................................................................... 1
1203 POLICY ................................................................................................................................................ 1
1203.1 COVERAGE AND LIMITATIONS .................................................................................................... 1
1203.1A PROVIDER RESPONSIBILITY.......................................................................................................... 8
1203.1B SERVICE DELIVERY MODEL ........................................................................................................ 12
1203.1C PRIOR AUTHORIZATION (PA) PROCEDURES ........................................................................... 19
1203.2 INTRAVENOUS (IV) THERAPY ..................................................................................................... 19
1204 HEARINGS .......................................................................................................................................... 1
APPENDIX A
APPENDIX B
TABLE OF CONTENTS .......................................................................................................................................... 1
Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1200
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
1200 INTRODUCTION
The Nevada Medicaid Pharmacy Services program pays for medically necessary prescription
services for eligible Medicaid recipients under the care of the prescribing practitioner. Such
services shall maintain a high standard of quality and shall be provided within the limitations and
exclusions hereinafter specified.
All providers participating in the Medicaid program must furnish services in accordance with the
rules and regulations of the Medicaid program. Conditions of participation are available from
Provider Services.
This Chapter describes covered services, service limitations and general reimbursement
methodology.
This manual obsoletes all previous policy and procedure manuals, bulletins and policy news.
All Medicaid policies and requirements (such as prior authorizations, etc.) are the same for Nevada
Check Up (NCU), with the exception of the four areas where Medicaid and NCU policies differ
as documented in the NCU Manual Chapter 1000.
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Section:
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Subject:
MEDICAID SERVICES MANUAL AUTHORITY
1201 AUTHORITY
A. The Code of Federal Regulations (CFR), Title 42, Public Health, Chapter IV, Center for
Medicare and Medicaid Services (CMS), Subchapter C Medical Assistance Programs,
Parts 430 through 456, states prescription drug coverage is an optional service under Title
XIX.
B. The Omnibus Budget Reconciliation Act (OBRA) of 1989 mandates additional preventive
health care services for infants, children and young adults (newborn through age 20)
eligible for Medicaid. These mandates provide that children and adolescents under age 21
receive follow-up services for a medically necessary condition discovered in a screening
examination, Early Preventative Screening and Diagnostic Testing (EPSDT), see Medicaid
Services Manual (MSM) Chapter 1500; this includes prescription services.
C. CFR Title 42 and Section 1927 of the Social Security Act (SSA), require states to provide
for a Drug Utilization Review (DUR) program for covered outpatient drugs in order to
assure that prescriptions are appropriate, medically necessary and not likely to result in
adverse medical results SSA, Title 19, (g)(1)(A)).
D. Section 1927 of the SSA allows a state to require a prior authorization on any covered
outpatient drug, providing the prior authorization program complies with the requirements
outlined in the act.
The SSA requires the establishment of a DUR board to monitor therapeutic
appropriateness, use of generic products, overutilization and underutilization of drugs and
quality of care consistent with protecting the health of program beneficiaries.
E. Chapter 422 of Nevada Revised Statute (NRS) amended by AB 384 to require the
Department of Health and Human Services (DHHS) to:
1. develop a list of preferred prescription drugs;
2. manage prescription drug use through the use of prior authorization and step
therapy; and
3. create the Pharmacy and Therapeutics Committee.
F. U.S. Troop Readiness, Veteran’s Health Care, Katrina Recovery and Iraq Accountability
Appropriations Act 2007, Section 7002(b) of the act requires Medicaid outpatient drugs
(defined in Section 1927(k)(2) of the SAA) will be reimbursable only if non-electronic
written prescriptions are executed on a tamper-resistant prescription pad.
G. The Deficit Reduction Act of 2005 requires Fee-for-Service (FFS) State Medicaid
programs to capture and report National Drug Codes (NDC) for outpatient drugs in order
for the state to receive federal financial participation.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1202
Subject:
MEDICAID SERVICES MANUAL RESERVED
1202 RESERVED
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1203
Subject:
MEDICAID SERVICES MANUAL POLICY
1203 POLICY
The Division of Health Care Financing and Policy (DHCFP), Nevada Medicaid, reimburses
pharmacies and practitioners for legend (prescription) and non-legend (over the counter)
pharmaceuticals dispensed or administered to Medicaid recipients. All prescribers must have a
license as a healthcare practitioner, such as a physician, podiatrist, osteopath, dentist, Advanced
Practice Registered Nurse (APRN), physician’s assistant, etc., keeping within the scope of their
practice. The DHCFP requires that pharmaceuticals are written, dispensed and prescribed in
accordance with the Nevada State Board of Pharmacy regulations and enforcement.
1203.1 COVERAGE AND LIMITATIONS
A. Covered drugs are subject to prior authorization and/or quantity limits and the following:
1. Section 1927(d)(1)(B)(i) of the SSA allows Medicaid to restrict coverage for an
outpatient drug if the prescribed drug is not for a medically accepted indication.
Section 1927(k)(6) defines a medically accepted indication as any use for a covered
outpatient drug, which is approved under the Federal Food, Drug and Cosmetic
Act, or the use of which is supported by one or more citations included or approved
for inclusion in any of the compendia:
a. American Hospital Formulary Service Drug Information;
b. United States Pharmacopeia;
c. DRUGDEX Information System; or
d. Peer-reviewed medical literature.
2. Pharmaceuticals must be manufactured by companies participating in the Federal
Medicaid Drug Rebate Program.
3. Medicaid is mandated by federal statute to require all written (non-electronic)
prescriptions for all outpatient drugs for Medicaid recipients to be on tamper-
resistant prescription pads. This requirement does not apply to e-prescriptions
transmitted to the pharmacy, prescriptions faxed to the pharmacy or prescriptions
communicated to the pharmacy by telephone by a prescriber. Refer to MSM
Addendum for more information on tamper-resistant prescription pads.
4. The Preferred Drug List (PDL) is a list of preferred outpatient drugs established by
the Silver State Scripts Board (formerly known as the Pharmacy and Therapeutics
(P&T) Committee). Reference Medicaid Operations Manual (MOM) Chapter 200
for the Silver State Scripts Board bylaws. Pharmaceuticals not on the PDL, but
within drug classes reviewed by the Silver State Scripts Board, require prior
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authorization, unless exempt under NRS or federal law or excluded through
recommendations of the Silver State Scripts Board or excluded by the DHCFP.
a. New pharmaceutical products not within reviewed PDL drug classes and
not excluded under the state plan or by NRS are covered without a Standard
Preferred Drug List Exception prior authorization until, or if, the Silver
State Scripts Board adds the drug class to the PDL and reviews the product
or evidence.
b. New Food and Drug Administration (FDA) approved drugs, or existing
pharmaceutical products within reviewed PDL drug classes, for which there
is new clinical evidence supporting its inclusion on the PDL and are not
excluded under state plan or by NRS, are covered with an approved
Standard Preferred Drug List Exception prior authorization until the Silver
State Scripts Board can review the new evidence or drug.
c. Pharmaceuticals may require prior authorization due to step therapy
protocols regardless of inclusion in the PDL.
d. If the Silver State Scripts Board determines that there are no significant
differences between drugs within specific classes based on clinical efficacy,
safety, and outcomes for patients, the DHCFP or its Quality Improvement
Organization (QIO)-like vendor, may consider cost in determining which
drugs are selected for inclusion on the PDL.
B. Standard Preferred Drug List Exception Criteria
Drugs that have a “non-preferred” status are a covered benefit for recipients if they meet
the coverage criteria.
1. Coverage and Limitations
a. Allergy to all preferred medications within the same class;
b. Contraindication to or drug-to-drug interaction with all preferred
medications within the same class;
c. History of unacceptable/toxic side effects to all preferred medications
within the same class;
d. Therapeutic failure of two preferred medications within the same class;
e. If there are not two preferred medications within the same class, therapeutic
failure only needs to occur on the one preferred medication;
f. An indication which is unique to a non-preferred agent, and is supported by
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peer-reviewed literature or a FDA-approved indication;
g. Psychotropic, Antidepressant Medication – Continuity of Care;
Recipients discharged from an institution on non-preferred psychotropic
and/or non-preferred anti-depressant medication(s), their drugs will
continue to be covered by Medicaid for up to six months to allow the
recipient time to establish outpatient mental health services;
h. For atypical or typical antipsychotic, anticonvulsant and antidiabetic
medications, the recipient demonstrated therapeutic failure on one preferred
agent.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms/aspx
C. Excluded
The DHCFP will not reimburse for the following pharmaceuticals:
1. Agents used for weight loss.
2. Agents used to promote fertility.
3. Agents used for cosmetic purposes or hair growth.
4. Yohimbine.
5. Drug Efficacy Study Implementation (DESI) list “Less than Effective Drugs”: In
accordance with current policy, federal financial participation is not allowed for
any drug on the Federal Upper Limit (FUL) listing for which the FDA has issued a
notice of an opportunity for a hearing as a result of the DESI program which has
been found to be a less than effective or is identical, related or similar to the DESI
drug. The DESI drug is identified by the FDA or reported by the drug manufacturer
for purposes of the Medicaid Drug Rebate Program. This listing is available on the
Centers for Medicare and Medicaid Services (CMS) website at:
http://www.cms.gov/MedicaidDrugRebateProgram/12_LTEIRSDrugs.asp
This includes pharmaceuticals designated “ineffective” or “less than effective”
(including identical, related or similar drugs) by the FDA as to substance or
diagnosis for which prescribed.
6. Pharmaceuticals considered “experimental” as to substance or diagnosis for which
prescribed. Pharmaceuticals manufactured by companies not participating in the
federal Medicaid Drug Rebate Program unless rated “1-A” by the FDA.
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7. Agents used for impotence/erectile dysfunction.
D. Refills
A refill is a prescription subject to the limitations below:
1. Authorized refills are valid only from the pharmaceutical provider dispensing the
original prescription, pursuant to Nevada Administrative Code (NAC) Chapter 639.
2. Refill intervals must be consistent with the dosage schedule indicated on the
original prescription. If a prescription is for a 34-day supply, a consistent refill
would be filled in 30 days; an inconsistent refill date would be filled in 20 days
from the original fill. Lost medications: Nevada Medicaid does not pay for
replacement of lost, stolen or otherwise destroyed medications even if a physician
writes a new prescription for the medication. It is the responsibility of the recipient
to replace these medications. Prior authorization may be granted in life-threatening
situations and for maintenance medications only. See “Maintenance Medications”
section for more information on maintenance medications.
E. Early Refills
1. Nevada Medicaid only pays for up to a 34-day supply of medications (100-day
supply for maintenance medications) for recipients each month. A prescription
refill will be paid for by Nevada Medicaid only when 80% of the non-controlled
substance prescription, and 90% of the controlled substance prescription, is used in
accordance with the prescriber’s orders on the prescription and on the label of the
medication.
2. In areas for which an emergency or disaster has been declared, Medicaid will waive
the requirement for 80% of a non-controlled substance prescription to be used
before paying for refills. Prescriptions for non-controlled substances will be
covered up to 30 days after the declaration or until the end of the emergency or
disaster, whichever is later.
3. In the instance that a recipient will be out of town when a refill is due, the
pharmacist may enter the appropriate override code to allow an early refill. This
override will be monitored by Nevada Medicaid for misuse/abuse by the recipient
and/or provider.
4. Medicaid will not pay for an early prescription refill when gross negligence or
failure to follow prescriber’s prescription instructions has been displayed by the
recipient.
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Section:
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Subject:
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F. Maintenance Medications
1. Exceptions to the 34-day supply of medications are allowed for maintenance
medications.
2. Maintenance medications are required to be filled in three-month (100-day)
supplies.
3. A one-time initial fill of less than three months will be allowed for the first fill to
assure tolerability and compliance.
4. Prescription quantities may be reviewed; in those cases where less than a 30-day
supply of maintenance drug is dispensed without reasonable medical justification,
the dispensing fee may be disallowed.
5. The following drug categories are considered maintenance medications and are
required to be filled in three-month (100-day) supplies:
a. Antianginals;
b. Antiarrhythmics;
c. Antidiabetics;
d. Antihypertensives;
e. Cardiac Glycosides;
f. Diuretics;
g. Estrogens; and
h. Progesterone.
6. Contraceptive drugs are considered maintenance medication. Contraceptive drugs
that are approved by the FDA are covered up to a 12-month supply.
a. This includes a drug for contraception or its therapeutic equivalent;
insertion of a device for contraception; removal of such a device that was
inserted while the insured was covered by the same policy of health
insurance; education and counseling relating to contraception; management
of side effects relating to contraception; and voluntary sterilization for
women.
b. Up to three months of contraception may be dispensed immediately, and up
to nine months of contraception may be dispensed at the subsequent visit.
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c. For a refill following the initial dispensing of a contraceptive drug, the
provider may dispense up to a 12-month supply or any amount that covers
the remainder rolling year.
d. If a prescription for a contraceptive drug is less than a one-year period, the
provider must dispense the contraceptive in accordance with the quantity
specified in the prescription order.
7. Anticonvulsants and thyroid preparations are considered maintenance medications,
but are not required to be filled in a three-month (100-day) supply.
8. Medications administered in a skilled nursing facility or physician’s office are
exempt from the three-month (100-day) supply requirement.
9. In long-term care facilities, if the prescriber fails to indicate the duration of therapy
for a maintenance drug, the pharmacy must estimate and provide at least a 30-day
supply. Exceptions may be based on reasonable stop orders. (For oral liquid
medications only, a 16 fluid ounce quantity will be considered sufficient to fulfill
the 30-day supply requirement.)
G. Emergency supply of medication
1. In an emergency situation, dispensing of up to a 96-hour supply of covered
outpatient drugs that require prior authorization will be allowed.
2. Nevada Medicaid requires prior payment authorization for medications identified
as requiring prior authorization.
3. The physician must indicate the diagnosis on the prescription (preferably with an
International Classification of Disease (ICD) code) to support the use of the
emergency policy.
4. As a follow-up to the dispensing of the emergency supply of medication, the
provider must contact the QIO-like vendor to obtain a verbal verification number.
5. An approved prior authorization (if required) will be necessary to get additional
medication.
H. Nevada Check Up (NCU)
All coverage and limitation policies and rules, including any prior authorization
requirements, outlined in this chapter apply to NCU recipients as well as Nevada Medicaid
FFS recipients. There are NO exceptions.
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I. Vaccines
Nevada Medicaid recognizes the importance of preventative health care through vaccines
and immunizations. Unless otherwise stated in this chapter, vaccines are covered without
prior authorization. Reference Appendix A of this chapter.
1. Childhood vaccines: All childhood vaccines are covered without prior
authorization under the Healthy Kids Program. Refer to MSM Chapter 1500,
Healthy Kids Program for more information on childhood vaccines.
2. Adult vaccines: Adult vaccines such as tetanus, flu vaccine and pneumococcal
vaccine are covered without prior authorization. For a list of covered adult vaccines,
please reference the Physician’s Fee Schedule at:
http://dhcfp.nv.gov/Resources/Rates/FeeSchedules/
3. Human Papillomavirus (HPV) Vaccine: The 9-valent HPV vaccine (for both males
and females) is covered for Medicaid eligible recipients ages nine years through 45
years, based on the US FDA approved indications. These may be accessed by
following the link: https://www.fda.gov/vaccines-blood-
biologics/vaccines/gardasil. The HPV vaccines are available through the State
Division of Public and Behavioral Health (DPBH) as part of the Vaccines for
Children (VFC) program for eligible females and males age nine through 18 years.
Please refer to MSM Chapter 1500 for more information on the VFC program.
4. Pharmacies may administer childhood and adult vaccines/immunizations.
a. Pharmacies must adhere to all Nevada State Board of Pharmacy (BOP)
regulations regarding vaccine/immunization administration including
certification to administer as documented in NAC Chapter 639.
b. Pharmacies must receive childhood vaccinations through the VFC Program.
The DHCFP or Nevada Medicaid and NCU do not reimburse for vaccines
included in the VFC Program.
c. Covered vaccinations not included in the VFC Program will be
reimbursable per the Nevada Medicaid and NCU Pharmacy Manual.
d. If the pharmacist administers the vaccinations, the dispensing fee will not
be reimbursed. An administration fee is paid instead.
J. Pharmacist Submitted Prior Authorizations
1. The DHCFP will allow pharmacists to submit a prior authorization if:
a. The requesting pharmacist has access to the recipient’s medical records.
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K. Dispensing Practitioners:
1. Must have a current Certificate of Registration through the Nevada State Board of
Pharmacy. Refer to NRS 639.070 and NAC 639.390; and
2. Must be enrolled with Nevada Medicaid provider enrollment as a Provider Type
(PT) 28; and
3. Dispensing practitioners’ offices must be located in the State of Nevada; and
4. All prior authorization criteria and quantity limitations apply to dispensing
practitioner claims; and
5. Only PT 28 can be reimbursed for a dispensing fee; and
6. All claims must be submitted in the National Council for Prescription Drug
Programs (NCPDP) format through Medicaid’s Point of Sale (POS) system; and
7. All dispensing practitioners must be compliant with all applicable BOP statutes and
regulations.
1203.1A PROVIDER RESPONSIBILITY
1. The pharmaceutical provider will maintain records for all prescriptions dispensed to
eligible recipients as may be required.
a. The provider will allow, upon request of proper representative, access to all records
that pertain to Medicaid recipients for fiscal review, audit or utilization review.
b. All fiscal records are to be maintained for a period of six years or as specified in
federal regulation.
2. Utilization Control
a. Prospective (Concurrent) Drug Utilization Review (Pro-DUR)
Pro-DUR functions will be carried out via the POS Systems.
1. Pro-DUR edits apply to POS claims.
2. Long Term Care (LTC) claims are subject to all Pro-DUR edits that apply
to retail.
3. Providers may submit override codes using the (NCPDP) standard
interactive DUR codes. Override codes may be submitted on the initial
claim. A denied claim does not have to be on file.
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4. No long term override codes are issued, codes must be entered each time
errors occur. Reference the Nevada Medicaid and NCU Pharmacy Manual
for more information on the current Pro-DUR edits and override
procedures.
5. All drugs are subject to quantity limitations. Refer to the Nevada Medicaid
and NCU Pharmacy Manual for established quantity limits.
b. Retro Drug Utilization Review (DUR)
Both recipient and provider profiles (i.e. claim payments) are reviewed to identify
patterns of excess. Verification of receipt of services is ongoing on a sample basis.
Providers may be audited on site.
c. Drug Utilization Review (DUR)
Nevada Medicaid policy and federal law allows the state appointed DUR Board to
conduct review of the information compiled about individual clients and providers
and allows the DUR Board to educate Medicaid providers about the changes in
drug therapeutics. Educational programs may include information such as drug
interactions between medications that physicians have prescribed for the clients and
medications they are prescribing that are unnecessarily expensive. In this case,
educational efforts will be directed to help providers improve their efficiency in the
allocation of the finite resources available for Medicaid clients.
d. Eligibility
Please refer to MSM Chapter 100 for information on Medicaid eligibility, eligibility
verification and the Eligibility Verification System (EVS).
e. Pharmacy Lock-In Program
The Pharmacy Lock-In Program is intended to prevent recipients from obtaining
excessive quantities of controlled substances through multiple visits to physicians,
clinics, and pharmacies.When a recipient has shown patterns of abuse/misuse of
Nevada Medicaid benefits, or the DHCFP has determined that the recipient requires
close medical management, the recipient may be “locked-in” to a specific
pharmacy. This means that Medicaid will only pay for controlled substance
prescriptions at a single pharmacy.
1. Pharmacy Lock-In Criteria.
a. The DHCFP conducts a comprehensive clinical review to determine
whether a recipient should be “locked-in” to a single pharmacy
using the following criteria:
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1. The recipient has filled ten or more controlled substance
prescriptions in the past 60-day period (includes controlled
substance pharmaceuticals given in the emergency room);
and
2. One of the following:
a. The recipient has utilized more than one pharmacy in
the past 60-day period; or
b. The recipient has utilized more than three physicians
in the past 60-day period; or
c. The recipient has utilized the emergency room(s) for
receiving controlled substances; or
d. The recipient has been diagnosed with a drug
dependency related condition; or
e. The dispensed quantity per prescription of controlled
substances appears excessive by the clinical review
team; or the recipient has other noted drug seeking
behaviors.
b. Recipients who are locked-in to one pharmacy are issued a written
Notice of Decision (NOD) 15 days prior to the implementation of
the pharmacy restriction. The NOD includes the individual’s right
to request a fair hearing within 90 days if he/she disagrees with the
findings and/or the DHCFP’s action.
c. The DHCFP assigns the pharmacy most frequently used by the
recipient for access of controlled substance prescriptions. Recipients
may change their locked-in pharmacy by contacting their Medicaid
District Office.
d. Upon implementation of pharmacy lock-in, the POS system will not
allow another pharmacy to bill for controlled substance
prescriptions, and a message will be given at the time of service to
notify the pharmacy that the recipient is locked-in. Any non-
controlled substance prescriptions can be filled at any pharmacy.
2. Duration of Lock-In Status.
a. Initially, a recipient remains in lock-in status for period lasting 36
months. Utilizing the pharmacy lock-in criteria, the DHCFP
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conducts a clinical review not less than a month prior the 36-month
mark to determine whether the recipient will remain or may be
removed from lock-in status.
1. A recipient may be placed on a second lock-in period lasting
108 months, if determined by the DHCFP that the recipient
is continuing to obtain excessive and/or inappropriate
controlled substance prescription or requires additional close
medical management or monitoring. Recipients placed on a
second lock-in period are re-evaluated at every 108-month
period to determine whether lock-in status still appropriate
or may be removed from lock-in status.
2. A written NOD is issued by the DHCFP 15 days prior the
effective date of continuation or removal of the pharmacy
restriction. The NOD includes the individual’s right to
request a fair hearing within 90 days if he/she disagrees with
the findings and/or the DHCFP action.
b. Recipients in lock-in status who are transitioning from a Nevada
Medicaid contracted Managed Care Organization (MCO) will start
a new initial 36-month lock-in period.
3. Pharmacy Lock-In Exemption
a. Some circumstances allow a recipient to receive medications from a
pharmacy other than their assigned locked-in pharmacy. A
Pharmacy may call the Technical Call Center to request an override
if:
1. The locked-in pharmacy is out of stock.
2. The locked-in pharmacy is closed.
3. The recipient is out of town and cannot access the locked-in
pharmacy.
3. Generic Substitution
Per NRS Chapter 639, if the practitioner has not indicated that generic substitution is
prohibited, the pharmacy provider must dispense, in substitution, another drug which is
available to him if the other drug:
a. is less expensive than the drug prescribed by brand name;
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b. is biologically equivalent to the drug prescribed by brand name;
c. has the same active ingredient or ingredient of the same strength, quantity and form
of dosage as the drug prescribed by brand name; and
d. is of the same generic type as the drug prescribed by brand name the least expensive
of the drugs that are available to him for substitution.
The pharmacy provider shall substitute the least expensive of the drugs available to him/her
for substitution.
4. Prescriber Brand Certification
Upper Limit cost limitations specified in this Chapter will not apply when a prescriber
certifies that a specific brand of medication is medically necessary for a particular patient.
The physician should document in the patient’s medical record the need for the brand name
product in place of the generic form. The procedure for certification must comply with the
following:
a. The certification must be in the physician's own handwriting.
b. Certification must be written directly on the prescription blank.
c. The phrase “Dispense as written” is required on the face of the prescription. For
electronically transmitted prescriptions “Dispense as written” must be noted. Not
acceptable: A printed box on the prescription blank checked by the prescriber to
indicate “brand necessary” or a handwritten statement transferred to a rubber stamp
and then stamped on the prescription.
d. A prior authorization is required to override genetic substitution.
e. Certification is not required if a generic is not manufactured.
f. A fax copy/verbal order may be taken by the pharmacist from the physician, but
the pharmacy must obtain an original printed copy and keep on file.
1203.1B SERVICE DELIVERY MODEL
For the rate and reimbursement methodology see MSM Chapter 700, Rates. For POS claims refer
to the Pharmacy Manual, and for Medicaid Management Information System (MMIS) claims refer
to the Nevada Medicaid and NCU Billing Manual (Billing Manual).
1. Institutional settings
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a. Medical/Surgical, Specialty, Psychiatric Hospitals and free-standing inpatient
hospice facilities – All pharmacy services are included in the daily per diem rate
for inpatient services, which are billed through MMIS.
b. Long Term Care (LTC)
1. Nursing Facilities (NF) – Legend (prescription) pharmaceutical services are
excluded from the daily per diem facility rate. This includes compound
prescriptions and Total Parenteral Nutrition (TPN) solution and additives.
Legend pharmaceuticals are billed separately directly by a licensed
pharmacy through POS.
Non-legend (over the counter) pharmaceuticals are not separately
reimbursable by the DHCFP.
2. Intermediate Care Facilities for Individuals with Intellectual Disabilities
(ICF/IID) – Legend and non-legend pharmaceuticals are excluded from the
facility rate. Pharmaceuticals are billed directly by a licensed pharmacy
through POS.
3. Hospice services in NFs, all drugs related to the documented terminal illness
and palliative, symptom relief are to be covered by the hospice and will not
be reimbursed by the DHCFP. Refer to MSM Chapter 3200, Hospice, for
more information.
2. Outpatient Pharmaceuticals
a. Covered outpatient drugs (COD(s)) are reimbursed separately from medical
services, in the following settings, in accordance with Section 1927 of the SSA.
1. Retail pharmacies (billed through POS).
2. Home Infusion Therapy (HIT)/Free Standing Infusion Clinics (billed
through POS).
a. Disposable supplies are billed separately with a 33 Provider Type
number (billed through MMIS).
b. Refer to the Nevada Medicaid and Check Up Pharmacy Billing
Manual.
3. COD(s) administered in an outpatient setting, such as a physician’s office
(NVPAD).
a. COD(s) are billed utilizing the appropriate National Drug Code
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(NDC) and NDC quantity (billed through MMIS).
b. The administration of the drug is billed using the appropriate
Current Procedural Terminology (CPT) code (billed through
MMIS).
4. Hospital based outpatient clinics.
a. COD(s) are billed utilizing the appropriate NDC and NDC quantity
(billed through MMIS).
b. The administration of the drug is billed using the appropriate CPT
code, (billed through MMIS).
5. End Stage Renal Disease (ESRD) Facilities.
a. Any COD(s) not included in the Prospective Payment System (PPS)
Rate are billed using the appropriate NDC and NDC quantity.
b. The administration of the drug is billed using the appropriate CPT
code, (billed through MMIS).
c. COD(s) included in the PPS Rate as documented in the CMS
Manual System, Publication # 100-04, Medicare Claims Processing,
Transmittal 2134 will deny if billed separately.
6. Emergency Rooms.
a. COD(s) are billed utilizing the appropriate NDC and NDC quantity
(billed through MMIS).
b. CODs are not reimbursed separately, in the following settings, in accordance with
1927(k)(2) of the SSA.
1. Ambulatory Surgical Centers (ASC). COD(s) are included in the facility
rate. COD(s) may not be billed separately.
2. Outpatient facilities/clinics/Federally Qualified Health Centers (FQHCs)
that are paid per encounter, cannot be reimbursed separately for CODs when
drugs are included in their encounter rate.
3. Outpatient hospice reimbursement for CODs related to the documented
terminal illness and palliative, symptom relief, are to be covered by the
hospice and will not be reimbursed by the DHCFP. Refer to MSM Chapter
3200, Hospice, for more information.
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3. Disposable Medical Supplies
Please refer to MSM Chapter 1300, Durable Medical Equipment (DME), for instructions
on billing and any applicable limitations for these items.
4. Unit Dose (Repackage and Re-Stock) Repackage
Nevada Medicaid provides reimbursement incentives for LTC providers who repackage
non-unit dose pharmaceuticals; An additional $0.43 per claim is given on pharmaceuticals
that are repackaged for unit dose dispensing. Pharmaceuticals that First Data Bank
classifies as unit dose products are not covered for this policy.
This incentive is available only to pharmacies supplying long-term care inpatients. The
pharmacy provider must apply to the QIO-like Vendor Pharmacy Department to enroll in
this incentive program.
In accordance with the CMS, State Medicaid Director Letter (SMDL) 06-005, repackaging
of pharmaceuticals must be in compliance with the Nevada State BOP. In addition, NFs
must properly credit the Medicaid program for the return of unused prescription medicines
upon discontinuance of the prescription or transfer, discharge or death of a Medicaid
beneficiary. This is to assure there is no double billing of the medication.
5. Coordination of Benefits (COB)
On-line COB (cost avoidance) is part of the Nevada Medicaid POS system.
a. If Nevada Medicaid is the recipient’s secondary carrier, claims for COB will be
accepted.
b. Nevada Medicaid is always the payer of last resort.
c. Other coverage will be identified by the presence of other carrier information on
the recipient eligibility file.
d. If the recipient shows other coverage, the claim will be denied. The POS system
will return a unique client-identified carrier code identifying the other carrier, the
recipient’s policy number and the carrier name in the additional message filed. It is
possible that a recipient may have more than one active other carrier; in that case,
the returned code will be from the first carrier, subsequent codes will be returned
until fully exhausted. Providers will be required to submit this code OTHER
PAYER ID (#340-7C) field as part of the override process.
e. Even if “no other insurance” is indicated on the eligibility file, the claim will be
processed as a Third Party Liability (TPL) claim if the pharmacy submits.
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f. If other insurance is indicated on the eligibility file, the claim will be processed as
a TPL regardless of what TPL codes the pharmacy submits.
g. In all cases, the Nevada Medicaid “allowed amount” will be used when calculating
payment. In some cases, this may result in a “0” payment, when the insurance
carrier pays more than the Medicaid “allowable amount.”
h. In order to facilitate the TPL/COB process, Nevada Medicaid will allow providers
to override “days supply limits” and/or “Drug Requires prior authorization”
conditions by entering a value of “5” (exemption from prescription limits) in the
PA/MC CODE field (NCPCP #416DG) if there are no prior authorization
requirements on these drugs from the primary insurer.
6. Pharmacy Billing Process
a. NCPDP Standard Billing Units
Nevada Medicaid reimburses for outpatient pharmaceuticals according to NCPDP
“Billing Unit Standard Format” guidelines. The standard provides for the billing of
pharmaceuticals in one of three billing units for all drug products. These units are
“each,” “milliliter (ml),” and “gram (g).” The following guidelines are to be used
when billing Nevada Medicaid for pharmaceuticals:
Tablets, Capsules, Suppositories, Pre-filled Syringes: must be billed by “each” or
by “mls.” For example, if 30 tablets of Metformin are dispensed, the quantity will
be 30.
Liquids, Liquid Orals, Suspensions, Solutions, Opthalmic/Otic Solutions: must be
billed by milliliters (mls). For example, if 560ml of guiafenesin is dispensed, the
quantity entered will be 560.
PLEASE NOTE:
Ounces must be converted to ml (1 ounce = 30ml).
Liters must be converted to ml (1L = 1000ml).
Ointments, Bulk Powders: must be billed by grams. For example, if a two ounce
tube of oxiconazole nitrate is dispensed, the quantity entered will be 60.
PLEASE NOTE:
Ounces must be converted to grams (1 ounce = 30g, ½ ounce = 15g). Oral
Contraceptives/Therapy packs: must be billed per “each” tablet dispensed, not the
number of packages. For example, Ortho Tri-Cyclen is a 28-day dial pack, the
quantity entered will be 28.
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Transdermal Patches/Powder Packets: must be billed per “each” patch/packet
dispensed, regardless of whether they are pre-packaged in a box or come in
individual pouches/packets. For example, Catapress-TTS comes in a box of four
patches. If two of these boxes are dispensed, the quantity entered will be eight.
Inhalers and Aerosols: must be billed as either grams or ml, as specified by the
manufacturer on the labeling. For example a 90mcg(microgram)/inh Albuterol
Inhaler has a total of 17gm in the canister. If one of these is dispensed, 17 will be
quantity entered.
Topical Products: must be billed as either grams or ml, as specified by the
manufacturer on the labeling.
PLEASE NOTE: Ounces must be converted to grams or ml.
1 ounce = 30ml
1 ounce = 30g
Reconstitutables (oral, otic, ophthalmic): must be billed per ml that are/will be in
the bottle after reconstitution according to the manufacturer’s instructions.
Liquid Injectables (vials, ampoules): must be billed by milliliters (ml). For
example, if a 10ml vial of Novolin 70/30 is dispensed, the quantity entered will be
10.
Powdered Injectables (vials): must be billed by “each” vial given per dose. For
example if the recipient receives Ampicillin 1g every six hours for one week, the
quantity entered will be 1, as only one vial is used per dose (assuming a 1gm vial
is used), and the number of doses entered will be 28 (four per day x seven days).
PLEASE NOTE: If the product is supplied with a diluent, the quantity entered is
only the number of powdered vials dispensed, the diluent is not factored in.
Intravenous Solutions: must be billed in ml administered per dose. For example, if
a recipient receives 250ml of Normal Saline four times per day, the quantity entered
will be 250, as that is the quantity per dose.
Blood Derived Products: products may vary in potency from batch to batch.
Anithemophilic products must be billed as the number of antihemophilic units
dispensed (each). Prolastin must similarly be billed as the number of milligrams
dispensed (each).
Kits: defined as products with at least two different or discreet items (excluding
diluents, applicators and activation devices) in the same package, intended for
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dispensing as a unit. Kits carry only a single NDC. Kits are intended to be dispensed
as a unit and should be billed as a unit of each kit dispensed (each).
For further information, refer to the NCPDP Billing Unit Standard Format Official
Release.
b. Provider Numbers
The state National Association of Boards of Pharmacy (NABP) provider number is
to be used and entered when billing online using the POS system or when using the
UCF.
7. State Maximum Allowable Cost (SMAC)
a. SMAC is the upper reimbursement limit for multi-source outpatient
pharmaceuticals established by the DHCFP or QIO-like vendor.
1. The DHCFP or QIO-like vendor will perform ongoing market analysis to
monitor pricing patterns and product availability.
2. The DHCFP or QIO-like vendor will perform monthly updates of the drugs
subject to the SMAC.
3. All drugs subject to the SMAC and updates will be posted on the following
website:
http://www.medicaid.nv.gov/providers/rx/MACinfo.aspx
b. Providers may appeal the current SMAC for a pharmaceutical product if a provider
determines that a particular multi-source drug is not available at the current SMAC
reimbursement.
1. The pharmacy must contact the QIO-like vendor technical call center to
initiate the appeal.
2. Information needed to make a decision will include the NDC number,
manufacturer, drug name, strength and price paid. A faxed copy of the
actual invoice for the drug may be requested.
3. Inquiries not resolved by the technical call center are forwarded to the QIO-
like vendor’s SMAC Coordinator for investigation and resolution.
4. If it is determined the SMAC is negatively impacting access to care for
recipients, the SMAC Coordinator has the authority to:
a. Adjust SMAC pricing for the particular claim being appealed; and
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b. Make changes to the SMAC pricing file.
5. Appeals will be responded to within three working days of the referral to
the SMAC Coordinator.
1203.1C PRIOR AUTHORIZATION PROCEDURES
1. Prior authorization requests may be done via phone, fax or via the internet. A facsimile
signature stamp is acceptable on faxed prior authorization requests.
2. Prior authorization requests must be submitted on the appropriate Prior Authorization
Request form. Pharmacy prior authorization forms can be found at the following web site:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. LTC drug claims are subject to prior authorization requirements.
4. The QIO-like vendor will process the prior authorization request within 24 hours of receipt.
a. The requesting practitioner will be advised of the prior authorization status
(approval, denial, pending further information) within 24 hours of the receipt.
b. For prior authorization requests in which the QIO-like vendor has pended the
request for further information, the prior authorization will deny if the practitioner
does not respond to a request for further information within three working days.
5. An approved prior authorization will be entered in the POS system prior to the dispensing
of the medication. There may be situations in which an authorization request is considered
after the fact (e.g. retroactive eligibility).
6. The Nevada Medicaid QIO-like vendor will send all Notice of Decision denial of service
letters. Reference MSM Chapter 3100 for the information on hearings.
7. Refer to the Nevada Medicaid and Check Up Pharmacy Billing Manual for more
information.
1203.2 INTRAVENOUS (IV) THERAPY
For specific instructions related to billing via the POS system, refer to the Nevada Medicaid Check-
Up Pharmacy Billing Manual.
A. Billing Guidelines
IV therapy is billed through the pharmacy POS system using the multi-ingredient
functionality. Drug coverage edits and prior authorization edits will be processed at the
individual ingredient level.
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B. Long Term Care (LTC)
1. For recipients in LTC, a daily dispensing fee of $10.17 will be applied to IV therapy
claims. This dispensing fee will be multiplied by the number of days the therapy
was provided
a. Non-Billable Items
IV hydration therapy of standard fluids without additives (e.g., antibiotics,
potassium and heparin) and supplies associated with IV therapy, enteral
nutrition and TPN administration are included in Nevada Medicaid’s
LTC/NF rate and may not be billed as a separate charge.
b. Billable Items
IV Drugs/TPN for recipients in LTC facilities may be billed as a separate
charge. Refer to MSM Chapter 500, Nursing Facilities, for further
information.
April 27, 2017 PRESCRIBED DRUGS Section 1203 Page 20
MTL 26/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1204
Subject:
MEDICAID SERVICES MANUAL HEARINGS
1204 HEARINGS
Please reference MSM Chapter 3100 for the Medicaid Hearings process.
October 1, 2015 PRESCRIBED DRUGS Section 1204 Page 1
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
DRUGS REQUIRING PRIOR AUTHORIZATION AND/OR QUANTITY LIMITATIONS............................... 6
A
ABSTRAL® (fentanyl citrate sublingual tablet) .................................................................................................... 19
ACTIQ® (fentanyl citrate transmucosal lozenge) .................................................................................................. 19
AGENTS USED FOR THE TREATMENT OF ATTENTION DEFICIT DISORDER (ADD)/ATTENTION
DEFICIT HYPERACTIVITY DISORDER (ADHD) ......................................................................................... 8
AIMOVIG® (erenumab-aooe) ............................................................................................................................... 57
AJOVY® (fremanezumab-vfrm) ............................................................................................................................ 57
ALBUTEROL NEBULIZER.................................................................................................................................. 61
AMITIZA® (lubiprostone) ................................................................................................................................... 142
AMPYRA® (dalfampridine) .................................................................................................................................. 75
ANTI-FUNGAL ONYCHOMYCOSIS.................................................................................................................. 22
ANTI-HEPATITIS AGENTS ................................................................................................................................. 90
ANTI-INSOMNIA AGENTS (Sedative Hypnotics) .............................................................................................. 63
ANTI-LIPIDEMIC AGENTS – PCSK9 INHIBITORS ....................................................................................... 159
ANTI-MIGRAINE MEDICATIONS ..................................................................................................................... 55
ANTIBIOTICS ..................................................................................................................................................... 192
ANTICONVULSANTS ........................................................................................................................................ 198
ANTIEMETICS ...................................................................................................................................................... 65
ANTIHEMOPHILIA AGENTS ............................................................................................................................. 88
AUSTEDO® (deutetrabenazine) .......................................................................................................................... 174
AUVI-Q® (epinephrine injection device) ............................................................................................................ 139
B
BENLYSTA® (belimumab) ................................................................................................................................... 24
BERINERT® (C1 esterase inhibitor) ................................................................................................................... 114
BEVYXXA® (betrixaban) ....................................................................................................................................... 7
BOTULINUM TOXIN ......................................................................................................................................... 188
BRILINTA® (ticagrelor) ...................................................................................................................................... 120
BRINEURA® (cerliponase alfa) .......................................................................................................................... 176
BUPRENORPHINE/NALOXONE ........................................................................................................................ 73
C
CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR INHIBITOR MEDICATIONS .................. 56
CANNABINOID ANTIEMETICS ......................................................................................................................... 65
CHRONIC IDIOPATHIC CONSTIPATION (CIC) AGENTS ........................................................................... 142
CINQAIR® (reslizumab)........................................................................................................................................ 43
CINRYZE® (C1 esterase inhibitor) ..................................................................................................................... 112
CODEINE AND TRAMADOL FOR CHILDREN .............................................................................................. 183
COLCHICINE (Colcrys®) ..................................................................................................................................... 84
COLONY STIMULATING FACTORS (POS CLAIMS ONLY) ....................................................................... 138
COMPOUNDED MEDICATIONS ...................................................................................................................... 190
CORLANOR® (ivabradine) ................................................................................................................................. 158
CYSTIC FIBROSIS AGENTS ............................................................................................................................. 116
D
DAKLINZA® (Daclatasvir) ................................................................................................................................... 95
DALIRESP® (roflumilast) ................................................................................................................................... 111
DOXEPIN TOPICAL ............................................................................................................................................. 64
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 1
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
DUCHENNE MUSCULAR DYSTROPHY (DMD) AGENTS .......................................................................... 169
DUEXIS® (ibuprofen/famotidine) ....................................................................................................................... 156
DUPIXENT® (dupilumab) ..................................................................................................................................... 47
E
EFFIENT® (prasugrel) ......................................................................................................................................... 120
ELIDEL® ............................................................................................................................................................... 36
EMGALITY® (galcanezumab-gnlm)..................................................................................................................... 57
EMFLAZA® (deflazacort) ................................................................................................................................... 170
ENTRESTO® (sacubitril/valsartan) ..................................................................................................................... 166
EPCLUSA® (sofosbuvir/velpatasvir) .................................................................................................................... 90
EPIDIOLEX® (cannabidiol) ................................................................................................................................ 198
EVENITY® (romosozumab-aqqg) ....................................................................................................................... 122
EVRYSDI® (risdiplam) ........................................................................................................................................ 26
EXONDYS 51® (eteplirsen) ................................................................................................................................ 169
F
FASENRA® (benralizamab) .................................................................................................................................. 46
FENTORA® (fentanyl citrate buccal tablet) .......................................................................................................... 19
FINTEPLA® (fenfluramine) ................................................................................................................................ 200
FIRAZYR® (icatibant) ......................................................................................................................................... 112
FORTEO® (Teriparatide) ..................................................................................................................................... 129
FUNCTIONAL GASTROINTESTINAL DISORDER AGENTS ....................................................................... 142
G
GnRH ANALOGS ................................................................................................................................................ 147
GONADOTROPIN RELEASING HORMONE RECEPTOR (GNRH) ANTAGONIST AND COMBINATIONS ......... 134
GROWTH HORMONES........................................................................................................................................ 10
H
HARVONI® (Ledipasvir/sofosbuvir) .................................................................................................................... 91
HEMATOPOIETIC/HEMATINIC AGENTS ........................................................................................................ 20
HEREDITARY ANGIOEDEMA AGENTS ........................................................................................................ 112
HETLIOZ® (tasimelteon)..................................................................................................................................... 165
HIGH DOLLAR CLAIM ..................................................................................................................................... 185
HORMONES AND HORMONE MODIFIERS ..................................................................................................... 82
I
IMMEDIATE-RELEASE FENTANYL PRODUCTS ........................................................................................... 19
IMMUNOMODULATOR DRUGS ....................................................................................................................... 32
INCRETIN MIMETICS ....................................................................................................................................... 115
INGREZZA® (valbenazine) ................................................................................................................................. 178
INVEGA TRINZA® (paliperidone palmitate) ..................................................................................................... 162
IRRITABLE-BOWEL SYNDROME AGENTS .................................................................................................. 142
K
KALBITOR® (ecallantide) .................................................................................................................................. 113
KALYDECO® (ivacaftor).................................................................................................................................... 116
L
LAZANDA® (fentanyl citrate nasal spray) ........................................................................................................... 19
LEMTRADA® (alemtuzumab) .............................................................................................................................. 75
LIDODERM 5% PATCHES® ............................................................................................................................... 40
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 2
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
LINZESS® (linaclotide) ....................................................................................................................................... 142
LONG-ACTING NARCOTICS ............................................................................................................................. 53
LOTRONEX® (alosetron).................................................................................................................................... 143
LUCEMYRA™ (lofexidine) .................................................................................................................................. 73
MAVENCLAD® (cladribine) ................................................................................................................................ 77
MAVYRET® (glecaprevir/pibrentasvir) ................................................................................................................ 96
MEDICATIONS FOR RECIPIENTS ON HOSPICE .......................................................................................... 163
MEDICATIONS FOR THE TREATMENT OF ACNE ...................................................................................... 141
MONOCLONAL ANTIBODY AGENTS ............................................................................................................. 41
MOTEGRITY® (prucalopride) ............................................................................................................................ 142
MULTIPLE SCLEROSIS (MS) AGENTS ............................................................................................................ 75
N
NARCOLEPSY AGENTS ................................................................................................................................... 151
NAYZILAM® (midazolam) ................................................................................................................................. 199
NEBULIZER SOLUTION ..................................................................................................................................... 61
NEUROKININ-1 ANTAGONISTS AND COMBINATIONS ............................................................................ 167
NUCALA® (mepolizumab) ................................................................................................................................... 43
NURTEC® (rimegepant) ........................................................................................................................................ 58
NUVIGIL® (armodafinil)..................................................................................................................................... 151
O
OCREVUS® (ocrelizumab) ................................................................................................................................... 78
OLYSIO® (simeprevir) .......................................................................................................................................... 90
OMONTYS® (Peginesatide) ................................................................................................................................ 137
ONSOLIS® (fentanyl citrate buccal film) .............................................................................................................. 19
OPIOIDS, OPIOID CONTAINING COUGH PREPARATIONS, OPIOIDS PRESCRIBED TO UNDER 18 .... 69
ORAL ONCOLOGY AGENTS ........................................................................................................................... 195
ORIAHNN® (elagolix, estradiol, and norethindrone) ......................................................................................... 135
ORILISSA® (elagolix) ......................................................................................................................................... 134
ORKAMBI® (lumacaftor/ivacaftor) .................................................................................................................... 116
OSTEOPOROSIS AGENTS ................................................................................................................................ 122
OVER-THE-COUNTER MEDICATIONS ............................................................................................................ 16
P
PLATELET INHIBITORS ................................................................................................................................... 120
PRALUENT® (alirocumab) ................................................................................................................................. 159
PROAIR® HFA ...................................................................................................................................................... 61
PROAIR RESPICLICK® ....................................................................................................................................... 61
PROLIA® (Denosumab) ...................................................................................................................................... 124
PROTON PUMP INHIBITORS (PPIs) .................................................................................................................... 6
PROTOPIC® .......................................................................................................................................................... 36
PROVENTIL® HFA .............................................................................................................................................. 61
PROVIGIL® (modafini) ....................................................................................................................................... 151
PULMONARY ARTERIAL HYPERTENSION AGENTS ................................................................................ 197
PSYCHOTROPIC MEDICATIONS FOR CHILDREN AND ADOLESCENTS ................................................. 37
Q__________________________________________________________________________________________
QUTENZA ® (capsaicin) ..................................................................................................................................... 172
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 3
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
R
RAYOS® (prednisone delayed-release) ............................................................................................................... 157
REPATHA® (evolocumab) .................................................................................................................................. 159
S
SAVELLA® (milnacipran)..................................................................................................................................... 72
SEROSTIM® (somatropin) .................................................................................................................................... 13
SEROTONIN 5-HT1 RECEPTOR AGONISTS (triptans) .................................................................................... 55
SEROTONIN RECEPTOR ANTAGONISTS (5 HT3 antiemetics) ...................................................................... 65
SHORT-ACTING BRONCHODILATORS ........................................................................................................... 61
SIVEXTRO® (tedizolid) ...................................................................................................................................... 192
SOMAVERT® (pegvisomant) ............................................................................................................................... 14
SOVALDI® (sofosbuvir) ....................................................................................................................................... 99
SPINAL MUSCULAR ATROPHY AGENTS ....................................................................................................... 26
SPINRAZA® (nusinersen) ..................................................................................................................................... 29
SPRAVATO™ (esketamine) ................................................................................................................................ 136
SUBSTANCE ABUSE AGENTS .......................................................................................................................... 73
SUBSYS® (fentanyl sublingual spray) .................................................................................................................. 19
SUNOSI® (solriamfetol) ...................................................................................................................................... 151
SYMDEKO® (tezacaftor/ivacaftor) ..................................................................................................................... 117
SYNAGIS® (Palivizumaub) .................................................................................................................................. 67
T
TECHNIVIE® (ombitasvir/paritaprevir/ritonavir) ............................................................................................... 107
THROMBIN INHIBITORS.................................................................................................................................... 87
TOBACCO CESSATION PRODUCTS ................................................................................................................ 60
TOPICAL ANDROGENS ...................................................................................................................................... 82
TOPICAL IMMUNOMODULATORS .................................................................................................................. 36
TORADOL® (ketorolac tromethamine) TABLETS .............................................................................................. 54
TRANSDERMAL FENTANYL ............................................................................................................................ 17
TRIKAFTA® (elexacaftor/tezacaftor/ivacaftor and ivacaftor) ............................................................................ 118
TRULANCE® (plecanatide) ................................................................................................................................ 142
TYMLOS® (abaloparatide) .................................................................................................................................. 131
U
UBRELVY® (ubrogepant) ..................................................................................................................................... 58
V
VALTOCO® (diazepam) ..................................................................................................................................... 199
VENTOLIN® HFA ................................................................................................................................................ 61
VIBERZI® (eluxadoline) ..................................................................................................................................... 143
VIEKIRA PAK®, (ombitasvir, paritaprevir, ritonavir tablets; dasabuvir tablets) ............................................... 102
VIMOVO® (naproxen/esomeprazole magnesium) .............................................................................................. 156
VIVITROL® (naltrexone) ...................................................................................................................................... 73
VOSEVI® (sofosbuvir/velpatasvir,voxilaprevir) ................................................................................................. 106
VYONDYS 53® (golodirsen) .............................................................................................................................. 171
W
WAKIX® (pitolisant) ........................................................................................................................................... 153
X
XADAGO® (safinamide) ..................................................................................................................................... 181
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 4
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
XARTEMIS® XR (oxycodone and acetaminophen) ........................................................................................... 146
XIFAXAN® (rifaximin) ....................................................................................................................................... 143
XOLAIR® (Omalizumab) ...................................................................................................................................... 41
XOPENEX®(Levalbuterol) .................................................................................................................................... 62
XYOSTED™ (testosterone enanthate) ................................................................................................................... 82
XYREM® (sodium oxybate) ................................................................................................................................ 151
XYWAV® (calcium, magnesium, potassium, and sodium oxybates) ................................................................. 154
Z
ZELNORM® (tegaserod) ..................................................................................................................................... 143
ZEPATIER® (elbasvir and grazoprevir) .............................................................................................................. 108
ZEPOSIA® (ozanimod).......................................................................................................................................... 79
ZOLGENSMA® (onasemnogene abeparvovec-xioi)............................................................................................. 30
ZORBTIVE®(somatropin) ..................................................................................................................................... 13
ZYVOX® (linezolid) ............................................................................................................................................ 193
All drugs in Appendix A may be subject to Quantity Limitations.
Check the Nevada Medicaid and Nevada Check Up Pharmacy Manual for a listing of the exact Quantity
Limitation.
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 5
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
1. DRUGS REQUIRING A PRIOR AUTHORIZATION AND/OR QUANTITY LIMITATION
A. Proton Pump Inhibitors (PPIs)
Therapeutic Class: Proton Pump Inhibitors
Last Reviewed by the DUR Board: April 30, 2020
PPIs are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Approval will be given if the following criteria are met and documented:
a. The recipient is not exceeding once daily dosing (quantity limit of one
unit/day).
b. Requests for PPIs exceeding once daily dosing must meet one of the
following:
1. The recipient has failed an appropriate duration of once daily
dosing; or
2. The recipient has a diagnosis of a hypersecretory condition (e.g.,
Zollinger-Ellison Syndrome), esophagitis, Barrett’s esophagitis,
reflux esophagitis or treatment of an ulcer caused by H.Pylori
c. Prior Authorization Guidelines
1. Prior authorization approval will be for up to 12 months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
August 31, 2020 PRESCRIBED DRUGS Appendix A Page 6
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
B. Bevyxxa® (betrixaban)
Therapeutic Class: Oral Anticoagulants
Last Reviewed by the DUR Board: January 25, 2018
Bevyxxa® (betrixaban) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Initial request:
1. The recipient has a diagnosis of prophylaxis of venous thromboembolism
(VTE); and
2. The recipient must be 18 years of age or older; and
3. The recipient has received Bevyxxa® during hospitalization and will be
continuing Bevyxxa® therapy following discharge from the hospital; and
4. The recipient is at risk for thromboembolic complications due to moderate
or severe restricted mobility and has other risk factors of VTE; and
5. The recipient has not received a cumulative 42 days of Bevyxxa® therapy.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for:
1. Prior Authorization Request: Up to a total treatment duration of 42 days.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
July 2, 2018 PRESCRIBED DRUGS Appendix A Page 7
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
C. Agents Used for the Treatment of Attention Deficit Disorder (ADD)/Attention Deficit
Hyperactivity Disorder (ADHD)
Therapeutic Class: ADD/ADHD Agents
Last Reviewed by the DUR Board: April 25, 2019
Agents for the treatment of ADD/ADHD are subject to prior authorization and quantity limits
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria is met and documented:
a. General Criteria (Children and Adults)
1. A diagnosis of ADD/ADHD or other FDA approved diagnosis.
2. Only one long-acting stimulant (amphetamine and methylphenidate
products) may be used at a time.
3. A 30-day transitional overlap in therapy will be allowed.
4. Other treatable causes of ADD/ADHD have been ruled out.
b. ADD/ADHD Criteria (Children up to age 18 years)
1. The recipient is at least three years of age (short-acting stimulants) or at
least six years of age (long-acting stimulants, long-acting alpha agonists,
atomoxetine).
An initial evaluation or regular examination has been done within the past
12 months with the treating prescriber.
2. Exception Criteria
a. Prescriptions for ADD/ADHD medications do not require prior authorization for
children five years of age, up to 18 years of age, if the following criteria are met
and documented:
1. The recipient is at least five years of age for short acting stimulants or at
least six years of age for long-acting stimulants, long acting alpha agonists,
atomoxetine);
2. The medication is prescribed by a psychiatrist; and
3. An ICD code for ADD with or without hyperactivity is documented on the
prescription and transmitted on the claim.
September 2, 2019 PRESCRIBED DRUGS Appendix A Page 8
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
3. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
September 2, 2019 PRESCRIBED DRUGS Appendix A Page 9
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
D. Growth Hormones
Therapeutic Class: Growth Hormone
Last Reviewed by the DUR Board: July 23,2020
Growth Hormones are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA Act and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Approval will be given if the following criteria are met and documented:
1. Children (with open epiphyses and with remaining growth potential) must
meet all of the following:
a. The recipient has had an evaluation by a pediatric endocrinologist
or pediatric nephrologist with a recommendation for growth
hormone therapy; and
b. The recipient has had an evaluation ruling out all other causes for
short stature; and
c. The recipient is receiving adequate replacement therapy for any
other pituitary hormone deficiencies, such as thyroid,
glucocorticoids or gonadotropic hormones.
The recipient must then meet one of the following:
1. The recipient has a diagnosis of Noonan Syndrome, Prader-
Willi Syndrome or Turner Syndrome and their height is at
least two standard deviations below the mean or below the
fifth percentile for the patient’s age and gender and the bone
age is less than 16 years for male recipients or less than 14
years for female recipients; or
2. The recipient has a diagnosis of Prader-Willi Syndrome; or
3. The recipient has a diagnosis of Turner Syndrome, is female
and has a bone age of less than 14 years; or
4. The recipient has a diagnosis of chronic renal insufficiency
(<75 mL/minute), and their height is at least two standard
deviations below the mean or below the third percentile for
the recipient’s age and gender; or
November 30, 2020 PRESCRIBED DRUGS Appendix A Page 10
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
5. The recipient has a diagnosis of being small for gestational
age, the recipient is two years of age or older, and the height
is at least two standard deviations below the mean or below
the third percentile for the recipient’s age and gender; or
6. The recipient is a newborn infant with evidence of
hypoglycemia, and has low growth hormone level (<20
ng/mL), low for age insulin like growth factor (IGF)-1 or
IGF binding protein (BP) 3 (no stimulation test required for
infants); or
7. The recipient has a diagnosis of growth hormone deficiency
or hypothalamic pituitary disease (e.g., hypopituitarism due
to structure lesions/trauma to the pituitary including pituitary
tumor, pituitary surgical damage, trauma or cranial
irradiation), and their height is at least two standard
deviations below the mean or below the third percentile for
the patient’s age and gender and their bone age is less than
16 years for male or less than 14 years for female.
And recipient must meet one of the following:
a. The recipient has failed two growth hormone
stimulation tests (<10 ng/mL); or
b. The recipient has failed one growth hormone
stimulation test (<10 ng/mL) and one IGF-1 or
IGFBP-3 test; or
c. The recipient has failed one growth hormone
stimulation test (<10 ng/mL) or IGF-1 or IGFBP-3
test and they have deficiencies in three or more
pituitary axes (e.g., thyroid stimulating hormone
(TSH), luteinizing hormone (LH), follicle
stimulating hormone (FSH), adrenocorticotropic
hormone (ACTH) or antidiuretic hormone (ADH)).
2. Adults (with closed epiphyses, and no remaining growth potential) must
meet all of the following:
a. The recipient is being evaluated by an endocrinologist; and
b. The recipient is receiving adequate replacement therapy for any
other pituitary hormone deficiencies, such as thyroid,
glucocorticoids or gonadotropic hormones; and
c. The recipient has a diagnosis of growth hormone deficiency or
hypothalamic pituitary disease (e.g., hypopituitarism due to
October 1, 2015 PRESCRIBED DRUGS Appendix A Page 11
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
structure lesions/trauma to the pituitary including pituitary tumor,
pituitary surgical damage, trauma or cranial irradiation); and
The recipient must then meet one of the following:
1. The recipient has failed two growth hormone stimulation
tests (<5 ng/mL); or
2. The recipient has failed one growth hormone stimulation test
(<5 ng/mL) and one IGF-1 or IGFBP-3 test; or
3. The recipient has failed one growth hormone stimulation test
(<5 ng/mL) or IGFBP-3 test and has deficiencies in three or
more pituitary axes (i.e., TSH, LH, FSH, ACTH, ADH), and
has severe clinical manifestations of growth hormone
deficiency as evident by alterations in body composition
(e.g., decreased lean body mass, increased body fat),
cardiovascular function (e.g., reduced cardiac output, lipid
abnormalities) or bone mineral density.
3. Continued authorization will be given for recipients (up to age 21, with
remaining growth potential) who meet all of the following:
a. The recipient has a diagnosis of chronic renal insufficiency, growth
hormone deficiency, hypothalamic pituitary disease, newborn infant
with evidence of hypoglycemia, Noonan Syndrome, Prader-Willi
Syndrome, small for gestational age or Turner Syndrome; and
b. The recipient’s epiphyses are open; and
c. The recipient’s growth rate on treatment is at least 2.5 cm/year; and
d. The recipient does not have evidence of an expanding lesion or
tumor formation; and
e. The recipient has not undergone a renal transplant.
4. Continued authorization will be given for recipients (age 21 years and
older, with closed epiphyses and no remaining growth potential) who meet
all of the following:
a. The recipient has a diagnosis of growth hormone deficiency or
hypothalamic pituitary disease; and
b. There is documentation of improvement in clinical manifestations
associated with growth hormone deficiency
5. Prior Authorization Guidelines
November 30, 2020 PRESCRIBED DRUGS Appendix A Page 12
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
a. Initial prior authorization will be for six months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
b. Serostim® (somatropin)
1. Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of Human Immune Deficiency Virus
(HIV) with wasting or cachexia; and
b. The medication is indicated to increase lean body mass, body weight
and physical endurance; and
c. The recipient is receiving and is compliant with antiretroviral
therapy; and
d. The recipient has experienced an involuntary weight loss of >10%
pre-illness baseline or they have a body mass index of <20 kg/m²;
and
e. The recipient has experienced an adverse event, allergy or
inadequate response to megestrol acetate, or the recipient has a
contraindication to treatment with this agent; and
f. The recipient has experienced an adverse event, allergy or
inadequate response to an anabolic steroid (e.g., testosterone,
oxandrolone, nandrolone) or the recipient has a contraindication to
treatment with these agents.
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 12 weeks.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Zorbtive® (somatropin)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient has a diagnosis of short bowel syndrome; and
b. The recipient is age 18 years or older; and
November 30, 2020 PRESCRIBED DRUGS Appendix A Page 13
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
c. The medication is being prescribed by or following a consultation
with a gastroenterologist; and
d. The recipient is receiving specialized nutritional support (e.g., high
carbohydrate, low-fat diets via enteral or parenteral nutrition).
2. Prior Authorization Guidelines
a. Initial authorization will be approved for six months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. Somavert® (pegvisomant)
1. Approval will be given if all the following criteria are met and
documented:
a. The recipient has a diagnosis of acromegaly; and
b. The recipient is 18 years age or older; and
c. One of the following:
1. The recipient has an inadequate response to one of the
following:
a. Surgery; or
b. Radiation Therapy; or
c. Dopamine agonist (e.g. bromocriptine, cabergoline)
therapy; or
2. The recipient is not a candidate for all the following:
a. Surgery; and
b. Radiation Therapy; and
c. Dopamine agonist (e.g. bromocriptine, cabergoline)
therapy; and
d. The recipient has tried and failed, a contraindication, or intolerance
to generic octreotide (a somatostatin analogue); and
November 30, 2020 PRESCRIBED DRUGS Appendix A Page 14
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e. The medication is prescribed by or in consultation with an
endocrinologist.
2. Recertification Criteria:
a. The recipient must meet the following:
1. The recipient must have a documented positive clinical
response to Somavert® therapy (e.g. biochemical control;
decrease or normalization of IGF-1 levels).
3. Prior Authorization Guidelines:
a. Initial authorization will be approved for 12 weeks.
b. Recertification approval will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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E. Over-the-Counter Medications
Last Reviewed by the DUR Board: N/A
Over-the-Counter (OTC) medications are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Any more than two prescription requests for medications within the same therapeutic class
will require prior authorization.
A Prior Authorization form must be submitted to the Nevada QIO-like vendor. The QIO-
like vendor will request further information needed on a case by case basis to determine
the necessity of the medication for the recipient.
Note: Insulin will be exempt from any prior authorization requirements.
Approval will be for a one month time limit.
Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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F. Transdermal Fentanyl
Therapeutic Class: Analgesics, Narcotic
Last Reviewed by the DUR Board: April 25, 2019
Transdermal fentanyl, a narcotic agonist analgesic, is indicated in the management of chronic pain
in patients requiring continuous opioid analgesia for pain that cannot be managed by lesser means
such as acetaminophen-opioid combinations, non-steroidal analgesics or PRN dosing with short-
acting opioids. Transdermal fentanyl is subject to prior authorization and quantity limitations based
on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Because serious or life-threatening hypoventilation could occur, fentanyl transdermal is
contraindicated in management of acute or postoperative pain, mild or intermittent pain
responsive to PRN or non-opioid therapy or in doses exceeding 25 mcg/hr at the initiation
of opioid therapy. Therefore, patients must meet the following criteria in order to gain prior
authorization approval:
a. Patient cannot be managed by lesser means such as acetaminophen-opioid
combinations, nonsteriodal analgesics or PRN dosing with short-acting opioid.
b. Patient requires continuous opioid administration.
c. Prescribers are required to check the Nevada State BOPs Prescription Monitoring
Program (PMP) prior to prescribing narcotic analgesics. Refer to the PMP website
at http://bop.nv.gov/links/PMP/.
d. If transitioning from another opioid, daily morphine equivalent doses are used to
calculate the appropriate fentanyl patch dose.
1. Morphine 60-134 mg/day PO; initial Transdermal Fentanyl dose 25 mcg/hr.
2. Morphine 135-224 mg/day PO; initial Transdermal Fentanyl dose 50
mcg/hr.
3. Morphine 225-314 mg/day PO; initial Transdermal Fentanyl dose 75
mcg/hr.
4. Morphine 315-404 mg/day PO; initial Transdermal Fentanyl dose 100
mcg/hr.
5. Morphine 405-494 mg/day PO; initial Transdermal Fentanyl dose 125
mcg/hr.
6. Morphine 495-584 mg/day PO; initial Transdermal Fentanyl dose 150
mcg/hr.
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7. Morphine 585-674 mg/day PO; initial Transdermal Fentanyl dose 175
mcg/hr.
8. Morphine 675-764 mg/day PO; initial Transdermal Fentanyl dose 200
mcg/hr.
9. Morphine 765-854 mg/day PO; initial Transdermal Fentanyl dose 225
mcg/hr.
10. Morphine 855-944 mg/day PO; initial Transdermal Fentanyl dose 250
mcg/hr.
11. Morphine 945-1034 mg/day PO; initial Transdermal Fentanyl dose 275
mcg/hr.
12. Morphine 1035-1124 mg/day PO; initial Transdermal Fentanyl dose 300
mcg/hr.
2. Prior Authorization Guidlines
a. Prior authorization approval will be given for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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G. Immediate-Release Fentanyl Products
Therapeutic Class: Analgesics, Narcotic
Last Reviewed by the DUR Board: July 25, 2013
Immediate-Release Fentanyl Products are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Subsys® (fentanyl sublingual spray), Onsolis® (fentanyl citrate buccal film),
Fentora® (fentanyl citrate buccal tablet), Lazanda® (fentanyl citrate nasal spray),
Abstral® (fentanyl citrate sublingual tablet) and Actiq® (fentanyl citrate
transmucosal lozenge):
The recipient must meet all of the following:
1. The recipient is > 18 years of age or > 16 years of age if requesting fentanyl
citrate transmucosal lozenge (Actiq®); and
2. The recipient has pain resulting from a malignancy; and
3. The recipient is already receiving and is tolerant to opioid therapy; and
4. The recipient is intolerant of at least two of the following immediate-release
opioids: hydrocodone, hydromorphone, morphine or oxycodone.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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H. Hematopoietic/Hematinic Agents
Therapeutic Class: Erythropoiesis Stimulating Agents (ESAs)
Last Reviewed by the DUR Board: October 17, 2019
This policy applies in all settings with the exception of inpatient facilities. Hematopoietics and
Hematinics are subject to prior authorizations and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. The recipient has been evaluated for adequate iron stores; and
b. Recent laboratory results are required for prior authorization, i.e. serum
hemoglobin, within seven days of prior authorization request; and
c. Recipients must meet one of the following criteria for coverage:
1. Achieve and maintain hemoglobin levels in one of the following conditions:
a. Treatment of anemia secondary to myelosuppressive anticancer
chemotherapy, Hb levels should not exceed 10 g/dL.
b. Treatment of anemia related to zidovudine therapy in HIV-infected
patients. Hb levels should not exceed 12 g/dL.
c. Treatment of anemia secondary to ESRD. Hb levels should not
exceed 11 g/dL if on dialysis or 10 g/dL if not on dialysis.
d. Epoetin alfa (Epogen®) is indicated to reduce the need for allogenic transfusions
in surgery patients when a significant blood loss is anticipated. It may be used to
achieve and maintain hemoglobin levels within the range of 10 to 13 gm/dl.
Darbepoetin Alfa (Aranesp®) does not have this indication.
2. Non-Covered Indications
a. Any anemia in cancer or cancer treatment patients due to folate deficiency, B-12
deficiency, iron deficiency, hemolysis, bleeding or bone marrow fibrosis.
b. Anemia associated with the treatment of acute and chronic myelogenous leukemias
(CML, AML) or erythroid cancers.
c. Anemia of cancer not related to cancer treatment.
d. Any anemia associated only with radiotherapy.
e. Prophylactic use to prevent chemotherapy-induced anemia.
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f. Prophylactic use to reduce tumor hypoxia.
g. Patients with erythropoietin-type resistance due to neutralizing antibodies.
h. Anemia due to cancer treatment if patients have uncontrolled hypertension.
3. Prior Authorization Guidelines
a. Prior approval will be given for a one month period.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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I. Anti-Fungal Onychomycosis
Therapeutic Class: Antifungal Agents
Last Reviewed by the DUR: September 3, 2015
Anti-Fungal Onychomycosis Agents are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. The agent is U.S. FDA approved for the treatment of onychomycosis (tinea
unguium).
b. And one of the following:
d. The recipient is experiencing pain which limits normal activity; or
2. The recipient’s disease is iatrogenically-induced; or
3. The recipient’s disease is associated with immunosuppression; or
4. The recipient has diabetes; or
5. The recipient has significant peripheral vascular compromise.
c. And the requested length of therapy is appropriate, based on the agent and infection
location.
d. And the drug and/or formulation-specific criteria is met:
1. Terbinafine: no pre-existing liver disease.
2. Itraconazole: The recipient does not have a diagnosis of heart failure and
there is no evidence of ventricular dysfunction.
3. Oral granules dosage form: clinical rationale documenting why the recipient
cannot or should not use terbinafine tablets or itraconazole capsules.
e. Topical dosage forms:
1. Inadequate response after an appropriate length of therapy with ciclopirox
8% solution or an adverse reaction or contraindication to ciclopirox 8%
solution; and
2. Inadequate response after an appropriate length of therapy to either
terbinafine tablets or itraconazole capsules or an adverse reaction or a
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contraindication to terbinafine tablets or itraconazole capsules or a clinical
rationale why the recipient cannot use terbinafine tablets or itraconazole
capsules.
f. Onmel (itraconazole) tablets: Clinical rationale documenting why the recipient
cannot or should not use terbinafine tablets or itraconazole capsules.
2. Prior Authorization Guidelines
a. The extent of prior authorization approvals will be based on the appropriate use for
the individual agents.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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J. Benlysta® (belimumab)
Therapeutic Class: Benlysta® (belimumab)
Last Reviewed by the DUR Board: January 25, 2018
Benlysta® (belimumab) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Initial request:
1. The recipient has a diagnosis of active Systemic Lupus Erythematosus
(SLE); and
2. The recipient must be 18 years of age or older; and
3. Documentation confirms that the recipient is autoantibody positive (i.e.,
anti-nuclear antibody (ANA) and/or anti-double-stranded DNA (anti-
dsDNA)); and
4. The recipient is currently receiving at least one standard of care treatment
for active SLE that includes one or more of the following agents (unless all
agents are contraindicated): antimalarials (e.g., Plaquenil
(hydroxychloroquine)), corticosteroids (e.g., prednisone), glucocorticoids,
or immunosuppressants (e.g., methotrexate, Imuran (azathioprine),
mycophenolate); and
5. The medication is prescribed by or in consultation with a rheumatologist;
and
6. The recipient must not have active CNS Lupus; and
7. The recipient must not currently be receiving treatment for a chronic
infection; and
8. The recipient must not have evidence of severe renal disease.
b. Recertification Request (the recipient must meet all the following criteria):
1. Authorization for continued use shall be reviewed at least every six months
when the following criteria are met:
a. Documentation of positive clinical response to Benlysta® therapy.
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2. Prior Authorization Guidelines
a. Prior authorization approvals will be for:
1. Initial request: six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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K. Spinal Muscular Atrophy (SMA) Agents
Therapeutic Class: Spinal Muscular Atrophy Agents
Last Reviewed by the DUR Board: January 28, 2021
SMA agents are subject to prior authorization and quantity limitatons based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid Check Up Pharmacy Manual for specific quantity limits.
1. Evrysdi® (risdiplam)
a. Approval will be given if the following criteria are met and documented:
1. Recipient has a diagnosis of SMA type I, II, or III; and
2. Both the following:
a. Recipient has mutation or deletion of genes in chromosome 5q
resulting in one of the following:
1. Homozygous gene deletion or mutation (e.g., homozygous
deletion of exon 7 at locus 5q13); or
2. Compound heterozygous mutation (e.g., deletion of survival
motor neuron 1 (SMN1) exon 7 [allele 1] and mutation of
SMN1 [allele 2]); and
b. Recipient has at least two copies of SMN2; and
3. Recipient is not dependent on invasive ventilation or tracheostomy and non-
invasive ventilation beyond use for naps and nighttime sleep; and
4. Recipient is at least two months of age or older; and
5. At least one of the following exams (based on the recipient’s age and motor
ability) have been conducted to establish baseline motor ability:
NOTE: Baseline assessments for patients less than two months of age
requesting risdiplam proactively are not necessary to not delay access to
initial therapy in recently diagnosed infants. Initial assessments shortly
post-therapy can serve as baseline with respect to efficacy reauthorization
assessment.
a. Hammersmith Infant Neurological Exam (HINE) (infant to early
childhood); or
b. Hammersmith Functional Motor Scale Expanded (HFMSE); or
c. Upper Limb Module (ULM) Test (Non ambulatory); or
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d. Children’s Hospital of Philadelphia Infant Test of Neuromuscular
Disorders (CHOP INTEND); or
e. Motor Function Measure 32 (MFM-32) Scale; and
6. The medication is prescribed by or in consultation with a neurologist with
expertise in the diagnosis and treatment of SMA; and
7. Recipient is not to receive concomitant chronic SMN modifying therapy for
the treatment of SMA (e.g. Spinraza®); and
8. One of the following:
a. Recipient has not previously received gene replacement therapy for
the treatment of SMA (e.g. Zolgensma®); or
b. Recipient has previously received gene therapy for the treatment of
SMA (e.g. Zolgesma®) and the provider attest that there has been
an inadequate response to gene therapy (e.g. sustained decrease in
at least one motor test score over a period of six months).
b. Recertification Request (recipient must meet all criteria):
1. The recipient has documentation of positive clinical response to therapy
from pretreatment baseline status as demonstrated by the most recent results
from one of the following exams:
a. One of the following HINE-2 milestones:
1. Improvement or maintenance of previous improvement of at
least a 2-point (or maximal score) increase in ability to kick;
or
2. Improvement or maintenance of previous improvement of at
least a 1-point increase in any other HINE-2 milestone (e.g.,
head control, rolling, sitting, crawling, etc.), excluding
voluntary grasp; or
3. Recipient exhibited improvement, or maintenance of
previous improvement in more HINE motor milestones than
worsening, from pretreatment baseline (net positive
improvement); or
4. The recipient has achieved and maintained any new motor
milestones when they would otherwise be unexpected to do
so (e.g., sit unassisted, stand, walk); or
b. One of the following HFMSE milestones:
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1. Improvement or maintenance of a previous improvement of
at least a 3-point increase in score from pretreatment
baseline; or
2. Recipient has achieved and maintained any new motor
milestone from pretreatment baseline when they would
otherwise be unexpected to do so (e.g., sit unassisted, stand,
walk); or
c. One of the following ULM test milestones:
1. Improvement or maintenance of a previous improvement of
at least a 2-point increase in score from pretreatment
baseline; or
2. Recipient has achieved and maintained any new motor
milestone from pretreatment baseline when they would
otherwise be unexpected to do so (e.g., sit unassisted, stand,
walk); or
d. One of the following CHOP INTEND milestones:
1. Improvement or maintenance of a previous improvement of
at least a 4-point increase in score from pretreatment
baseline; or
2. Recipient has achieved and maintained any new motor
milestone from pretreatment baseline when they would
otherwise be unexpected to do so (e.g., sit unassisted, stand,
walk); or
e. One of the following MFM-32 milestones:
1. Improvement or maintenance of a previous improvement of
at least a 3-point increase in score from pretreatment
baseline; or
2. Recipient has achieved and maintained any new motor
milestone from pretreatment baseline when they would
otherwise be unexpected to do so (e.g., sit unassisted, stand,
walk); and
2. Recipient remains not be dependent on invasive ventilation or tracheostomy
and use of non-invasive ventilation beyond use for naps and nighttime sleep;
and
3. The medication is prescribed by or in consultation with a neurologist with
expertise in the diagnosis and treatment of SMA; and
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4. Recipient is not to receive concomitant chronic SMN modifying therapy for
the treatment of SMA (e.g. Spinraza®); and
5. One of the following:
1. Recipient has not previously received gene replacement therapy for
the treatment of SMA (e.g. Zolgensma®); or
2. Recipient has previously received gene therapy for the treatment of
SMA (e.g. Zolgesma®) and the provider attest that there has been
an inadequate response to gene therapy (e.g. sustained decrease in
at least one motor test score over a period of six months).
c. Prior Authorization Guidelines:
1. Initial authorization will be approved for 12 months.
2. Recertification request will be approved for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Spinraza® (nusinersen)
a. Approval will be given if the following criteria are met and documented:
1. Initial request:
a. The recipient has a diagnosis of SMA, and
b. The medication is prescribed by or in consultation with a neurologist
who has experience treating SMA.
2. Recertification Request (the recipient must meet all the following criteria):
a. The recipient has been on therapy for less than 12 months; and
b. The recipient is maintaining neurological status; and
c. The recipient is tolerating therapy; and
d. The medication is prescribed by or in consultation with a neurologist
who has experience treating SMA, or all the following:
1. The recipient has been on therapy for 12 months or more;
and
2. The recipient has experienced a benefit from therapy (e.g.,
disease amelioration compared to untreated patients); and
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3. The recipient is maintaining neurological status; and
4. The recipient is tolerating therapy; and
3. Prior Authorization Guidelines
a. Initial request will be approved for 12 months.
b. Recertification request will be approved for 12 months.
c. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. Zolgensma® (onasemnogene abeparvovec-xioi)
a. Approval will be given if the following criteria are met and documented:
1. The recipient must be two years of age or younger; and
a. The recipient must have the mutation or deletion of genes in
chromosome 5q in one of the following: homozygous gene deletion
or mutation of SMN1 gene (e.g., homozygous deletion of exon 7 at
locus 5q13); or
b. Compound heterozygous mutation of SMN1 gene (e.g., deletion of
SMN1, exon 7 [allele 1] and mutation of SMN1 [allele 2]); and
1. The recipient has a diagnosis of SMA confirmed by a
neurologist with expertise in the diagnosis of SMA; or
2. The recipient has a diagnosis of SMA based on the results of
SMA newborn screening with three copies or less of SMN
2; and
c. The recipient is not dependent on either invasive ventilation or
tracheostomy or use of non-invasive ventilation beyond use of naps
and nighttime sleep; and
d. Submission of medical records (e.g., chart notes, laboratory values)
documenting the recipient’s anti-AAV9 antibody titers are less than
or equal to 1:50; and
e. The recipient is not to receive concomitant SMN modifying therapy
(e.g. Spinraza®); and
f. The medication is prescribed by a neurologist with expertise in the
diagnosis of SMA; and
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g. The recipient has never received Zolgensma® treatment in their
lifetime.
b. Prior Authorization Guidelines
1. Prior authorization approval is limited to once in a lifetime.
2. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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L. Immunomodulator Drugs
Therapeutic Class: Immunomodulators
Last Reviewed by the DUR Board: October 18, 2018
Actemra® (tocilizumab) Ilaris® (canakinumab) Remicade® (infliximab)
Amevive® (alefacept) Ilumya® (tildrakizumab) Renflexis® (infliximab)
Arcalyst® (rilonacept) Infle ctra® (infliximab) Siliq® (brodalumab)
Cimzia® (certolizumab pegol) Kevzara® (sarilumab) Simponi® (golimumab)
Consentyx® (secukinumab) Kineret® (ankinra) Simponi® ARIA™ (golimumab)
Enbrel® (etanercept) Olumiant® (baricitinib) Stelara® (ustekinumab)
Entyvio® (vedolizumab) Orencia® (abatacept) Taltz® (ixekizumab)
Humira® (adalimumab) Otezla® (apremilast) Xeljanz® (tofacitinib)
Immunomodulator Drugs are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. For all recipients:
1. The recipient has had a negative tuberculin test; and
2. The recipient does not have an active infection or a history of recurring
infections; and
3. The approval will not be given for the use of more than one biologic at a
time (combination therapy); and
4. Each request meets the appropriate diagnosis-specific criteria (b-j).
b. Rheumatoid Arthritis (RA):
1. The recipient has a diagnosis of moderately to severely active RA; and
2. The recipient is 18 years of age or older; and
3. The recipient has had a rheumatology consultation, including the date of the
visit; and one of the following:
a. The recipient has had RA for less than six months (early RA) and
has high disease activity; and an inadequate or adverse reaction to a
disease modifying antirheumatic drug (DMARD) (methotrexate,
hydroxychloroquine, leflunomide, minocycline and sulfasalazine);
or
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b. The recipient has had RA for greater than or equal to six months
(intermediate or long-term disease duration) and has moderate
disease activity and has an inadequate response to a DMARD
(methotrexate, hydroxychloroquine, leflunomide, minocycline or
sulfasalazine); or
c. The recipient has had RA for greater than or equal to six months
(intermediate or long-term disease duration) and has high disease
activity.
a. Psoriatic Arthritis:
1. The recipient has a diagnosis of moderate or severe psoriatic arthritis; and
2. The recipient is 18 years of age or older; and
3. The recipient has had a rheumatology consultation including the date of the
visit or a dermatology consultation including the date of the visit; and
4. The recipient had an inadequate response or a contraindication to treatment
with any one nonsteroidal anti-inflammatory (NSAID) or to any one of the
following DMARDs: methotrexate, leflunomide, cyclosporine or
sulfasalazine.
b. Ankylosing Spondylitis:
1. The recipient has a diagnosis of ankylosing spondylitis; and
2. The recipient is 18 years or older; and
3. The recipient has had an inadequate response to NSAIDs; and
4. The recipient has had an inadequate response to any one of the DMARDs
(methotrexate, hydroxychloroquine, sulfasalazine, leflunomide,
minocycline).
c. Juvenile Rheumatoid Arthritis/Juvenile Idiopathic Arthritis:
1. The recipient has a diagnosis of moderately or severely active juvenile RA
or juvenile idiopathic arthritis; and
2. The recipient is at an appropriate age, based on the requested agent, and:
a. Abatacept: Six years of age or older
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b. Adalimumab, canakinumab, etanercept, tocilizumab: Two years of
age or older.
3. And the recipient has at least five swollen joints; and
4. The recipient has three or more joints with limitation of motion and pain,
tenderness or both; and
5. The recipient has had an inadequate response to one DMARD.
d. Plaque Psoriasis:
1. The recipient has a diagnosis of chronic, moderate to severe plaque
psoriasis; and
2. The recipient is 18 years of age of older; and
3. The agent is prescribed by a dermatologist; and
4. The recipient has failed to adequately respond to a topical agent; and
5. The recipient has failed to adequately respond to at least one oral treatment.
g. Crohn’s Disease:
1. The recipient has a diagnosis of moderate to severe Crohn’s Disease; and
2. The recipient is at an appropriate age, based on the requested agent:
a. Adalimumab, infliximab: Six years of age or older.
b. All others: 18 years of age or older.
3. And the recipient has failed to adequately respond to conventional therapy
(e.g. sulfasalazine, mesalamine, antibiotics, corticosteroids, azathioprine, 6-
mercaptopurine, leflunomide); or
4. The recipient has fistulizing Crohn’s Disease.
h. Ulcerative Colitis:
1. The recipient has a diagnosis of moderate to severe ulcerative colitis; and
2. The recipient is at an appropriate age, based on the requested agent:
a. Infliximab: Six years of age or older.
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b. All others: 18 years of age or older.
3. And the recipient has failed to adequately respond to one or more of the
following standard therapies:
a. Corticosteroids;
b. 5-aminosalicylic acid agents;
c. Immunosuppressants; and/or
d. Thiopurines.
i. Cryopyrin-Associated Periodic Syndromes (CAPS): Familial Cold
Autoinflammatory Syndromes (FCAS) or Muckle-Wells Syndrome (MWS):
1. The recipient has a diagnosis of FCAS or MWS; and
2. The recipient is at an appropriate age, based on the requested agent:
a. Canakinumab: Four years of age or older.
b. Rilonacept: 12 years of age or older.
j. Cryopyrin-Associated Periodic Syndromes (CAPS): Neonatal-Onset Multisystem
Inflammatory Disease (NOMID):
1. The recipient has a diagnosis of NOMID.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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M. Topical Immunomodulators
Therapeutic Class: Topical Immunomodulators
Last Reviewed by the DUR Board: October 17, 2019
Topical Immunomodulators drugs are a subject to prior authorization and quantity limitations and
quantity limitations based on the Application of Standards in Section 1927 of the SSA and/or
approved by the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for
specific quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. Patient has a documented diagnosis of Atopic Dermatitis:
1. Elidel® for mild to moderate, for ages > two years.
2. Eucrisa® for mild to moderate, for ages ≥ two years.
3. Protopic® 0.03%; moderate to severe, for ages > two years.
4. Protopic® 0.1%; moderate to severe, for ages > 16 years.
b. Not for chronic use.
c. Elidel® is not recommended for use on patients with Netherton’s syndrome due to
the potential for systemic absorption.
d. Not recommended for use in immunocompromised patients.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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N. Psychotropic Medications for Children and Adolescents
Therapeutic Class: Psychotropic Agents
Last Reviewed by the DUR Board: July 23, 2020
Psychotropic medications for children and adolescents are subject to prior authorization based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for billing information.
Authorization will be given if the following criteria are met and documented.
1. Coverage and Limitations
The DHCFP requires prior authorization approval for children and adolescents for the
psychotropic therapeutic classes below and medication combinations considered to be
polypharmacy. The DHCFP has adopted the following practice standards to strengthen
treatment outcomes for our children and adolescents.
a. The psychotropic therapeutic classes subject to this policy are:
1. Antipsychotics
2. Antidepressants
3. Mood Stabilizers (including lithium and anticonvulsants used for behavioral
health indications.)
4. Sedative hypnotics
5. Antianxiety agents
b. For all children under 18 years of age, the following must be documented in the
medical record for authorization.
1. For psychotropic medications in this age group, when possible, be
prescribed by or in consultation with a child psychiatrist.
2. Psychotropic medication must be part of a comprehensive treatment plan
that addresses the education, behavioral management, living home
environment and psychotherapy.
3. Physician and/or prescriber monitoring is required while the recipient is
utilizing any psychotropic medication.
a. For recipients who are in initial treatment (have not received any
doses previously) or are continuing therapy but are considered
unstable (has had a dose change in the last three months), medical
documentation must support a monthly or more frequent visit with
the physician and/or prescriber. If the recipient was discharged from
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an institution on the medication, the follow-up visit(s) can be with
their treating physician and/or prescriber.
b. For recipients who are considered stable in their medication therapy,
medical documentation must support visits with the treating
physician at least every three months.
c. Polypharmacy: Each psychotropic medication prescribed must be independently
treating a specific symptom and/or diagnosis.
1. Polypharmacy (intra-class) is defined as more than one drug within the same
therapeutic class within a 60-day time period.
a. Prior authorization approval is required for two or more drugs in the
same therapeutic class within a 60-day period.
2. Polypharmacy (inter-class) is defined as more than one drug across different
therapeutic classes within a 60-day time period.
a. Prior authorization approval is required for four or more drugs
across all psychotropic therapeutic classes listed in this policy
within a 60-day time period.
3. Approval for polypharmacy may be given in situations where the requested
medication(s) will be used for cross tapering and situations where the
recipient will be discontinuing the previously prescribed agent. A 30-day
cross-taper will be allowed.
4. Approval for polypharmacy may be given for a medication to augment the
effect of another psychotropic medication as long as the purpose of the poly-
pharmacy is clearly documented in the recipient’s medical record and each
agent is supported by individual authorizations.
5. The recipient must have a trial of each individual medication alone. The
reasons for an inadequate response must be documented in the medical
record.
6. For intra-class and inter-class polypharmacy, all psychotropic medications
must be utilized for a medically accepted indication as established by the
FDA, and/or peer reviewed literature.
7. Polypharmacy rules will be bypassed for antidepressants, antipsychotics,
anticonvulsants, and mood stabilizers, if the medication is prescribed by a
board-certified child psychiatrist.
d. For children under six years of age, in addition to the Coverage and Limitation
requirements, all psychotropic medications require a prior authorization approval
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and must be utilized for a medically accepted indication as established by the FDA
and/or peer-reviewed literature.
e. Continuity of Care. In an effort to improve recipient safety and quality of care:
1. For recipients under 18 years of age, who have been discharged from an
institutional facility, they will be allowed to remain on their discharge
medication regimen for up to six months to allow the recipient time to
establish outpatient mental health services. The initial prior authorization
after discharge must document the name of the discharge institution and the
date of discharge.
2. For all other recipients under the age of 18, a six month prior authorization
will be granted to cover current medication(s) when it is documented that
the recipient has been started and stabilized. This will allow the recipient
time to establish services if necessary and to transition to medication(s) per
Nevada Medicaid policy.
2. Exceptions to Criteria for Anticonvulsants and ADD/ADHD Medications:
a. Treatment for seizure disorders with anticonvulsants are not subject to this policy.
The ICD Codes for Epilepsy and/or Convulsions will bypass the prior authorization
requirement at the pharmacy POS if the correct ICD Code is written on the
prescription and transmitted on the claim. Or the prior authorization requirement
will be overridden for anticonvulsant medications when the prescriber has a
provider Specialty Code of 126, neurology or 135, pediatric neurology, in the POS
system.
b. The current policy for treatment of ADD/ADHD is to be followed. Refer to this
Chapter’s Appendix A.
3. Prior Authorization Guidelines
a. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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O. Lidoderm 5% Patches®
Therapeutic Class: Topical, Local Anesthetics
Last Reviewed by the DUR Board: October 17, 2019
1. Coverage and Limitations
Topical Lidoderm Patches® are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the
DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
Authorization will be given if one of the following criteria are met and documented:
a. If an ICD code for herpes zoster is documented on the prescription; or
b. Completion of a prior authorization documenting a diagnosis of Post Herpetic
Neuralgia/Neuropathy.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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P. Monoclonal Antibody Agents
Therapeutic Class: Respiratory Monoclonal Antibody Agents
Last Reviewed by the DUR Board: January 23, 2020
Monoclonal Antibody Agents are subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Xolair® (Omalizumab)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient will not use the requested antiasthmatic monoclonal
antibody in combination with other antiasthmatic monoclonal
antibodies.
2. All the following criteria must be met and documented for a
diagnosis of moderate to severe persistent asthma:
a. The recipient must be six years of age or older; and
b. The recipient must have a history of a positive skin test or
Radioallergosorbent (RAST) test to a perennial
aeroallergen; and
c. The prescriber must be either a pulmonologist or allergist/
immunologist; and
d. The recipient must have had an inadequate response, adverse
reaction or contraindication to inhaled, oral corticosteroids;
and
e. The recipient must have had an inadequate response, adverse
reaction or contraindication to a leukotriene receptor
antagonist; and
f. The recipient must have had a pretreatment serum total
Immunoglobulin E (IgE) level between 30 IU/mL and 700
IU/mL; and
g. The recipient's current weight must be recorded; and
h. The requested dose is appropriate for the recipient’s pre-
treatment serum IgE and body weight (see Table 1).
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2. All the following criteria must be met and documented for diagnosis of
chronic idiopathic urticaria (CIU):
a. The recipient is 12 years of age or older; and
b. The recipient must have had an inadequate response, adverse
reaction or contraindication to two different oral second-generation
antihistamines; and
c. The recipient must have had an inadequate response, adverse
reaction or contraindication to an oral second-generation
antihistamine in combination with a leukotriene receptor antagonist;
and
d. The prescriber must be either an allergist/immunologist,
dermatologist or a rheumatologist or there is documentation in the
recipient’s medical record that a consultation was done by an
allergist/immunologist, dermatologist or a rheumatologist regarding
the diagnosis and treatment recommendations; and
e. The requested dose is:
1. Initial therapy: 150 mg every four weeks or 300 mg every
four weeks and clinical rationale for starting therapy at 300
mg every four weeks has been provided.
2. Continuation of therapy: 150 mg or 300 mg every four
weeks.
3. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
Table 1: Dosing for Xolair® (omalizumab)*
Pre-treatment Body Weight (kg)
Serum IgE 30-60 >60-70 >70-90 >90-150
(IU/mL)
≥30-100 150 mg 150 mg 150 mg 300 mg
>100-200 300 mg 300 mg 300 mg 225 mg
>200-300 300 mg 225 mg 225 mg 300 mg
>300-400 225 mg 225 mg 300 mg
>400-500 300 mg 300 mg 375 mg
>500-600 300 mg 375 mg
>600-700 375 mg DO NOT DOSE
Every 2 Weeks Dosing
Every 4 Weeks Dosing
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b. Nucala® (mepolizumab), Cinqair® (reslizumab)
1. All the following criteria must be met and documented:
a. The recipient will not use the requested antiasthmatic monoclonal
antibody in combination with other antiasthmatic monoclonal
antibodies; and
b. The recipient must have a diagnosis of severe eosinophilic-
phenotype asthma; and
c. The recipient must be of FDA indicated appropriate age:
1. Mepolizumab: six years of age or older
2. Reslizumab: 18 years of age or older
d. And, the prescriber must be either a pulmonologist or allergist/
immunologist; and
e. The recipient must be uncontrolled on current therapy including
high dose corticosteroid and/or on a secondary asthma inhaler; and
f. There is documentation of the recipient’s vaccination status; and
g. The requested dose is appropriate:
1. Mepolizumab: 100 mg subcutaneously every four weeks.
2. Reslizumab: 3 mg/kg via intravenous infusion of 20 to 50
minutes every four weeks.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
c. Nucala® (mepolizumab) for the treatment of severe asthma
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of severe asthma; and
b. The asthma is an eosinophilic phenotype as defined by one of the
following:
1. Baseline (pre-treatment) peripheral blood eosinophil level
greater than or equal to 150 cells/microliter; or
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2. Peripheral blood eosinophil levels were greater than or equal
to 300 cells/microliter within the past 12 months; and
c. One of the following:
1. The recipient has had at least one or more asthma
exacerbations requiring systemic corticosteroid within the
past 12 months; or
2. The recipient has had prior intubation for an asthma
exacerbation; or
3. The recipient has had prior asthma-related hospitalization
within the past 12-months; and
d. The recipient is currently being treated with one of the following
(unless there is a contraindication or intolerance to these
medications)
1. Both the following:
a. High-dose inhaled corticosteroid (ICS) (e.g., greater
than 500 mcg fluticasone propionate
equivalent/day); and
b. Additional asthma controller medication (e.g.,
leukotriene receptor antagonist, long acting beta-2
agonist [LABA], theophylline); or
2. One maximally dosed combination ICS/LABA product
(e.g., Advair [fluticasone propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
e. The recipient age is greater than or equal to six years; and
f. The medication must be prescribed by or in consultation with one of
the following:
1. Pulmonologist; or
2. Allergist/Immunologist
2. Recertification request (the recipient must meet all the criteria)
a. Documentation of positive clinical response to therapy (e.g.
reduction in exacerbations, improvement in forced expiratory
volume in one second [FEV1], decreased use of rescue
medications); and
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b. The recipient is currently being treated with one of the following
unless there is a contraindication or intolerance to these
medications:
1. Both the following:
a. ICS; and
b. Additional asthma controller medication (e.g.,
leukotriene receptor antagonist, long acting beta-2
agonist [LABA], theophylline); or
2. A combination ICS/LABA product (e.g., Advair [fluticasone
propionate/salmeterol], Dulera [mometasone/formoterol],
Symbicort [budesonide/formoterol]); and
c. The medication must be prescribed by or in consultation with one of
the following:
1. Pulmonologist; or
2. Allergist/Immunologist
3. Prior Authorization Guidelines
a. Initial authorization will be approved for six months.
b. Recertification will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
d. Nucala® (mepolizumab) for the treatment of Eosinophilic Granulomatosis with
Polyangiitis (EGPA)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of EGPA; and
b. The recipient’s disease has relapsed or is refractory to standard of
care therapy (i.e. corticosteroid treatment with or without
immunosuppressive therapy); and
c. The recipient is currently receiving corticosteroid therapy; and
d. The medication must be prescribed or in consultation with one of
the following:
1. Pulmonologist; or
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2. Rheumatologist; or
3. Allergist/Immunologist.
2. Recertification Requests (the recipient must meet the following criteria)
a. Documentation of positive clinical response to therapy (e.g. increase
in remission time).
3. Prior Authorization Guidelines
a. Initial authorization will be approved for 12 months.
b. Recertification request will be approved 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
e. Fasenra® (benralizumab)
1. All the following criteria must be met and documented:
a. The recipient must be 12 years of age or older; and
b. The recipient will not use the requested antiasthmatic monoclonal
antibody in combination with other antiasthamtic monoclonal
antibodies; and
c. The recipient must have a diagnosis of severe eosinophilic
phenotype asthma; and
d. One of the following:
1. Patient has had at least two or more asthma exacerbations
requiring systemic corticosteroids within the past 12 months;
or
2. Any prior intubation for an asthma exacerbation; or
3. Prior asthma-related hospitalization within the past 12
months.
e. Patient is currently being treated with one of the following unless
there is a contraindication or intolerance to these medications:
1. Both a high-dose ICS (e.g., greater than 500 mcg fluticasone
propionate equivalent/day) and an additional asthma
controller medication (e.g., leukotriene receptor antagonist,
long-acting beta-2 agonist (LABA), theophylline); or
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2. One maximally dosed combination ICS/LABA product
(e.g., Advair (fluticasone propionate/salmeterol), Dulera
(mometasone/formoterol), Symbicort (budesonide/
formoterol)).
f. Prescribed by or in consultation with one of the following:
1. Pulmonologist; or
2. Allergy/Immunology specialist.
2. Recertification Request: Authorization for continued use shall be reviewed
at least every 12 months when the following criteria are met:
a. There is documentation of a positive clinical response (e.g.,
reduction in exacerbation).
b. Patient is currently being treated with one of the following unless
there is a contraindication or intolerance to these medications:
1. Both an ICS (5,E) and an additional asthma controller
medication (e.g., leukotriene receptor antagonist, long-
acting beta-2 agonist (LABA), theophylline); or
2. A combination ICS/LABA product (e.g., Advair (fluticasone
propionate/salmeterol), Dulera (mometasone/formoterol),
Symbicort (budesonide/formoterol)).
c. Prescribed by or in consultation with one of the following:
1. Pulmonologist; or
2. Allergy/Immunology specialist.
3. Prior Authorization Guidelines
a. Initial prior authorization will be for 12 months.
b. Recertification request will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
d. Dupixent® (dupilumab)
1. Atopic Dermatitis
a. Approval will be given if all the following criteria are met and
documented:
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1. The recipient must have a diagnosis of moderate to severe
atopic dermatitis; and
2. One of the following:
a. Trial and failure, contraindication, or intolerance to
one medium to high potency topical
corticosteroid(e.g. betamethasone, tramcinolone); or
b. Trial and failure or intolerance to one of the
following, unless the recipient is not a candidate for
therapy (e.g. immunocompromised)
1. Elidel® (pimecrolumus) topical cream; or
2. Tacrolimus topical ointment; and
3. The medication must be prescribed by or in consultation
with one of the following:
1. Dermatologist; or
2. Allergist/Immunologist
b. Recertification request (the recipient must meet all criteria)
1. Documentation of positive clinical response to Dupixent®
therapy.
c. Prior Authorization Guidelines
1. Initial authorization approval will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Eosinophilic Asthma
a. Approval will be given if all the following criteria are met and
documented:
1. The recipient has a diagnosis of moderate to severe asthma;
and
2. Asthma is an eosinophilic phenotype as defined by a
baseline (pre-treatment) peripheral blood eosinophil level
greater than or equal to 150 cells per microliter; and
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3. Age is greater or equal to 12 years; and
4. One of the following:
a. The recipient has had at least one or more asthma
exacerbations requiring systematic corticosteroid
within the past 12 months; or
b. The recipient has had prior intubation for an asthma
exacerbation; or
c. The recipient has had prior asthma-related
hospitalization within the past 12 months; and
5. The recipient is currently being treated with one of the
following unless there is a contraindication or ntolerance to
these medications:
a. Both the following:
1. High-dose ICS [e.g., greater than 500 mcg
fluticasone propionate equivalent/day]; and
2. Additional asthma controller medication
[e.g., leukotriene receptor antagonist, long
acting beta-2 agonist (LABA), theophylline];
or
b. One maximally dosed combination ICS/LABA
product (e.g., Advair [fluticasone
propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
6. The medication must be prescribed by or in consultation
with one of the following:
1. Pulmonologist; or
2. Allergist/Immunologist.
b. Recertification request (recipient must meet all the criteria):
1. Documentation of a positive clinical response to Dupixent
therapy (e.g., reduction in exacerbations, improvement in
FEV1, decreased use of rescue medications); and
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2. The recipient is currently being treated with one of the
following unless there is a contraindication or intolerance to
these medications:
a. Both the following:
1. Inhaled corticosteroid (ICS); and
2. Additional asthma controller medication
[e.g., leukotriene receptor antagonist, long
acting beta-2 agonist (LABA), theophylline];
or
b. A combination ICS/LABA product (e.g., Advair
[fluticasone propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
3. The medication is prescribed by or in consultation with one
of the following:
a. Pulmonologist; or
b. Allergist/Immunologist
c. Prior Authorization Guidelines
1. Initial prior authorization will be for six months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Oral Corticosteroid Dependent Asthma
a. Approval will be given if all the following criteria are met and
documented
1. The recipient must have a diagnosis of moderate to severe
asthma; and
2. The recipient is greater or equal to 12 years of age; and
3. The recipient is currently dependent on oral corticosteroids
for the treatment of asthma; and
4. The recipient is currently being treated with one of the
following unless there is a contraindication or intolerance to
these medications:
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a. Both the following:
1. High-dose ICS [e.g., greater than 500 mcg
fluticasone propionate equivalent/day]; and
2. Additional asthma controller medication
[e.g., leukotriene receptor antagonist, long
acting beta-2 agonist (LABA), theophylline];
or
b. One maximally dosed combination ICS/LABA
product (e.g., Advair [fluticasone
propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
5. The medication must be prescribed by or in consultation
with one of the following:
a. Pulmonologist; or
b. Allergist/Immunologist.
b. Recertification Request (the recipient must meet all criteria)
1. Documentation of a positive clinical response to Dupixent®
therapy (e.g., reduction in exacerbations, improvement in
FEV1, reduction in oral corticosteroid dose); and
2. The recipient is currently being treated with one of the
following unless there is a contraindication or intolerance to
these medications:
a. Both the following:
1. ICS; and
2. Additional asthma controller medication
[e.g., leukotriene receptor antagonist, long
acting beta-2 agonist (LABA), theophylline];
or
b. A combination ICS/LABA product (e.g., Advair
[fluticasone propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
3. The medication must be prescribed by or in consultation
with one of the following:
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a. Pulmonologist; or
b. Allergist/Immunologist.
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for six months.
2. Recertification approval will be 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)
a. Approval will be given if all the following criteria are met and
documented:
1. The recipient must have a diagnosis of CRSwNP; and
2. Unless contraindicated, the recipient has had an inadequate
response to two months of treatment with an intranasal
corticosteroid (e.g., fluticasone, mometasone) [Document
drug(s), dose, duration and date of trial]; and
3. The medication will not be used in combination with another
agent for CRSwNP; and
4. The medication must be prescribed by or in consultation
with an Allergist/Immunologist
b. Recertification request (the recipient must meet all criteria)
1. Documentation of a positive clinical response to therapy;
and
2. The medication will not be used in combination with another
agent for CRSwNP; and
3. The medication is prescribed by or in consultation with an
allergist/Immunologist.
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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Q. Long-Acting Narcotics
Therapeutic Class: Analgesics, Narcotic
Last Reviewed by DUR Board: April 28, 2016
Long-Acting Narcotics are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
The current criteria for the use of fentanyl transdermal patches (Appendix A, (F.)) or
oxycodone/acetaminophen ER tablets (Appendix A, (XX.)) is to be met.
For all other long-acting narcotics requests that exceed the quantity limit, the following
criteria must be met and documented:
a. The recipient has a diagnosis of terminal cancer; or
b. All the the following criteria must be met:
1. The recipient is 18 years of age or older; and
2. The requested agent will be used for the management of pain severe enough
to require daily, around-the-clock, long-term opioid treatment; and
3. There is documentation in the recipient’s medical record that alternative
agents (e.g., non-opioid analgesics or immediate-release opioids) are
ineffective, not tolerated or would be otherwise inadequate to provide
sufficient management of pain.
2. Prior Authorization Guidelines
a. The prior authorization approval will be for three months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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R. Toradol® (ketorolac tromethamine) tablets
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Last Reviewed by the DUR Board: April 30, 2020
Toradal® is subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Ketorolac is indicated for the short-term (up to five days) management of moderately
severe acute pain that requires analgesia at the opioid level. It is not indicated for minor or
chronic painful conditions. The following criteria must be met:
a. Oral treatment must be indicated only as continuation therapy to IV/IM therapy;
and
b. Oral treatment must not not to exceed five days; and
c. Oral treatment must not exceed 40 mg/day.
2. Prior Authorization Guidelines
a. Initial request will be approved for up to five days.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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S. Anti-Migraine Medications
Therapeutic Class: Serotonin 5-HT1 receptor agonists (triptans)
Last Reviewed by the DUR Board: July 25, 2019
Therapeutic Class: Calcitonin Gene-Related Peptide (CGRP) Receptor Inhibitor Medications
Last Reviewed by the DUR Board: April 22, 2021
Serotonin 5-HT1 receptor agonists commonly referred to as “triptans” and CGRP Receptor
Inhibitor medications or anti-migraine medications are subject to prior authorization and quantity
limitations based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Serotonin 5-HT1 Receptor Agonists (triptans)
a. An approved prior authorization is required for any prescription exceeding the
quantity limits. Approval for additional medication beyond these limits will be
considered only under the following circumstances:
1. The recipient’s current medication history documents the use of
prophylactic medications for migraine headache, or the medical provider
agrees to initiate such therapy which includes beta-blockers, tricyclic
antidepressants, anticonvulsants, Selective Serotonin Reuptake Inhibitors
(SSRIs) and/or calcium channel blockers; or
2. The medical provider is aware of and understands the implications of daily
use and/or overuse of triptans and agrees to counsel the patient on this issue
in an effort to taper the quantity of triptan medication required monthly.
a. Recipient’s current medication history must NOT have Monoamine
Oxidase (MAO) Inhibitors present for approval of Imitrex®
(sumatriptan), Maxalt® (rizatriptan) or Zomig® (zolmitriptan).
b. Recipients whose current medication history indicates the use of
propranolol will NOT be granted prior authorization of Maxalt®
(rizatriptan) 10mg tablet or 10mg orally disintegrating tablet.
c. Prior authorization will NOT be given to patients with ischemic
heart disease.
b. Prior Authorization Guidelines:
1. Approval for exceeding the quantity limits on triptans will be provided for
a two-month period.
2. The prior authorization must be initiated by the prescriber. The approved
prior authorization must be available if requested.
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3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. Calcitonin Gene-Related Peptide (CGRP) Receptor Inhibitor Medications
a. Approval will be given if the following criteria are met and documented:
1. CGRP General Criteria
a. The recipient must have one of the following:
1. Both the following:
a. The recipient has a diagnosis of episodic migraines;
and
b. The recipient has four to 14 migraine days per month,
but not more than headache days per month: or
2. All the following:
a. The recipient has a diagnosis of chronic migraines;
and
b. The recipient has greater than or equal to 15
headache days per month, of which at least eight
must be migraine days for at least three months; and
c. The recipient has been considered for medication
overuse headache (MOH) and potentially offending
medication(s) have been discontinued; and
b. The recipient is 18 years of age or older; and
c. The medication must be prescribed by or in consultation with either
a Neurologist or a Pain Specialist; and
d. The recipient must meet two of the following:
1. One of the following:
a. The recipient has documented history of failure (after
at least a two-month trial) or intolerance to Elavil®
(amitriptyline) or Effexor® (venlafaxine); or
b. The recipient has a contraindication to Elavil®
(amitriptyline) and Effexor® (venlafaxine); or
2. One of the following:
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a. The recipient has documented history of failure (after
at least a two-month trial) or intolerance to
Depakote®/Depakote® ER (divalproex sodium) or
Topamax® (topiramate); or
b. The recipient has a contraindication to both
Depakote®/Depakote® ER (divalproex sodium) and
Topamax® (topiramate); or
3. One of the following:
a. The recipient has documented history of failure (after
at least a two-month trial) or intolerance to one of the
following beta blockers:
1. Atenolol; or
2. Propranolol; or
3. Nadolol; or
4. Timolol; or
5. Metoprolol; or
b. The recipient has a contraindication to all the
following beta blockers:
1. Atenolol; or
2. Propranolol; or
3. Nadolol; or
4. Timolol; or
5. Metoprolol.
2. Recertification Request:
a. The recipient must have a documented positive response to
Aimovig® (erenumab-aooe), Ajovy® (fremanezumab-vfrm) or
Emgality® (galcanezumab-gnlm) therapy, demonstrated by a
reduction in headache frequency and/or intensity; and
b. The recipient has had a decrease in use of acute migraine
medications (e.g., NSAIDs, triptans) since the start of CGRP
therapy; and
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c. The medication must be prescribed by or in consultation with either
a Neurologist or a Pain Specialist; and
d. For chronic migraine only: The recipient continues to be monitored
for MOH.
3. Prior Authorization Guidelines:
a. Initial request will be approved for six months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Acute Migraines
a. Ubrelvy® (ubrogepant), Nurtec® ODT (rimegepant).
1. Approval will be given if all the following criteria are met and documented:
a. Recipient must have a diagnosis of acute migraine with or without
aura; and
b. Recipient is 18 years of age or older; and
c. The prescribed dose will not exceed two doses per migraine and
treating no more than eight migraine episodes per 30 days; and
d. The recipient has had at least one trial and failure of triptan agent;
and
e. The medication must be prescribed by or in consultation with either
a Neurologist or a Pain Specialist.
2. Recertification Request:
a. The recipient must have a documented positive response to the
CGRP therapy; and
b. The medication must be prescribed by or in consultation with either
a Neurologist or a Pain Specialist.
3. Prior Authorization Guidelines:
a. Initial request will be approved for six months.
b. Recertification request will be approved for 12 months.
c. Prior authorization forms are available at:
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https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Episodic Cluster Headache
a. Emgality® (galcanezumab-gnlm)
1. Approval will be given if all the following criteria are met
and documented
a. The recipient has a diagnosis of episodic cluster
headache; and
b. The recipient has experienced at least two cluster
periods lasting from seven days to 365 days,
separated by pain-free periods lasting at least three
months.
c. The recipient is 18 years of age or older.
d. The medication must be prescribed by or in
consultation with either a Neurologist or a Pain
Specialist.
2. Recertification Request:
a. The recipient has documented positive response to
Emgality® therapy, demonstrated by a reduction in
headache frequency and/or intensity; and
b. The medication must be prescribed by or in
consultation with either a Neurologist or a Pain
Specialist.
3. Prior Authorization Guidelines:
a. Initial request will be approved for three months.
b. Recertification request will be approved for 12
months.
c. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.
aspx
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T. Tobacco Cessation Products
Therapeutic Class: Tobacco Cessation Agents
Last Reviewed by the DUR Board: April 30, 2020
Smoking cessation products, including patches, gums, lozenges and inhalers (based on the
recipients’ route of choice), are subject to quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
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U. Short-Acting Bronchodilators
Therapeutic Class: Beta Adrenergic Agents
Last Reviewed by the DUR Board: January 24, 2019
Short-Acting Bronchodilators are subject to PA and quantity limitations based on the Application
of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. This criteria applies to, but is not limited to, the following list:
Proventil® HFA ProAir® HFA ProAir RespiClick®
Ventolin® HFA Albuterol Nebulizer Nebulizer Solution
a. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
1. Quantity Limits:
a. Albuterol Metered Dose Inhalers (MDI): two units per month.
b. Albuterol Nebulizer Solution: three bottles of 20ml each or 125
nebulizer units per month.
2. In order to exceed the quantity limit, a recipient must meet all of the
following:
a. The recipient must have a diagnosis of asthma; and
b. The recipient has been assessed for causes of asthma and external
triggers have been removed or reduced where possible.
3. For recipients 18 years of age or younger the following criteria must be met:
a. The recipient has a diagnosis of asthma; and
b. The recipient requires an additional inhaler unit for school or
equivalent program.
b. Prior Authorization Guidelines
1. Prior authorization approval will be for 12 months.
2. Prior authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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2. Xopenex®
a. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
1. Authorization only for recipients experiencing side effects on one other
beta-adrenergic agent of any formulation.
2. Authorization for patients whose cardiovascular status is considered to be
in severe deteriorating condition.
b. Prior Authorization Guidelines
Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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V. Anti-Insomnia Agents (Sedative Hypnotics)
Therapeutic Class: Anxiolytics, Sedatives and Hypnotics
Last Reviewed by the DUR Board: September 3, 2015
See Section N of this Appendix for criteria for Sedatives and Hypnotics when prescribed for a
psychotropic indication.
Sedatives Hypnotics are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented.
a. An FDA approved ICD diagnosis code, such as insomnia, is documented on the
prescription and transmitted on the claim; or
b. A PA with an FDA approved diagnosis, such as insomnia, is submitted.
2. Prior Authorization Guidelines
a. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms/aspx
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W. Doxepin Topical
Therapeutic Class: Other Topical Anti-Pruiritics
Last Reviewed by DUR Board: October 22, 2020
Doxepin Topical is subject to prior authorization and quantity limits based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for billing information.
1. Authorization will be given if the following criteria are met and documented:
a. The recipient has a documented diagnosis of pruritus with atopic dermatitis or
lichen simplex chronicus; and
b. The recipient is 18 years of age or older; and
c. Treatment must not exceed eight days.
2. Prior Authorization Guidelines:
a. Prior Authorization approval will be given for eight days.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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X. Antiemetics
Therapeutic Class: Antiemetics, (Serotonin Receptor Antagonists (5 HT3 Antiemetics))
Last Reviewed by the DUR Board: October 28, 2010
Therapeutic Class: Antiemetic (Cannabinoid Antiemetics)
Last Reviewed by DUR Board: October 18, 2018
Antiemetics are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
An approved prior authorization is required for any prescription exceeding the quantity limits.
Approval for additional medication beyond these limits will be considered only under the
following circumstances:
Serotonin Receptor Antagonists (5 HT3 Antiemetics)
1. Coverage and Limitations
a. The recipient has failed on chemotherapy-related antiemetic therapy at lower doses;
or
b. The recipient is receiving chemotherapy treatments more often than once a week;
or
c. The recipient has a diagnosis of Acquired Immune Deficiency Syndrome (AIDS)
associated nausea and vomiting; or
d. The recipient has a diagnosis of hyperemesis gravidarum and has failed at least one
other antiemetic therapy or all other available therapies are medically
contraindicated.
2. Prior Authorization Guidelines
A prior authorization to override the quantity limits to allow for a 30-day fill for these drugs
may be effective for up to six months.
Cannabinoid Antiemetics
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Nabilone
1. The recipient has a diagnosis of chemotherapy-induced nausea and/or
vomiting; and
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2. The recipient has experienced an inadequate response, adverse event or has
a contraindication to at least one serotonin receptor antagonist; and
3. The recipient has experienced an inadequate response, adverse event or has
a contraindication to at least one other antiemetic agent; and
4. The prescriber is aware of the potential for mental status changes associated
with the use of this agent and will closely monitor the recipient.
b. Dronabinol
1. The recipient has a diagnosis of chemotherapy-induced nausea and/or
vomiting; and
a. The recipient has experienced an inadequate response, adverse event
or has a contraindication to at least one serotonin receptor
antagonist; and
b. The recipient has experienced an inadequate response, adverse event
or has a contraindication to at least one other antiemetic agent; and
c. The prescriber is aware of the potential for mental status changes
associated with the use of this agent and will closely monitor the
recipient; or
2. The recipient has been diagnosed with Acquired Immune Deficiency
Syndrome (AIDS) and has anorexia associated with weight loss; and the
recipient has experienced an inadequate response, adverse event or has a
contraindication to megestrol (Megace®); and
a. The prescriber is aware of the potential for mental status changes
associated with the use of this agent and will closely monitor the
recipient.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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Y. Synagis® (palivizumaub)
Therapeutic Class: Antiviral Monoclonal Antibodies
Last Reviewed by the DUR Board: January 22, 2015
Synagis® (palivizumab) injections are subject to prior authorization and quantity limitations based
on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
For consideration outside these guidelines, a prior authorization may also be submitted with
supporting medical necessity documentation.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Recipients younger than 12 months of age at the start of Respiratory Syncytial Virus
(RSV) season, must meet one of the following criteria:
1. The recipient was born at 28 weeks, six days of gestation or earlier; or
2. The recipient has a diagnosis of chronic lung disease (CLD) of prematurity;
or
3. The recipient has hemodynamically significant congenital heart disease; or
4. The recipient has congenital abnormalities of the airways or neuromuscular
disease; or
5. The recipient has a diagnosis of cystic fibrosis; and
a. The recipient has clinical evidence of CLD and/or nutritional
compromise.
b. Recipients younger than two years of age at the start of RSV season must meet one
of the following criteria:
1. The recipient has a diagnosis of CLD of prematurity; and
a. The recipient has required medical therapy (e.g., bronchodilator,
diuretics, oxygen, coritcosteroids) within six months to the start of
RSV season; or
2. The recipient has had a cardiac transplant; or
3. The recipient is severely immunocompromised (solid organ or
hematopoietic stem cell transplant, chemotherapy or other conditions)
during the RSV season; or
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4. The recipient has had a cardiopulmonary bypass and continues to require
prophylaxis after surgery or at the conclusion of extracorporeal membrane
oxygenation; or
5. The recipient has a diagnosis of cystic fibrosis; and
a. The recipient has had manifestations of severe lung disease
(previous hospitalization for pulmonary exacerbation in the first
year of life or abnormalities on chest radiography or chest computed
tomography that persists when stable) or weight for length less than
the tenth percentile.
2. Prior Authorization Guidelines
a. Prior authorization approval will be up to five doses per RSV season for recipients
meeting criteria.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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Z. Opioids, Opioid Containing Cough Preparations, Opioids Prescribed to Under Age 18
Therapeutic Class: Opioids, Last reviewed by the DUR Board: July 26, 2018
Opioid Containing Cough Preparations Last reviewed by the DUR Board: July 26, 2018
Opoids Prescribed to Under Age 18: Last Reviewed by the DUR Board: October 18, 2018
Opioids, Opioid Containing Cough Preparations and Opioids Prescribed to Under Age 18 are
subject to prior authorization and quantity limitations based on the Application of Standards in
Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada Medicaid and
Check Up Pharmacy Manual for specific quantity limits.
Opioids
1. Coverage and Limitations
a. Opioids will be covered without prior authorization:
1. For initial prescriptions of seven days or less; and
2. For a total of 13 seven-day prescriptions in any rolling 12 month period;
and
3. For prescriptions of 60 mg morphine equivalents or less per day.
b. Recipients currently on chronic opioid medications will not be subject to the seven-
day requirement for an opioid(s) they have been receiving in the past 45 days.
c. Prior Authorization Criteria: To exceed the number of seven-day prescriptions, or
to exceed the seven-day limit, or to exceed the 60 mg morphine equivalents or less
per day:
1. All of the following criteria must be met and documented:
a. The recipient has chronic pain or requires an extended opioid
therapy and is under the supervision of a licensed prescriber; and
b. Pain cannot be controlled through the use of non-opioid therapy
(acetaminophen, NSAIDs, antidepressants, anti-seizure
medications, physical therapy, etc.); and
c. The lowest effective dose is being requested; and
d. A pain contract is on file.
d. Exceptions to this policy:
1. Recipients with cancer/malignancy related pain; or
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2. Recipients who are post-surgery with an anticipated prolonged recovery
(greater than three months); or
3. Recipients receiving palliative care; or
4. Recipients residing in a long-term care facility; or
5. Recipients receiving treatment for HIV/AIDS; or
6. Prescriptions written by or in consultation with a pain specialist.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. CDC Guidance:
a. http://www.cdc.gov/drugoverdose/prescribing/guideline.html.
4. Opioid Containing Cough Preparations
a. The recipient must be 18 years of age or older.
b. Prior authorization approval will be for six months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. For references purposes, codeine and tramadol for children prior authorization
criteria can also be found within this chapter in Section TTT.
5. Opioids Prescribed to Under Age 18
a. Short Acting Opioids will be covered without PA for:
1. Initial prescription of three days or less; and
2. A total of 13 three-day prescriptions in any rolling 12-month period; and
3. Prescriptions of 60 morphine milligram equivalents (MME) or less per day.
b. Recipients currently on chronic opioid medications will not be subject to the three-
day requirement for an opioid(s) they have been receiving in the past 45 days.
c. To exceed the number of three-day prescriptions, or to exceed the three-day limit,
or to exceed the 60 MME or less per day:
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1. All of the following criteria must be met and documented:
a. The recipient has chronic pain or requires an extended opioid
therapy and is under the supervision of a licensed prescriber; and
b. Pain cannot be controlled through the use of non-opioid therapy
(acetaminophen, NSAIDs, antidepressants, anti-seizure
medications, physical therapy, chiropractic treatment, etc.); and
c. The lowest effective dose is being prescribed; and
d. A pain contract is on file.
d. Exceptions:
1. Recipients with cancer/malignancy related pain, recipients who are post-
surgery with an anticipated prolonged recovery (greater than three months),
recipients residing in a long-term care facility, recipients receiving
treatment for HIV/AIDS, hospice, palliative care or end-of-life care.
2. Prescriptions written by or in consultation with a pain specialist.
e. Prior Authorization Guidelines
1. Prior authorization approval will be for three months.
f. Prescribing Guidance:
1. CDC Guidance:
https://www.cdc.gov/drugoverdose/prescribing/guideline.html
2. HHS Opioids and Adolescents: https://www.hhs.gov/ash/oah/adolescent-
development/substance-use/drugs/opioids/index.html
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AA. Savella® (milnacipran)
Therapeutic Class: Fibromyalgia Agents: Serotonin-Norepinephrine Reuptake Inhibitor
Last Reviewed by DUR Board: July 23, 2020
Savella® (milnacipran) is subject to prior authorization.
1. Approval will be given if all of the following criteria are met and documented:
a. The recipient has a diagnosis of Fibromyalgia:
1. If an ICD code for Myalgia and Myositis unspecified is documented on the
prescription; or
2. Completion of a prior authorization documenting a diagnosis of
Fibromyalgia and/or Myalgia and Myositis, unspecified.
2. Prior Authorization Guidelines:
a. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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BB. Substance Abuse Agents
Therapeutic Class: Narcotic Withdrawal Therapy Agents
Last Reviewed by the DUR Board: July 23, 2020
Buprenorphine/Naloxone and Buprenorphine are subject to prior authorization and quantity
limitations based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Coverage and Limitations
a. Buprenorphine/Naloxone and Buprenorphine
1. Approval will be given if all of the following criteria are met and
documented:
a. Prior authorization approval will be required for all prescriptions
over 24 mg.
b. Requires diagnosis of opioid dependence.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
b. Lucemyra™ (lofexidine)
1. Approval will be given if all of the following criteria are met and
documented:
a. The recipient has a diagnosis of opioid withdrawal with symptoms
due to abrupt opioid discontinuation; and
b. The requested quantity must not exceed 2.88 mg/day for up to 14
days.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 14 days.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
c. Vivitrol® (naltrexone)
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1. Coverage and Limitations Approval will be given if the following criteria
are met and documented:
a. The drug is being used for an FDA approved indication; and
b. The drug must be delivered directly to the prescriber’s office; and
c. The drug is only to be administered once per month; and
d. Routine urine screening and monitoring is recommended.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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CC. Multiple Sclerosis (MS) Agents
Therapeutic Class: Agents for the treatment of Neuromuscular Transmission Disorder
Last Reviewed by the DUR Board: April 22, 2021
MS Agents are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of MS.
2. Ampyra® (dalfampridine)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient must have a diagnosis of MS; and
2. The medication is being used to improve the recipient’s walking speed; and
3. The medication is being prescribed by or in consultation with a neurologist;
and
4. The recipient is ambulatory and has an EDSS score between 2.5 and 6.5;
and
5. The recipient does not have moderate to severe renal dysfunction (CrCL
less than 50 ml/min); and
6. The recipient does not have a history of seizures; and
7. The recipient is not currently pregnant or attempting to conceive.
b. Prior Authorization Guidelines
1. Initial prior authorization approval will be for three months.
2. Request for continuation of therapy will be approved for one year.
3. Relapsing Forms of MS Agents:
a. Approval will be given if all the following criteria are met and documented:
1. The recipient must have a diagnosis of a relapsing form of MS (e.g.,
relapsing-remitting MS, secondary-progressive MS with relapses).
b. Lemtrada® (alemtuzumab)
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1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of a relapsing form of MS; and
one of the following:
1. Both the following:
a. The recipient has not been previously treated with
alemtuzumab; and
b. The recipient has had failure after a trial of at least
four weeks; a contraindication, or intolerance to two
of the following disease-modifying therapies for MS:
1. Aubagio (teriflunomide)
2. Avonex (interferon beta-1a)
3. Betaseron (interferon beta-1b)
4. Copaxone/Glatopa (glatiramer acetate)
5. Extavia (interferon beta-1b)
6. Gilenya (fingolimod)
7. Mavenclad (cladrivine)
8. Mayzent (siponimod)
9. Ocrevus (ocrelizumab)
10. Plegridy (peginterferon beta-1a)
11. Rebif (interferon beta-1a)
12. Tecfidera (dimethyl fumarate)
13. Tysabri (natalizumab); or
14. Zinbryta (daclizumab)
c. Both the following:
a. The recipient has previously received
treatment with alemtuzumab; and
b. The recipient has had at least 12 months
elapsed or will have elapsed since the most
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recent treatment course with alemtuzumab;
and
2. The medication will not be used in combination with another
disease-modifying therapy for MS.
2. Prior Authorization Guidelines
a. Initial authorization approval will be for 12 months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Mavenclad® (cladribine)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of a relapsing form of MS (e.g.,
relapsing-remitting MS, secondary-progressive MS with relapses);
and one of the following:
1. Both the following:
a. The recipient has not been previously treated with
cladribine; and
b. The recipient has had failure after a trial of at least
four weeks; contraindication, or intolerance to two of
the following disease-modifying therapies for
MS:
1. Aubagio (teriflunomide)
2. Avonex (interferon beta-1a)
3. Betaseron (interferon beta-1b)
4. Copaxone/Glatopa (glatiramer acetate)
5. Extavia (interferon beta-1b)
6. Gilenya (fingolimod)
7. Lemtrada (alemtuzumab)
8. Mayzent (siponimod)
9. Ocrevus (ocrelizumab)
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10. Plegridy (peginterferon beta-1a)
11. Rebif (interferon beta-1a)
12. Tecfidera (dimethyl fumarate)
13. Tysabri (natalizumab); or
14. Zinbryta (daclizumab)
2. Both the following:
a. The recipient has previously received treatment with
cladribine; and
b. The recipient has not already received the FDA-
recommended lifetime limit of two treatment courses
(or four treatment cycles total) of cladribine; and
b. The medication will not be used in combination with another
disease-modifying therapy for MS.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one month.
b. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. Ocrevus® (ocrelizumab)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient has a diagnosis of a relapsing form of MS (e.g.,
relapsing-remitting MS, secondary-progressive MS with relapses);
and
b. The medication must not be used in combination with another
disease-modifying therapy for MS; and
c. The medication must not be used in combination with another B-
cell targeted therapy (e.g., rituximab [Rituxan], belimumab
[Benlysta], ofatumumab [Arzerra]); and
d. The medication must not be used in combination with another
lymphocyte trafficking blocker (e.g., alemtuzumab [Lemtrada],
mitoxantrone).
2. Recertification Request (the recipient must meet all criteria):
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a. Documentation of a positive clinical response to Ocrevus®
therapy; and
b. The medication must not be used in combination with another
disease-modifying therapy for MS; and
c. The medication must not be used in combination with another B-
cell targeted therapy (e.g., rituximab [Rituxan], belimumab
[Benlysta], ofatumumab [Arzerra]); and
d. The medication must not be used in combination with another
lymphocyte trafficking blocker (e.g., alemtuzumab [Lemtrada],
mitoxantrone).
3. Prior Authorization Guidelines
a. Initial prior authorization approval will be 12 months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
e. Zeposia® (ozanimod)
1. Approval will be given if all the following criteria is met and documented:
a. The recipient has a documented diagnosis of a relapsing form of MS
(e.g., relapsing-remitting MS, secondary-progressive MS with
relapses); and
b. One of the following:
1. The agent is used for continuation of therapy; or
2. The recipient has had failure after a trial of at least 4 weeks,
contraindication, or intolerance to at least two of the
following disease-modifying therapies for MS:
a. Avonex (interferon beta-1a)
b. Betaseron (interferon beta-1b)
c. Copaxone/Glatopa (glatiramer acetate)
d. Tecfidera (dimethyl fumarate); and
c. The medication is prescribed by or in consultation with a
neurologist.
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2. Recertification Criteria (the recipient must meet all criteria):
a. The recipient has documentation of positive clinical response to
therapy (e.g., improvement in radiologic disease activity, clinical
relapses, disease progression); and
b. The medication is prescribed by or in consultation with a
neurologist.
3. Prior Authorization Guidelines:
a. Prior authorization approval will be for 12 months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Primary Progressive Forms of Multiple Sclerosis (PPMS) Agents:
a. Ocrevus® (ocrelizumab)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of PPMS; and
b. The medication must not be used in combination with another
disease-modifying therapy for MS; and
c. The medication must not be used in combination with another B-
cell targeted therapy (e.g., rituximab [Rituxan], belimumab
[Benlysta], ofatumumab [Arzerra]); and
d. The medication must not be used in combination with another
lymphocyte trafficking blocker (e.g., alemtuzumab [Lemtrada],
mitoxantrone).
2. Recertification Request (the recipient must meet all criteria):
a. Documentation of a positive clinical response to Ocrevus® therapy;
and
b. The medication must not be used in combination with another
disease-modifying therapy for MS; and
c. The medication must not be used in combination with another B-
cell target therapy (e.g., rituximab [Rituxan], belimumab [Benlysta],
ofatumumab [Arzerra]); and
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d. The medication must not be used with another lymphocyte
trafficking blocker (e.g., alemtuzumab [Lemtrada], mitoxantrone).
3. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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DD. Hormones and Hormone Modifiers
Therapeutic Class: Androgenic Agents
Last Reviewed by the DUR Board: April 25, 2019
Topical Androgens
1. Coverage and Limitations
Recipients must meet all of the criteria for coverage:
2. Criteria for approval
a. Recipient is a male;
b. Use is for the FDA approved indication:
Primary (congenital or acquired) or secondary (congenital or acquired)
hypogonadism with an ICD code for hypogonadism;
c. The patient has two morning pre-treatment testosterone levels below the lower limit
of the normal testosterone reference range of the individual laboratory used;
d. The patient does not have breast or prostate cancer, a palpable prostate nodule or
induration, prostate-specific antigen greater than 4 ng/ml or severe lower urinary
symptoms with an International Prostate Symptom Score (IPSS) > 19;
e. The patient does not have a hematocrit > 50%;
f. The patient does not have untreated severe obstructive sleep apnea; and
g. The patient does not have uncontrolled or poorly controlled heart failure.
3. Prior Authorization Guidelines
a. Prior authorization approval will be for up to one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
Xyosted™ (testosterone enanthate)
1. Coverage and Limitations with Diagnosis of Hypogonadism
a. Diagnosis of hypogonadism (e.g. testicular hypofunction, male hypogonadism,
ICD-10 E29.1); and
b. The recipient is a male patient at birth; and
c. One of the following:
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1. Two pre-treatment serum total testosterone levels less than 300 ng/dL (<
10.4 nmol/L) or less than the reference range for the lab; or both of the
following:
a. Recipient has a condition that may cause altered sex hormone
binding globulin (SHBG) (e.g. thyroid disorder, HIV, liver disorder,
diabetes, obesity); and
b. One pre-treatment calculated free or bioavailable testosterone level
less than 5 ng/dL (< 0.17 nmol/L) or less than the reference range
for the lab; or
2. Recipient has a history of one of the following: bilateral orchiectomy,
panhypopituitarism or a genetic disorder known to cause hypogonadism
(e.g. congenital anorchia, Klinefelter’s syndrome).
2. Coverage and Limitation with Diagnosis of Gender Dysphoria
a. Diagnosis of gender dysphoria, as defined by the current version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM); and
b. The recipient is using the hormones to changes their physical characteristics; and
c. The recipient is a female-to-male transsexual.
3. Prior Authorization Guidelines
a. Length of prior authorization approval with diagnosis of hypogonadism will be for
one year.
b. Length of prior authorization approval with diagnsosis of gender dysphoria will be
for six months for recipients new to testosterone therapy or for 12 months for
recipients continuing testosterone therapy without a current authorization on file
with OptumRx.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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EE. Colchicine (Colcrys®)
Therapeutic Class: Antigout Agents
Last Reviewed by the DUR Board:January 28, 2016
Colchicine (Colcrys®) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Colchicine Tablets
1. The recipient has a diagnosis of acute gout (does not require prophylaxis)
and the recipient must meet all of the following:
a. The recipient is 16 years of age or older; and
d. The recipient has had an inadequate response, adverse reaction or
contraindication to an NSAID (indomethacin, naproxen, ibuprofen,
sulindac or ketoprofen); and
e. The recipient has had an inadequate response, adverse reaction or
contraindication to a corticosteroid (oral or intra-articular).
2. For prophylaxis of chronic gout:
a. The recipient is 16 years of age or older and must meet one of the
following:
1. There is documentation that the recipient will be treated with
colchicine in combination with allopurinol, Uloric®
(febuxostat) or probenecid; or
2. There is documentation that the recipient will be treated with
colchicine monotherapy and the recipient must meet all of
the following:
a. The recipient has had an inadequate response to
allopurinol at a dose of 600 mg/day for at least two
weeks or had an adverse reaction or contraindication
to allopurinol; and
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b. The recipient has had an inadequate response to
Uloric® (febuxostat) at a dose of 80 mg/day for at
least two weeks or has had an adverse reaction or
contraindication to Uloric® (febuxostat).
3. For Familial Mediterranean Fever (FMF):
a. The recipient is four years of age or older.
4. Requests exceeding the quantity limit may be approved for colchicine
tablets if all of the following are met and documented:
a. The recipient is 12 years of age or older; and
b. The recipient has a diagnosis of FMF; and
c. The recipient’s dose is ≤ 2.4 mg daily (120 tablets/30 days); and
d. Medical necessity must be provided and documented in the
recipient’s medical record that the recipient had an inadequate
response to 1.8 mg daily (90 tablets/30 days).
b. Colchicine Capsules
1. For Prophylaxis of chronic gout:
a. The recipient is 18 years of age or older and the recipient must meet
one of the following:
1. There is documentation that the recipient will be treated with
colchicine in combination with allopurinol, Uloric®
(febuxostat) or probenecid; or
2. There is documentation that the recipient will be treated with
colchicine monotherapy, and the recipient must meet all of
the following:
a. The recipient has had an inadequate response to
allopurinol at a dose of 600 mg/day for at least two
weeks or had an adverse reaction or contraindication
to allopurinol; and
b. The recipient has had an inadequate response to
Uloric® (febuxostat) at a dose of 80 mg/day for at
least two weeks or has had an adverse reaction or
contraindication to Uloric® (febuxostat).
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2. Prior Authorization Guidelines
a. Prior authorization approval will be given based on diagnosis.
1. For FMF and chronic gout: one year.
2. For acute gout: two months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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FF. Thrombin Inhibitors
Therapeutic Class: Thrombin Inhibitors
Last Reviewed by the DUR Board: January 22, 2015
Thrombin Inhibitors are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA Act and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. A diagnosis code associated with the FDA approved indication(s) is documented
on the prescription and transmitted on the claim; and
b. There are no contraindications to prescribing this medication; or
c. An approved Prior Authorization documenting the recipient meeting all of the
criteria above (1.) (a. and b.).
2. Prior Authorization Guidelines
a. Prior authorization approval will be for up to one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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GG. Antihemophilia Agents
Therapeutic Class: Antihemophilia Agents
Last Reviewed by the DUR Board: July 26, 2018
Antihemophilia Agents are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. The medication being prescribed must be for an FDA approved indication; or
b. One of the following:
1. The diagnosis is supported as a use of American Hospital Formulary Service
Drug Information (AHFS DI); or
2. The diagnosis is supported in the FDA Uses/Non-FDA Uses section in
DRUGDEX Evaluation with a Strength of Recommendation rating of IIb or
better (see DRUGDEX Strength of Recommendation table); or
3. Both of the following:
a. Diagnosis is listed in the FDA Uses/Non-FDA Uses section in
DRUGDEX Evaluation with a Strength of Recommendation rating
of III or Class Indeterminant (see DRUGDEX Strength of
Recommendation table); and
b. Efficacy is rated as “effective” or “evidence favors efficacy” (see
DRUGDEX Efficacy Rating and Prior Authorization Approval
Status table); or
4. Diagnosis is supported in any other section of DRUGDEX; or
5. The use is supported by clinical research in two articles from major peer
reviewed medical journals that present data supporting the proposed off-
label use or uses as generally safe and effective unless there is clear and
convincing contradictory evidence presented in a major peer-reviewed
medical journal; and
a. One of the following:
1. The dosage quantity/duration of the medication is
reasonably safe and effective based on information
contained in the FDA approved labeling, peer-reviewed
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medical literature or accepted standards of medical practice;
or
2. The dosage/quantity/duration of the medication is
reasonably safe and effective based on one of the following
compendia:
a. AHFS Compendium;
b. Thomson Reuters (Healthcare) Micromedex/
DRUGDEX (not Drug Points) Compendium;
c. Elsevier Gold Standard’s Clinical Pharmacology
Compendium;
d. National Comprehensive Cancer Network Drugs and
Biologics Compendium; and
c. The dispensing provider will monitor the amount of product a recipient has left to
avoid over-stock; and
d. The prescriber is a specialist in treating hemophilia; and
e. A new prior authorization will be required for any dose adjustment in excess of 5%
(increase or decrease).
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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HH. Anti-Hepatitis Agents
Therapeutic Class: Anti-Hepatitis Agents
Last Reviewed by the DUR Board: April 22, 2021
Anti-Hepatitis Agents are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA Act and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Epclusa® (sofosbuvir and velpatasvir)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient is not receiving Epclusa® (sofosbuvir and velpatasvir) in
combination with another HCV direct acting antiviral agent (e.g., Sovaldi®,
Olysio®); and
2. The medication must be prescribed by or in consultation with one of the
following:
a. Hepatologist
b. Gastroenterologist
c. Infectious Disease Specialist
d. HIV Specialist (certified through the American Academy of
HIV Medicine)
b. Genotype 1, 2, 3, 4, 5 or 6, without decompensated liver disease
1. The recipient has a documented diagnosis of chronic hepatitis C virus
genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart notes,
laboratory values); and
2. The recipient must not have decompensated liver disease; and
3. Epclusa® must be used alone; and
4. The request is FDA approved for recipient weight and age; and
5. Prior authorization approval will be for 12 weeks.
c. Genotype 1, 2, 3, 4, 5 or 6 with decompensated liver disease
1. The recipient has a documented diagnosis of chronic hepatitis C virus
genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart notes,
laboratory values); and
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2. The recipient has decompensated liver disease; and
3. Epclusa® is being used in combination with Ribavirin; and
4. The request is FDA approved for recipient weight and age; and
5. Prior authorization approval will be for 24 weeks.
d. Genotype 1, 2, 3, 4, 5 or 6 Ribavirin intolerance/ineligible or prior Sovaldi®
(sofosbuvir) or NS5A-based treatment failure.
1. The recipient has a documented diagnosis of chronic hepatitis C virus
genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart notes,
laboratory values); and
2. The recipient has decompensated liver disease; and
a. One of the following:
1. The recipient is Ribavirin intolerant or ineligible; or
2. Both of the following:
a. The recipient has had prior failure (defined as viral
relapse, breakthrough while on therapy, or is a non-
responder to therapy) to Sovaldi® or NS5A-based
treatment; and
b. Epclusa® is used in combination with Ribavirin®.
3. Prior authorization approval will be for 24 weeks.
2. Harvoni® (ledipasvir/sofosbuvir)
a. Approval will be given if the following criteria are met and documented:
1. The recipient is not receiving Harvoni® in combination with another HCV
direct acting antiviral agent (e.g., Sovaldi®, Olysio®); and
2. The medication must be prescribed by or in consultation with one of the
following:
a. Hepatologist
b. Gastroenterologist
c. Infectious Disease Specialist
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d. HIV Specialist (certified through the American Academy of HIV
Medicine)
b. Genotype 1, treatment naïve, without cirrhosis and pre-treatment HCV RNA is less
than six million IU/mL
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
a. The recipient does not have cirrhosis; and
b. The recipient is treatment naïve; and
c. Medical records documenting pre-treatment HCV RNA less than six
million IU/mL must be submitted; and
d. Prior authorization approval will be for eight weeks.
c. Genotype 1, treatment naïve, without cirrhosis and pre-treatment HCV RNA is
greater than or equal to six million IU/mL
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
2. The recipient does not have cirrhosis; and
3. The recipient is treatment naïve; and
4. Medical records documenting pre-treatment HCV RNA greater than or
equal to six million IU/mL must be submitted; and
5. Prior authorization approval will be for 12 weeks.
d. Genotype 1, treatment naïve with compensated cirrhosis
3. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
4. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has cirrhosis; and
5. The recipient is treatment naïve; and
6. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
7. Prior authorization approval will be for 12 weeks.
e. Genotype 1, treatment experienced without cirrhosis
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1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
2. The recipient does not have cirrhosis; and
3. One of the following:
a. The recipient has experienced treatment failure with a previous
treatment regimen that included peginterferon plus Ribavirin or an
HCV protease inhibitor (e.g., Incivek® (telaprevir), Olysio®
(simeprevir), Victrelis® (boceprevir)) plus peginterferon plus
Ribavirin; or
b. Both of the following:
1. The recipient has experienced treatment failure with a
previous treatment regimen that included Sovaldi®
(sofosbuvir) except in combination with Olysio®
(simeprevir); and
2. The medication is used in combination with Ribavirin.
4. Prior authorization approval will be for 12 weeks.
f. Genotype 1, Ribavirin eligible, treatment experienced and with compensated
cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
2. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has cirrhosis; and
3. The recipient has experienced treatment failure with a previous treatment
regimen that included peginterferon plus Ribavirin or an HCV protease
inhibitor (e.g., Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) plus peginterferon plus Ribavirin; and
4. The medication is used in combination with Ribavirin; and
5. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
6. Prior authorization approval will be for 12 weeks.
g. Genotype 1, Ribavirin ineligible, treatment experienced and with compensated
cirrhosis
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1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
2. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has cirrhosis; and
3. The recipient has experienced treatment failure with a previous treatment
regimen that included peginterferon plus Ribavirin or an HCV protease
inhibitor (e.g., Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) plus peginterferon plus Ribavirin; and
4. The recipient is Ribavirin ineligible; and
5. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
6. Prior authorization approval will be for 24 weeks.
h. Genotype 1, 4, 5 or 6, decompensated cirrhosis or post-liver transplant
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1, 4, 5 or 6 (submission of medical records e.g., chart notes, laboratory
values); and
2. One of the following:
a. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has decompensated cirrhosis (e.g.,
Child-Pugh class B or C); or
b. Both of the following:
1. The recipient is a liver transplant recipient; and
2. The recipient is without decompensated liver disease (e.g.,
Child-Pugh class B or C); and
3. The medication is used in combination with Ribavirin; and
4. Prior authorization approval will be for 12 weeks.
i. Genotype 1,4, 5, or 6, decompensated cirrhosis, Ribavirin ineligible or prior failure
of Sovaldi® or NS5A based regimen
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1, 4, 5 or 6 (submission of medical records e.g., chart notes, laboratory
values); and
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2. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has decompensated cirrhosis (e.g., Child-
Pugh class B or C); and
3. One of the following:
a. The recipient is Ribavirin ineligible; or
b. Both of the following:
1. The recipient has experienced treatment failure with a
previous treatment regimen that included Sovaldi®
(sofosbuvir) or an NS5A inhibitor (e.g., Daklinza®
(daclatasvir)); and
2. The medication is used in combination with Ribavirin; and
4. Prior authorization approval will be for 24 weeks.
j. Genotype 4, treatment naïve or treatment experienced (peginterferon plus
Ribavirin)
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
4 (submission of medical records e.g., chart notes, laboratory values); and
2. One of the following:
a. The recipient is treatment naïve; or
b. One of the following:
1. The recipient has experienced failure with a previous
treatment regimen that included peginterferon plus Ribavirin
and is without cirrhosis; or
2. Both of the following:
a. The recipient has experienced failure with a previous
treatment regimen that included peginterferon plus
Ribavirin and has compensated cirrhosis (Child-
Pugh class A); and
b. The medication is used in combination with
Ribavirin.
3. Prior authorization approval will be for 12 weeks.
k. Genotype 5 or 6, treatment naïve or treatment experienced (peginterferon plus
Ribavirin)
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1. The recipient has a documented diagnosis of chronic hepatitis C genotype
5 or 6 (submission of medical records e.g., chart notes, laboratory values);
and
2. One of the following:
a. The recipient is treatment naïve; or
b. The recipient has experienced failure with a previous treatment
regimen that included peginterferon plus Ribavirin; and
3. Prior authorization approval will be for 12 weeks.
3. Mavyret® (glecaprevir/pibrentasvir)
a. Approval will be given if the following criteria are met and documented:
1. The recipient is not receiving Mavyret® in combination with another HCV
direct acting antiviral agent (e.g., Harvoni® (ledipasvir/sofosbuvir),
Zepatier® (elbasvir/grazoprevir)); and
2. The medication must be prescribed by or in consultation with one of the
following:
a. Hepatologist
b. Gastroenterologist
c. Infectious Disease Specialist
d. HIV Specialist (certified through the American Academy of HIV
Medicine)
b. Genotype 1, 2, 3, 4, 5 or 6, treatment naïve without cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart notes, laboratory
values); and
2. The recipient is treatment naïve; and
3. The recipient is without cirrhosis; and
4. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
5. Prior authorization approval will be for 12 weeks.
c. Genotype 1, 2, 3, 4, 5 or 6, treatment naïve with compensated cirrhosis
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1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart notes, laboratory
values); and
2. The recipient is treatment naïve; and
3. The recipient has compensated cirrhosis (Child-Pugh class A); and
4. Prior authorization approval will be for eight weeks.
d. Genotype 1, treatment experienced (prior failure to an NS3/4A protease inhibitor),
without decompensated cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
2. The recipient has experienced failure with a previous treatment regimen that
included an HCV NS3/4A protease inhibitor (e.g., Incivek® (telaprevir),
Olysio® (simeprevir), Victrelis® (boceprevir)); and
3. The recipient has had no previous treatment experience with a treatment
regimen that included an NS5A inhibitor (e.g., Daklinza® (daclatasvir));
and
4. The recipient is without decompensated cirrhosis (Child-Pugh class B or
C); and
5. Prior authorization approval will be for 12 weeks.
e. Genotype 1, treatment experienced (prior failure to an NS5A inhibitor), without
decompensated cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
2. The recipient has experienced failure with a previous treatment regimen that
included an NS5A inhibitor (e.g., Daklinza® (daclatasvir)); and
3. The recipient has had no previous treatment experience with a treatment
regimen that included an HCV NS3/4A protease inhibitor (e.g., Incivek®
(telaprevir), Olysio® (simeprevir), Victrelis® (boceprevir)); and
4. The recipient is without decompensated cirrhosis (Child-Pugh class B or
C); and
5. Prior authorization approval will be for 16 weeks.
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f. Genotype 3, treatment experienced (interferon or Sovaldi® based regimen),
without decompensated cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
3 (submission of medical records e.g., chart notes, laboratory values); and
2. The recipient has experienced failure with a previous treatment regimen that
included interferon, peginterferon, Ribavirin, and/or Sovaldi® (sofosbuvir);
and
3. The recipient has had no previous treatment experience with a treatment
regimen that included an HCV NS3/4A protease inhibitor (e.g., Incivek®
(telaprevir), Olysio® (simeprevir), Victrelis® (boceprevir)) or an NS5A
inhibitor (e.g., Daklinza® (daclatasvir)); and
4. The recipient is without decompensated cirrhosis (Child-Pugh class B or
C); and
5. Prior authorization approval will be for 16 weeks.
g. Genotype 1, 2, 4, 5 or 6, treatment experienced (interferon or Sovaldi® based
regimen), without cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1, 2, 4, 5 or 6 (submission of medical records e.g., chart notes, laboratory
values); and
2. The recipient has experienced failure with a previous treatment regimen that
included interferon, peginterferon, Ribavirin, and/or Sovaldi® (sofosbuvir);
and
3. The recipient has had no previous treatment experience with a treatment
regimen that included an HCV NS3/4A protease inhibitor (e.g., Incivek®
(telaprevir), Olysio® (simeprevir), Victrelis® (boceprevir)) or an NS5A
inhibitor (e.g., Daklinza® (daclatasvir)); and
4. The recipient is without cirrhosis; and
5. Prior authorization approval will be for eight weeks.
h. Genotype 1, 2, 4, 5 or 6, treatment experienced (interferon or Sovaldi® based
regimen), with compensated cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1, 2, 4, 5 or 6 (submission of medical records e.g., chart notes, laboratory
values); and
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2. The recipient has experienced failure with a previous treatment regimen that
included interferon, peginterferon, Ribavirin, and/or Sovaldi® (sofosbuvir);
and
3. The recipient has had no previous treatment experience with a treatment
regimen that included an HCV NS3/4A protease inhibitor (e.g., Incivek®
(telaprevir), Olysio® (simeprevir), Victrelis® (boceprevir)) or an NS5A
inhibitor (e.g., Daklinza® (daclatasvir)); and
4. The recipient has compensated cirrhosis (e.g., Child-Pugh class A); and
5. Prior authorization approval will be for 12 weeks.
4. Sovaldi® (sofosbuvir)
a. Approval will be given if the following criteria are met and documented:
1. The medication must be prescribed by or in consultation with one of the
following:
a. Hepatologist
b. Gastroenterologist
c. Infectious Disease Specialist
d. HIV Specialist (certified through the American Academy of HIV
Medicine)
b. Genotype 1 or 4, without decompensated liver disease
1. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 or 4 (submission of medical records e.g., chart notes,
laboratory values); and
2. The medication is used in combination with peginterferon alfa and
Ribavirin; and
3. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
4. The recipient has not experienced failure with a previous treatment
regimen that includes Sovaldi®; and
5. Prior authorization approval will be for 12 weeks.
c. Genotype 3, without decompensated liver disease
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1. The recipient has a documented diagnosis of chronic hepatitis C genotype
3 (submission of medical records e.g., chart notes, laboratory values); and
2. The recipient must be 18 years of age or older; or
3. Both of the following:
a. The recipient has a documented diagnosis of chronic hepatitis C
virus (HCV) genotype 3 (submission of medical records e.g., chart
notes, laboratory values); and
b. The recipient is 12 to 17 years of age; or both of the following:
1. The recipient weighs at least 35 kg; and
2. The recipient is less than 12 years of age; and
4. The medication is used in combination with Ribavirin; and
5. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
6. The recipient has not experienced failure with a previous treatment regimen
that includes Sovaldi®; and
7. Prior authorization approval will be for 24 weeks.
d. Genotype 2, without decompensated liver disease
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
2 (submission of medical records e.g., chart notes, laboratory values); and
2. The recipient must be 18 years of age or older; or
3. Both of the following:
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 2 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient is 12 to 17 years of age; or both of the following:
1. The recipient weighs at least 35 kg; and
2. The recipient is less than 12 years of age; and
4. The medication is used in combination with Ribavirin; and
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5. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
6. The recipient has not experienced failure with a previous treatment regimen
that includes Sovaldi®; and
7. Prior authorization approval will be for 12 weeks.
e. Genotype 1, without cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
2. The medication is used in combination with Olysio® (simeprevir); and
3. The recipient is without cirrhosis; and
4. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
5. The recipient has not experienced failure with a previous treatment regimen
that includes Olysio® or other HCV NS3/4A protease inhibitors (e.g.,
Incivek® (telaprevir), Victrelis® (boceprevir)); and
6. Prior authorization approval will be for 12 weeks.
f. Genotype 1, with cirrhosis
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
2. The medication is used in combination with Olysio® (simeprevir); and
3. The recipient has cirrhosis; and
4. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
5. The recipient has not experienced failure with a previous treatment regimen
that includes Olysio® or other HCV NS3/4A protease inhibitors (e.g.,
Incivek® (telaprevir), Victrelis® (boceprevir)); and
6. Prior authorization approval will be for 12 weeks.
g. Genotype 1
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 (submission of medical records e.g., chart notes, laboratory values); and
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2. The medication is used in combination with Daklinza® (daclatasvir); and
3. The recipient has not experienced failure with a previous HCV NS5A
treatment regimen (e.g., Daklinza® (daclatasvir)); and
4. One of the following:
a. The recipient is without decompensated cirrhosis and is not a liver
transplant recipient; or
b. Both of the following:
1. The recipient has decompensated cirrhosis and/or is a liver
transplant recipient; and
2. The medication is used in combination with Ribavirin.
5. Prior authorization approval will be for 12 weeks.
h. Genotype 3
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
3 (submission of medical records e.g., chart notes, laboratory values); and
2. The medication is used in combination with Daklinza® (daclatasvir); and
3. The recipient has not experienced failure with a previous HCV NS5A
treatment regimen (e.g., Daklinza® (daclatasvir)); and
4. One of the following:
a. The recipient is without cirrhosis and is not a liver transplant
recipient; or
b. Both of the following:
1. The recipient has cirrhosis (compensated or decompensated)
and/or is a liver transplant recipient; and
2. The medication is used in combination with Ribavirin.
5. Prior authorization approval will be for 12 weeks.
5. Viekira Pak® (ombitasvir, paritaprevir, ritonavir tablets, dasabuvir tablets)
a. Genotype 1a or Mixed Genotype 1 Infection without Cirrhosis and without Liver
Transplant
1. Approval will be given if all criteria are met and documented:
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a. Submission of medical records (e.g., chart notes, laboratory values)
documenting the recipient’s diagnosis of chronic hepatitis C
genotype 1a or mixed genotype 1 infection; and
b. The recipient is without cirrhosis; and
c. The medication is used in combination with ribavirin; and
d. The recipient is without decompensated liver disease (e.g., Child-
Pugh Class B or C); and
e. The medication is prescribed by or in consultation with one of the
following:
1. Hepatologist
2. Gastroenterologist
3. Infectious disease specialist
4. HIV specialist certified through the American Academy of
HIV Medicine; and
f. The recipient has not experienced failure with a previous treatment
regimen that includes a HCVNS3/4A protease inhibitor (e.g.,
Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) or an NS5A inhibitor (Daklinza® (daclatasvir).
2. Prior Authorization Guidelines:
a. Prior authorization will be for 12 weeks.
b. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
b. Genotype 1a or Mixed Genotype Infection with Cirrhosis and without Liver
Transplant
1. Approval will be given if all criteria are met and documented:
a. Submission of medical records (e.g., chart notes, laboratory values)
documenting the recipient’s diagnosis of chronic hepatitis C
genotype 1a or mixed genotype 1 infection; and
b. Submission of medical records (e.g., chart notes, laboratory values)
documenting the recipient has cirrhosis; and
c. The medication is being used in combination with ribavirin; and
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d. The recipient is without decompensated liver disease (e.g., Child-
Pugh Class B or C); and
e. The medication is prescribed by or in consultation with one of the
following:
1. Hematologist
2. Gastroenterologist
3. Infectious Disease Specialist
4. HIV Specialist Certified through the Academy of HIV
Medicine; and
f. The recipient has not experienced failure with a previous treatment
regimen that includes a HCVNS3/4A protease inhibitor (e.g.,
Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) or an NS5A inhibitor (Daklinza® (daclatasvir)); and
g. The recipient is not receiving Viekira® in combination with another
HCV direct acting antiviral agent (e.g., Harvoni®
(ledipasvir/sofosbuvir), Sovaldi® (sofosbuvir).
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 24 weeks.
b. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Genotype 1b without Liver Transplant
1. Approval will be given if all criteria are met and documented:
a. Submission of medical records (e.g., chart notes, laboratory values)
documenting the recipient’s diagnosis of chronic hepatitis C
genotype 1b; and
b. The recipient is without decompensated liver disease (e.g., Child-
Pugh Class B or C); and
c. The medication is prescribed by or in consultation with one of the
following:
1. Hepatologist
2. Gastroenterologist
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3. Infectious Disease Specialist
4. HIV Specialist Certified through the Academy of HIV
Medicine; and
d. The recipient has not experienced failure with a previous treatment
regimen that includes a HCVNS3/4A protease inhibitor (e.g.,
Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) or an NS5A inhibitor (Daklinza® (daclatasvir)); and
e. The recipient is not receiving Viekira® in combination with another
HCV direct acting antiviral agent (e.g., Harvoni®
(ledipasvir/sofosbuvir), Sovaldi® (sofosbuvir).
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 12 weeks.
b. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. Genotype 1 (Regardless of Sub genotype) – Liver Transplant Recipient
1. Approval will be given if all criteria are met and documented:
a. Submission of medical records (e.g., chart notes, laboratory values)
documenting diagnosis of chronic hepatitis C genotype 1; and
b. Documentation confirming the recipient is a liver transplant
recipient; and
c. Submission of medical records (e.g., chart notes or laboratory
values) documenting the recipient’s normal hepatic function and
mild fibrosis (e.g., METAVIR fibrosis score less than or equal to
F2); and
d. The medication is used in combination with ribavirin; and
e. Prescribed by or in consultation with one of the following:
1. Hepatologist
2. Gastroenterologist
3. infectious disease specialist
4. HIV specialist certified through the American Academy of
HIV Medicine; and
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f. The recipient has not experienced failure with a previous treatment
regimen that includes a HCVNS3/4A protease inhibitor (e.g.,
Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) or an NS5A inhibitor (Daklinza® (daclatasvir)); and
g. The recipient is not receiving Viekira® in combination with another
HCV direct acting antiviral agent (e.g., Harvoni®
(ledipasvir/sofosbuvir), Sovaldi® (sofosbuvir).
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 24 weeks.
b. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
6. Vosevi® (sofosbuvir/velpatasvir/voxilaprevir)
a. Approval will be given if all criteria are met and documented:
1. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
2. The recipient is not receiving Vosevi® in combination with another HCV
direct acting antiviral agent (e.g., Harvoni® (ledipasvir), Zepatier®
(elbasvir/grazoprevir)); and
3. The medication must be prescribed by or in consultation with one of the
following:
a. Hepatologist
b. Gastroenterologist
c. Infectious Disease Specialist
d. HIV Specialist (certified through the American Academy of HIV
Medicine)
b. Genotype 1, 2, 3, 4, 5 or 6; without decompensated cirrhosis, prior relapse to
NS5A based regimen
1. Approval will be given if all criteria are met and documented:
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart
notes, laboratory values); and
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b. The recipient is a previous relapser to an NS5A based regimen (e.g.,
Daklinza® (daclatasvir), Epclusa® (ledipasvir/sofosbuvir),
Mavyret® (glecaprevir/pibrentasvir), Technivie® (ombitasvir/
paritaprevir/ ritonavir), Viekira® (ombitasvir/ paritaprevir/
ritonavir/dasabuvir), Zepatier® (elbasvir/grazoprevir); and
c. Submission of medical records (e.g., chart notes or laboratory
values) documenting normal hepatic function and mild fibrosis (e.g.,
METAVIR fibrosis score less than or equal to F2); and
2. Prior Authorization Guidelines:
1. Prior authorization approval will be for 12 weeks.
3. Genotype 1a, without decompensated cirrhosis, prior relapse to sofosbuvir
based regimen without an NS5A inhibitor
a. Approval will be given if all criteria are met and documented:
1. The recipient has a documented diagnosis of chronic
hepatitis C genotype 1a (submission of medical records e.g.,
chart notes, laboratory values); and
2. The recipient is a previous relapser to a sofosbuvir based
regimen without an NS5A inhibitor; and
b. Prior Authorization Guidelines:
1. Prior authorization approval will be for 12 weeks.
2. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Genotype 3, without decompensated cirrhosis, prior relapse to sofosbuvir
based regimen without an NS5A inhibitor
a. Approval will be given if all criteria are met and documented:
1. The recipient has a documented diagnosis of chronic
hepatitis C genotype 3 (submission of medical records e.g.,
chart notes, laboratory values); and
2. The recipient is a previous relapser to a sofosbuvir based
regimen without an NS5A inhibitor; and
b. Prior Authorization Guidelines:
1. Prior authorization approval will be for 12 weeks.
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2. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
7. Zepatier® (elbasvir/grazoprevir)
1. Approval will be given if all criteria are met and documented:
a. The recipient does not have moderate to severe hepatic impairment
(e.g., Child-Pugh class B or C); and
b. The recipient is not receiving Zepatier® in combination with
another HCV direct acting antiviral agent (e.g., Sovaldi®
(sofosbuvir), Olysio® (simeprevir)); and
c. The medication must be prescribed by or in consultation with one of
the following:
1. Hepatologist
2. Gastroenterologist
3. Infectious Disease Specialist
4. HIV Specialist (certified through the American Academy of
HIV Medicine)
2. Genotype 1a, treatment naïve, or PegIFN/RBV experienced, or
PegIFN/RBV/protease inhibitor experienced, without NS5A
polymorphisms
a. Approval will be given if all criterias are met and documented:
1. The recipient has a documented diagnosis of chronic
hepatitis C genotype 1a (submission of medical records e.g.,
chart notes, laboratory values); and
2. One of the following:
a. The recipient is treatment naïve; or
b. The recipient has had prior failure to peginterferon
alfa plus Ribavirin treatment; or
c. The recipient has had prior failure to treatment with
peginterferon alfa plus Ribavirin plus an HCV
NS3/4A protease inhibitor (e.g., boceprevir,
simeprevir or telaprevir); and
3. Both of the following:
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1. The recipient has been tested for the presence of
NS5A resistance associated polymorphisms; and
2. The recipient has baseline NS5A resistance
associated polymorphisms (e.g., polymorphisms at
amino acid positions 28, 30, 31, or 93); and
4. The medication is used in combination with Ribavirin; and
b. Prior Authorization Guidelines:
1. Prior authorization approval will be for 16 weeks.
2. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Genotype 1b, treatment naïve, or PegIFN/RBV experienced, or
PegIFN/RBV/protease inhibitor experienced
a. Approval will be given if all criteria are met and documented:
1. The recipient has a documented diagnosis of chronic
hepatitis C genotype 1b (submission of medical records e.g.,
chart notes, laboratory values); and
2. One of the following:
a. The recipient is treatment naïve; or
b. The recipient has had prior failure to peginterferon
alfa plus Ribavirin treatment; or
c. Both of the following:
1. The recipient has had prior failure to
treatment with peginterferon alfa plus
Ribavirin plus an HCV NS3/4A protease
inhibitor (e.g., boceprevir, simeprevir or
telaprevir); and
2. The medication is used in combination with
Ribavirin; and
b. Prior Authorization Guidelines:
1. Prior authorization approval will be for 12 weeks.
2. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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d. Genotype 4, treatment naïve
1. Approval will be given if all criteria are met and documented:
a. The recipient has a documented diagnosis of chronic
hepatitis C genotype 4 (submission of medical records e.g.,
chart notes, laboratory values); and
b. The recipient is treatment naïve; and
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 12 weeks.
b. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
a. Genotype 4, PegIFN/RBV experienced
1. Approval will be given if all criteria are met and documented:
a. The recipient has a documented diagnosis of chronic
hepatitis C genotype 4 (submission of medical records e.g.,
chart notes, laboratory values); and
b. The recipient has had prior failure to peginterferon alfa plus
Ribavirin; and
c. The medication is used in combination with Ribavirin; and
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 16 weeks.
b. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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II. Daliresp® (roflumilast)
Therapeutic Class: Phosphodiesterase-4 Inhibitors.
Last Reviewed by the DUR Board: October 17, 2019
Daliresp® (roflumilast) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. The recipient has experienced an inadequate response, adverse event or has a
contraindication to a long-acting anticholinergic agent;
b. The recipient has experienced an inadequate response, adverse event or has a
contraindication to a long-acting beta () agonist;
c. The recipient has experienced an inadequate response, adverse event or has a
contraindication to an inhaled corticosteroid;
d. The recipient has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD);
and
e. The recipient has a history of COPD exacerbations.
2. Contraindication
a. Daliresp (roflumilast) may not be approved for a recipient with a diagnosis of
moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment.
3. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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JJ. Hereditary Angioedema Agents
Therapeutic Class: Hereditary Angioedema Agents
Last Reviewed by DUR Board: April 22, 2021
Hereditary Angioedema (HAE) agents are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Cinryze® (C1 esterase inhibitor), Haegarda® (C1 estarase inhibitor), Orladeyo®
(berotralstat) or Takhzyro® (ianadelumab-flyo)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a diagnosis of HAE; and
2. The recipient’s diagnosis has been confirmed by C1 inhibitor (C1-INh)
deficiency or dysfunction (type I or II HAE) as documented by one of the
following:
a. C1-INh antigenic level below the lower limit of normal; or
b. C1-INh functional level below the lower limit of normal; and
1. The medication is being prescribed by or in consultation
with an allergist or immunologist.
c. The medication is being used as prophylaxis against attacks; and
b. Prior Authorization Guidelines:
1. Prior authorization approval will be approved for 12 months.
2. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. Cinryze® (C1 esterase inhibitor) *, Firazyr® (icatibant), Ruconest® (C1 esterase inhibitor)
Note: * off label use
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a diagnosis of HAE; and
2. The recipient’s diagnosis has been confirmed by C1 inhibitor (C1-INh)
deficiency or dysfunction (type I or II HAE) as documented by one of the
following:
a. C1-INh antigenic level below the lower limit of normal; or
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b. C1-INh functional level below the lower limit of normal; and
3. The medication is being used for the treatment of acute HAE attacks; and
4. The medication is not used in combination with other approved treatment
for acute HAE attacks; and
5. The medication is prescribed by or in consultation with an allergist or
immunologist.
b. Prior Authorization Guidelines:
1. Prior authorization approval will be approved for 12 months.
2. Prior authorization forms are available
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. Kalbitor® (ecallantide)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a diagnosis of HAE; and
2. The recipient’s diagnosis has been confirmed by C1 inhibitor (C1-INh)
deficiency or dysfunction (type I or II HAE) as documented by one of the
following:
a. C1-INh antigenic level below the lower limit of normal; or
b. C1-INh functional level below the lower limit of normal; and
3. The medication is being used for the treatment of acute HAE attacks; and
4. The recipient is 12 years of age or older; and
5. The medication is not used in combination with other approved treatments
for acute HAE attacks; and
6. The medication is prescribed by or in consultation with an allergist or
immunologist.
b. Prior Authorization Guidelines:
1. Prior authorization approval will be approved for 12 months.
2. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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4. Berinert® (C1 esterase inhibitor)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a diagnosis HAE; and
2. The recipient’s diagnosis has been confirmed by C1 inhibitor (C1-INh)
deficiency or dysfunction (type I or II HAE) as documented by one of the
following:
a. C1-INh antigenic level below the lower limit of normal; or
b. C1-INh functional level below the lower limit of normal; and
3. The medication is not used in combination with other approved treatments
for acute HAE attacks; and
4. The medication is being prescribed by or in consultation with an allergist or
immunologist; and
5. The medication is being used to treat acute HAEattacks and
6. One of the following:
a. The recipient has trial and failure, contraindication, or intolerance to
Ruconest®; or
b. The recipient is 12 year of age or younger and there is
documentation that the recipient has history of laryngeal attacks.
b. Prior Authorization Guidelines:
1. Prior authorization approval will be approved for 12 months.
2. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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KK. Incretin Mimetics
Therapeutic Class: Incretin Mimetics
Last Reviewed by the DUR Board: January 26, 2017
Previously reviewed by the DUR Board: July 26, 2012
Incretin Mimetics are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. An ICD code for Type 2 Diabetes Mellitus is documented on the prescription and
transmitted on the claim; or
b. A prior authorization documenting a diagnosis of Type 2 Diabetes Mellitus has
been submitted.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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LL. Cystic Fibrosis Agents
Therapeutic Class: Cystic Fibrosis Agents
Last Reviewed by the DUR Board: April 30, 2020
Cystic Fibrosis (CF) Agents are subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Approval will be given for a single agent concomitantly if the following criteria are met
and documented:
A. Kalydeco® (ivacaftor)
1. Approval will be given if the following criteria are met and documented:
a. The recipient is six months of age or older; and
b. The recipient has a diagnosis of CF; and
c. There is documentation that the recipient has had an FDA-approved
cystic fibrosis mutation test confirming the presence of one of the
gene mutations listed in the FDA-approved package insert; and
d. The medication is prescribed by or in consultation with a
pulmonologist or a specialist affiliated with a CF care center.
2. Recertification Request (the recipient must meet all the following criteria)
1. Documentation of a positive clinical response to Kalydeco®
therapy.
3. Prior Authorization Guidelines
a. Initial request will be approved for 12 months.
b. Recertification request will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
B. Orkambi® (lumacaftor/ivacaftor)
1. Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of cystic fibrosis; and
b. The recipient is two years of age or older; and
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c. The recipient is homozygous for the F508del mutation in the cystic
fibrosis transmembrane conductance regulator (CFTR) gene; and
d. The requested dose is two tablets every 12 hours; or
e. The requested dose is one tablet every 12 hours in the presence of
severe hepatic impairment.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for one year.
b. Prior Authorizaition forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
C. Symdeko® (tezacaftor/ivacaftor)
1. Approval will be given if the following criteria are met and documented:
a. Initial Request:
1. The recipient is six years of age or older; and
2. The recipient has a documented diagnosis of CF; and
3. The medication must be prescribed by or in consultation
either a Pulmonolist or a specialist associated with a CF care
center.
4. One of the following:
a. The recipient is homozygous for the F508del
mutation as detected by an FDA cleared CF mutation
test or Clinical Laboratory Improvement
Amendments (CLIA) approved facility; or
b. The recipient has one of the FDA approved package
insert listed mutations on at least one allele in the
(CFTR) gene as detected by FDA cleared CF
mutation test or CLIA approved facility.
b. Recertification Request (the recipient must meet the following
criteria):
1. Documentation of a positive clinical response to Symdeko®
(tezacaftor/ivacaftor) therapy (e.g., improvement in lung
function or decreased number of pulmonary exacerbations).
2. Prior Authorization Guidelines
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a. Initial request will be approved for 12 months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
D. Trikafta® (elexacaftor/tezacaftor/ivacaftor and ivacaftor)
1. Approval will be given if the following criteria are met and documented:
a. The recipient is 12 years of age and older; and
b. The recipient has a documented diagnosis of CF; and
c. The recipient has at least one F508del mutation in the CFTR gene
as detected by an FDA cleared CF mutation test, or a test performed
at a CLIA approved facility; and
d. The medication is prescribed by or in consultation with either a
Pulmanologist or a specialist affiliated with a CF care center.
2. Recertification Request
a. The recipient must have documentation of a positive clinical
response to Trikafta® therapy (e.g. improvement in lung function
[percent predicted forced expiratory volume in one second
{PPFEV1}] or decreased number of pulmonary exacerbations)
3. Prior Authorization Guidelines
a. Initial request will be approved for 12 months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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MM. RESERVED FOR FUTURE USE
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NN. Platelet Inhibitors
Therapeutic Class: Platelet Inhibitors
Last Reviewed by the DUR Board: April 22, 2021
Platelet Inhibitors are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Authorization will be given if the following criteria are met and documented:
a. Brilinta® (ticagrelor)
1. The recipient has a diagnosis of Acute Coronary Syndrome (ACS) (unstable
angina, non-ST elevation myocardial infarction or ST elevation myocardial
infarction); and
2. The recipient does not have an active pathological bleed or history of
intracranial hemorrhage; and
3. The recipient will be receiving concomitant treatment with aspirin in a dose
of less than 100 mg/daily; and
4. One of the following:
a. The recipient has been started and stabilized on the requested
medication; or
b. The recipient has experienced an adverse event with or has an
allergy or contraindication to clopidogrel; or
c. Another clinically appropriate rationale is provided for why
clopidogrel cannot be used.
b. Effient® (prasugrel)
1. The recipient has a diagnosis of ACS (unstable angina, non-ST elevation
myocardial infarction or ST elevation myocardial infarction); and
2. The recipient does not have an active pathological bleed or history of
transient ischemic attack or cerebral vascular accident (CVA); and
3. The recipient will be receiving concomitant treatment with aspirin in a dose
of less than 100 mg/daily; and
4. The recipient has a history of percutaneous coronary intervention; and
5. One of the following:
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a. The recipient has been started and stabilized on the requested
medication; or
b. The recipient has experienced an adverse event with or has an
allergy or contraindication to clopidogrel; or
c. Another clinically appropriate rationale is provided for why
clopidogrel cannot be used.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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OO. Osteoporosis Agents
Therapeutic Class: Bone Resorption Inhibitors (Osteoporosis Agents)
Last Reviewed by DUR Board: October 22, 2020
Osteoporosis agents are subject to prior authorization based on the Application of Standards in
Section 1927 of the SSA and/or approved by the DUR Board.
1. Coverage and Limitations
a. Evenity® (romosozumab-aqqg)
1. Approval will be given if all criteria are met and documented:
a. The recipient has a diagnosis of postmenopausal osteoporosis or
osteopenia; and
b. One of the following:
1. Both the following:
a. The recipient’s Bone Mineral Density (BMD) T-
score is -2.5 or lower in the lumbar spine, femoral
neck, total hip, or radius (one-third radius site); and
b. One of the following:
1. The recipient has documented history of low-
trauma fracture of the hip, spine, proximal
humerus, pelvis, or distal forearm; or
2. The recipient has documented trial and
failure, contraindication, or intolerance to
one anti-resorptive treatment (e.g.,
alendronate, risedronate, zoledronic acid,
Prolia [denosumab]); or
c. Both the following:
1. The recipient has a BMD T-score between -
1.0 and -2.5 in the lumbar spine, femoral
neck, total hip, or radius (one-third radius
site); and
2. One of the following:
a. The recipient has a documented
history of low-trauma fracture of the
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hip, spine, proximal humerus, pelvis,
or distal forearm; or
b. Both the following:
1. The recipient has a
documented trial and failure,
contraindication, or
intolerance to one anti-
resorptive treatment (e.g.,
alendronate, risedronate,
zoledronic acid, Prolia
[denosumab]); and
2. One of the following FRAX
(Fracture Risk Assessment
Tool) 10-year probabilities:
a. The recipient has a
major osteoporotic
fracture at 20% or
more in the U.S., or
the country-specific
threshold in other
countries or regions.
b. The recipient has a hip
fracture at 3% or more
in the U.S., or the
country-specific
threshold in other
countries or regions;
and
c. The recipient has a documented trial and failure, contraindication,
or intolerance to one of the following:
a. Forteo® (teriparatide)
b. Tymlos® (abaoparatide); and
d. Treatment duration of Evenity® (romosozumab-aqqg) has not
exceeded a total of 12 months during the recipient’s lifetime.
2. Prior Authorization Guidelines:
a. Prior authorization approval will be given for 12 months.
b. Prior Authorization forms are available at:
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http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
b. Prolia® (denosumab)
1. For bone loss in men receiving androgen deprivation therapy for
nonmetastatic prostate cancer.
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of nonmetastatic prostate
cancer; and
2. The recipient is undergoing androgen deprivation therapy
with one of the following:
a. Luteinizing hormone-releasing hormone
(LHRH)/gonadotropin releasing hormone (GnRH)
agonist [e.g., Eligard/Lupron (leuprolide), Trelstar
(triptorelin), Vantas (histrelin), and Zoladex
(goserelin)]; or
b. Bilateral orchiectomy (i.e., surgical castration); and
3. One of the following:
a. The recipient is 70 years of age or older; or
b. Both the following:
1. The recipient is less than 70 years of age; and
a. One of the following:
1. BMD scan T-score is less than
-1.0 (1.0 standard deviation or
greater below the mean for
young adults); or
2. Documented history of one of
the following resulting from
minimal trauma:
a. Vertebral
compression fracture
b. Fracture of the hip
c. Fracture of the distal
radius
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d. Fracture of the pelvis
e. Fracture of the
proximal numerous;
and
b. Recertification Request (the recipient must meet all criteria):
1. The recipient is undergoing androgen depravation therapy
with one of the following:
a. Luteinizing hormone-releasing hormone
(LHRH)/gonadotropin releasing hormone (GnRH)
agonist [e.g., Eligard/Lupron (leuprolide), Trelstar
(triptorelin), Vantas (histrelin), and Zoladex
(goserelin)]; or
b. Bilateral orchiectomy (i.e., surgical castration); and
2. The recipient has no evidence of metastases; and
3. Documentation that the recipient is benefiting from therapy
(e.g., improved or stabilized BMD, no new fractures,
improved biochemical markers, etc.)
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. Bone loss in women receiving adjuvant aromatase inhibitor therapy for
breast cancer.
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of breast cancer; and
2. The recipient is receiving adjuvant aromatase inhibitor
therapy (e.g., Arimidex [anastrozole], Aromasin
[exemestane], Femara [letrozole]); and
3. One of the following:
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a. The recipient’s BMD scan T-score is less than -1.0
(1.0 standard deviation or greater below the mean for
young adults); or
b. Documented history of one of the following resulting
from minimal trauma:
1. Vertebral compression fracture
2. Fracture of the hip
3. Fracture of the distal radius
4. Fracture of the pelvis
5. Fracture of the proximal humerous; and
4. The recipient has a documented trial and failure, intolerance,
or contraindication to one bisphosphonate (e.g. alendronate)
b. Recertification Request (recipient must meet all criteria):
1. The recipient is receiving adjuvant aromatase inhibitor
therapy (e.g., Arimidex [anastrozole], Aromasin
[exemestane], Femara [letrozole]); and
2. Documentation that the recipient is benefiting from therapy
(e.g., improved or stabilized BMD, no new fractures,
improved biochemical markers, etc.)
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. For Postmenopausal Osteoporosis or Osteopenia
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of postmenopausal
osteoporosis or osteopenia; and
2. One of the following:
a. The recipient has a BMD scan indicative of
osteoporosis: T-score less than or equal to -2.5 in the
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lumbar spine, femoral neck, total hip, or radius (one-
third radius site); or
b. Both the following:
1. The recipient has a BMD scan indicative of
osteopenia: T-score between -1.0 and -2.5
(BMD T-score greater than -2.5 and less than
or equal to -1.0) in the lumbar spine, femoral
neck, total hip, or radius (one-third radius
site); and
2. One of the following FRAX 10-year
probabilities:
a. Major osteoporotic fracture at 20% or
more in the U.S., or the country-
specific threshold in other countries
or regions; or
b. Hip fracture at 3% or more in the
U.S., or the country-specific
threshold in other countries or
regions; or
c. The recipient has a documented history of one of the
following resulting from minimal trauma:
1. Vertebral compression fracture
2. Fracture of the hip
3. Fracture of the distal radius
4. Fracture of the pelvis
5. Fracture of the proximal humerous; and
3. The recipient has a documented trial and failure, intolerance,
or contraindication to one bisphosphonate (e.g.,
alendronate).
b. Recertification Request:
1. Documentation that indicates the recipient is benefiting from
therapy (e.g., improved or stabilized BMD, no new fractures,
improved biochemical markers, etc.) without significant
adverse effects.
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c. Prior Authorization Guidelines:
1. Prior authorization approval will be for 24 months.
2. Recertification approval will be for 24 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Glucocorticoid-Induced Osteoporosis
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of glucocorticoid-induced
osteoporosis; and
2. The recipient is initiating or continuing greater than or equal
to 7.5 mg/day of prednisone (or its equivalent) and is
expected to remain on glucocorticoid therapy for at least 6
months; and
3. One of the following:
a. The recipient has a BMD T-score less than or equal
to -2.5 based on BMD measurements from lumbar
spine, femoral neck, total hip, or radius (one-third
radius site); or
b. One of the following FRAX 10-year probabilities:
1. Major osteoporotic fracture at 20% or more
in the U.S., or the country-specific threshold
in other countries or regions; or
2. Hip fracture at 3% or more in the U.S., or the
country-specific threshold in other countries
or regions; or
c. The recipient has a documented history of one of the
following fractures resulting from minimal trauma:
1. Vertebral compression fracture
2. Fracture of the hip
3. Fracture of the distal radius
4. Fracture of the pelvis
5. Fracture of the proximal humerous; and
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4. The recipient has a documented trial and failure, intolerance,
or contraindication to one bisphosphonate (e.g.,
alendronate).
b. Recertification Request:
1. Documentation that the recipient is benefiting from therapy
(e.g., improved or stabilized BMD, no new fractures,
improved biochemical markers, etc.) without significant
adverse effects.
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for 24 months.
2. Recertification request will be approved for 24 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Forteo® (teriparatide)
1. For Postmenopausal Osteoporosis or Osteopenia, or Men with Primary or
Hypogonadal Osteoporosis or Osteopenia at High Risk for Fracture
a. Approval will be given if all criteria are met and documented:
1. The recipient has a diagnosis of postmenopausal osteoporosis or
osteopenia, or primary or hypogonadal osteoporosis or osteopenia;
and
2. One of the following:
a. Both the following:
1. The recipient has a BMD T-score of -2.5 or lower in
the lumbar spine, femoral neck, total hip, or radius
(one-third radius site); and
2. One of the following
a. The recipient has documented history of low-
trauma fracture of the hip, spine, proximal
humerus, pelvis, or distal forearm; or
b. Documented trial and failure,
contraindication intolerance to one
osteoporosis treatment (e.g., alendronate,
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risedronate, zoledronic acid, Prolia
[denosumab]); or
b. Both the following:
1. The recipient has a BMD T-score between -1.0 and -
2.5 in the lumbar spine, femoral neck, total hip, or
radius (one-third radius site); and
2. One of the following:
a. Recipient has documented history of low-
trauma fracture of the hip, spine, proximal
humerus, pelvis, or distal forearm; or
b. Both the following:
1. Recipient has a documented trial and
failure, contraindication, or
intolerance to one osteoporosis
treatment (e.g., alendronate,
risedronate, zoledronic acid, Prolia
[denosumab]); and
2. One of the following FRAX 10-year
probabilities:
a. Major osteoporotic fracture at
20% or more in the U.S., or
the country-specific threshold
in other countries or regions;
or
b. Hip fracture at 3% or more in
the U.S., or the country-
specific threshold in other
countries or regions; and
3. Recipient’s treatment duration of parathyroid hormones (e.g.,
teriparatide, Tymlos [abaloparatide]) has not exceeded a total of 24
months during the patient's lifetime.
2. For Glucocorticoid-Induced Osteoporosis at High Risk for Fracture
a. Approval will be given if all criteria are met and documented:
1. The recipient has a diagnosis of glucocorticoid-induced
osteoporosis; and
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2. The recipient has documented history of prednisone or its equivalent
at a dose greater than or equal to 5 mg/day for greater than or equal
to three months; and
3. One of the following:
a. BMD T-score less than or equal to -2.5 based on BMD
measurements from lumbar spine, femoral neck, total hip, or
radius (one-third radius site); or
b. The recipient has one of the following FRAX 10-year
probabilities:
1. Major osteoporotic fracture at 20% or more in the
U.S., or the country-specific threshold in other
countries or regions; or
2. Hip fracture at 3% or more in the U.S., or the
country-specific threshold in other countries or
regions; or
c. The recipient has documented history of one of the following
fractures resulting from minimal trauma:
1. Vertebral compression fracture
2. Fracture of the hip
3. Fracture of the distal radius
4. Fracture of the pelvis
5. Fracture of the proximal humerous; and
4. Documented trial and failure, contraindication, or intolerance to one
bisphosphonate (e.g., alendronate); and
5. The recipient’s treatment duration of parathyroid hormones (e.g.,
teriparatide, Tymlos [abaloparatide]) has not exceed a total of 24
months during the patient's lifetime.
3. Prior Authorization Guidelines:
a. Prior authorization approval will be for 24 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. Tymlos® (abaloparatide)
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1. Approval will be given if all criteria are met and documented:
a. The recipient has a diagnosis of postmenopausal osteoporosis or osteopenia;
and
b. One of the following:
1. Both the following:
a. BMD T-score of -2.5 or lower in the lumbar spine, femoral
neck, total hip, or radius (one-third radius site); and
b. One of the following:
1. Documented history of low-trauma fracture of the
hip, spine, proximal humerus, pelvis, or distal
forearm; or
2. Documented trial and failure, contraindication, or
intolerance to one osteoporosis treatment (e.g.,
alendronate, risedronate, zoledronic acid, Prolia
[denosumab]); or
2. Both the following:
a. Recipient has a BMD T-score between -1.0 and -2.5 in the
lumbar spine, femoral neck, total hip, or radius (one-third
radius site); and
b. One of the following:
1. Recipient has a documented history of low-trauma
fracture of the hip, spine, proximal humerus, pelvis,
or distal forearm; or
2. Both the following:
a. Documented trial and failure,
contraindication, or intolerance to one
osteoporosis treatment (e.g., alendronate,
risedronate, zoledronic acid, Prolia
[denosumab]); and
b. The recipient has one of the following FRAX
10-year probabilities:
1. Major osteoporotic fracture at 20% or
more in the U.S., or the country-
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specific threshold in other countries
or regions; or
2. Hip fracture at 3% or more in the
U.S., or the country-specific
threshold in other countries or
regions; and
c. Recipient’s treatment duration of parathyroid hormones (e.g., teriparatide,
Tymlos [abaloparatide]) has not exceeded a total of 24 months during their
lifetime.
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 24 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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PP. Gonadotropin Releasing Hormone Receptor (GnRH) Antagonist and Combinations
Therapeutic Class: GnRH Antagonist and Combinations
Last Reviewed by DUR Board: October 22, 2020
GnRH Antagonist and Combinations are subject to prior authorization based on the Application
of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
1. Orilissa® (elagolix)
a. Approval will be given if all criteria are met and documented:
1. The recipient has a diagnosis of moderate to severe pain associated with
endometriosis; and
2. One of the following:
a. The recipient has documented history of inadequate pain control
response following a trial of at least three months or the recipient
has documented history of intolerance or contraindication:
1. Danazol; or
2. Combination (estrogen/progesterone) oral contraceptive; or
3. Progestins; or
b. The recipient has had surgical ablation to prevent occurrence.
3. For Orilissa 200 mg request only, the treatment will not exceed six months.
b. Recertification Request (All criteria must be met and documented):
1. The recipient has documented improvement in pain associated with
endometriosis improvement in dysmenorrhea and non-menstrual pelvic
pain); and
2. Treatment duration has not exceeded a total of 24 months; and
3. The request is for Orilissa 150 mg.
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for six months.
2. Recertification approval will be for six months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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2. Oriahnn® (elagolix, estradiol, and norethindrone)
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of heavy menstrual bleeding associated with
uterine leiomyomas (fibroids); and
2. One of the following:
a. The recipient has documented history of inadequate pain control
response following a trial of at least three months or the recipient
has documented history of intolerance or contraindication:
1. Danazol; or
2. Combination (estrogen/progesterone) oral contraceptive; or
3. Progestins; or
b. The recipient has had surgical ablation to prevent occurrence.
b. Recertification Request:
1. The recipient has documented improvement in menstrual bleeding; and
2. Treatment duration will not exceed a total of 24 months.
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for six months.
2. Recertification approval will be for six months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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QQ. Spravato™ (esketamine)
Therapeutic Class: Miscellaneous Anti-Depressant
Last Reviewed by the DUR Board: July 25, 2019
Spravato™ (esketamine) is subject to prior authorization and quantity limits based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Initial approval will be given if the following criteria are met and documented:
1. The recipient is 18 years of age or older; and
2. Recipient must have a diagnosis of treatment resistant depression as
evidence of failure of two antidepressants; and
3. Medication must be administered under the direct supervision of a
healthcare provider with post-administration observation; and
4. Treatment must be in conjunction with an oral antidepressant; and
5. The medication must be prescribed by or in consultation with a psychiatrist;
and
6. The recipient must not have an aneurism or AV (arteriovenous)
malformation.
b. Approval will not be given for recipients who are currently pregnant or lactating
and breastfeeding.
2. Recertification Request:
a. In addition to the prior authorization criteria listed above (initial approval), the
recipient must also have a positive clinical response to the medication treatment.
3. Prior Authorization Guidelines
a. Initial prior authorization approval will be given for four weeks.
b. Recertification authorization approval will be given for six months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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RR. Omontys® (Peginesatide)
Therapeutic Class: Erythropoiesis Stimulating Agent (ESA)
Last Reviewed by DUR Board: October 25, 2012
Omontys® (Peginesatide) is subject to prior authorization based on the Application of Standards
in Section 1927 of the SSA and/or approved by the DUR Board.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of anemia secondary to chronic kidney disease;
b. The recipient must be over 18 years of age;
c. The recipient is receiving dialysis;
d. Other causes for anemia have been evaluated and ruled out (e.g., iron, vitamin B12
or folate deficiencies);
e. The recipient’s hemoglobin level is <10 g/dL, (laboratory values from the previous
14 days must accompany the request); and
f. The target hemoglobin level will not exceed 11 g/dL.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one month.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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SS. Colony Stimulating Factors (POS Claims Only)
Therapeutic Class: Colony Stimulating Factors
Last Reviewed by the DUR Board: April 28, 2016
Colony Stimulating Factors are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The requested agent is being used for an FDA-approved indication.
b. The requests for a diagnosis of nonmyeloid malignancy must meet one of the
following criteria:
1. The recipient is receiving myelosuppressive anticancer drugs that are
associated with a febrile neuropenia risk of ≥ 20%; or
2. The recipient is at high risk for complications from neutropenia (e.g., sepsis
syndrome, current infection, age > 65 years, absolute neutrophil count
(ANC) < 100 cells/μL or the expected duration of neutropenia is > 10 days);
or
3. The recipient has experienced a prior episode of febrile neutropenia and the
requested drug will be used as secondary prophylaxis.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one month.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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TT. Auvi-Q® (epinephrine injection device)
Therapeutic Class: Anaphylaxis-Self Injectable Epinephrine
Last Reviewed by the DUR Board: January 23, 2014
Auvi-Q® (Epinephrine Injection Device) is subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient or recipient’s caregiver is unable to read or comprehend written
directions.
2. Prior Authorization Guidelines
a. Initial prior authorization approval will be for one year.
b. Recertification approval will be for one year.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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UU. RESERVED
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VV. Medications for the Treatment of Acne
Therapeutic Class: Acne Agents
Last Reviewed by the DUR Board: July 24, 2014
Acne agents are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
No prior authorization necessary for recipients up to 21 years of age.
Approval will be given if the following criteria are met and documented:
a. The recipient is age 21 years of age or older; and
b. The recipient has a diagnosis of moderate to severe acne (Grade III or higher).
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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WW. Functional Gastrointestinal Disorder Agents
Therapeutic Class: Chronic Idiopathic Constipation (CIC) Agents, Irritable-Bowel Syndrome
Agents, Opioid-Induced Constipation Agents
Last Reviewed by the DUR Board: January 23, 2020
Functional Gastrointestinal Disorder Agents are subject to prior authorization and quantity limits
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Chronic Idiopathic Constipation (CIC) Agents
a. Approval will be given if all the following criteria are met and documented:
1. The requested drug must be FDA approved for the recipient’s age; and
2. Must have a diagnosis of CIC; and
3. Recipient has trial and failure, contraindication or intolerance to either
lactulose or polyethylene glycol (Miralax); and
4. Recipient has trial and failure, contraindication or intolerance to at least one
stimulant laxative, such as sessosides (Ex-lax, Senokot), bisacodyl
(Dulcolax) or cascara sagrada; and
5. The maximum allowable dose for CIC indication are as follows:
a. Linzess® (linaclotide): 145 mcg, once daily
b. Amitiza® (lubiprostone): 24 mcg, twice daily
c. Motegrity® (prucalopride): 2mg, once daily
d. Trulance® (plecanatide): 2mg, once daily
b. Prior Authorization Guidelines
1. Prior authorization approval will be for one year.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Irritable-Bowel Syndrome Agents
a. Coverage and Limitations
1. Approval will be given if the following criteria are met and documented:
a. The recipient is 18 years of age or older; and
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b. The requested agent is being prescribed based on FDA approved
guidelines; and
1. For requests for a diagnosis of Irritable-Bowel Syndrome
with Constipation (IBS-C):
a. For requests for Amitiza® (lubiprostone), the
recipient must be female.
b. The requested dose is appropriate based on
indication and age.
1. Linzess® (linaclotide): 290 μg daily.
2. Amitiza® (lubiprostone): 16 μg daily.
3. Trulance® (plecanatide): 3 μg daily.
2. For requests for a diagnosis of Irritable-Bowel Syndrome
with Diarrhea (IBS-D):
a. The medication is being prescribed by or in
consultation with a gastroenterologist; and
b. The requested dose is appropriate based on
indication and age.
1. Lotronex® (alosetron): 0.5 mg twice daily or
1 mg twice daily.
2. Viberzi® (eluxadoline): 75 mg twice daily or
100 mg twice daily.
3. Xifaxan® (rifaximin): 550 mg three times a
day for 14 days.
b. Prior Authorization Guidelines
1. Prior authorization approval will be given for an appropriate length of
therapy based on the requested agent and diagnosis, not to exceed one year.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
c. Zelnorm® (tegaserod)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient has a diagnosis of IBS-C; and
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b. The recipient is female; and
c. The recipient is less than 65 years of age; and
d. The recipient has had trial and failure, contraindication, or
intolerance to one of the following:
1. Lactulose; or
2. Polyethylene glycol.
2. Reauthorization Request (the recipient must meet all criteria):
a. Documentation of positive clinical response to Zelnorm® therapy.
3. Prior Authorization Guidelines
a. Initial prior authorization approval will be for six weeks.
b. Recertification approval will be 12 months.
c. Prior authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Opioid-Induced Constipation Agents
a. Approval will be given if all the following criteria are met and documented:
1. The recipient is 18 years of age or older; and
2. The requested medication is being used for an FDA approved indication;
and
3. The recipient must meet the following criteria:
a. There is documentation in the recipient’s medical record of an
inadequate response, adverse reaction or contraindication to one
agent from three of the four traditional laxative drug classes:
1. Bulk forming laxatives;
2. Osmotic laxatives;
3. Saline laxatives;
4. Stimulant laxatives.
4. And, requests for methylnaltrexone bromide that exceed the quantity limit
must meet all the following criteria:
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a. The recipient has opioid-induced constipation in advanced illness,
is receiving palliative care, and is not enrolled in the DHCFP’s
hospice program; and
b. The requested dose is 0.15 mg/kg; and
c. The recipient’s current weight is >114 kg.
b. Prior Authorization Guidelines
1. Prior authorization approval will be for one year.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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XX. Xartemis® XR (oxycodone and acetaminophen)
Therapeutic Class: Opioid Analgesic
Last Reviewed by the DUR Board: January 22, 2015
Xartemis® XR (oxycodone and acetaminophen) is subject to prior authorization and quantity
limitations based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient is 18 years or older; and
b. A diagnosis code of Acute Pain is documented on the prescription and transmitted
on the claim; or
c. An approved prior authorization documenting the recipient meeting the following
criteria:
1. The recipient is 18 years or older; and
2. A diagnosis code of Acute Pain is documented on the Prior Authorization
form.
2. Prior Authorization Guidelines
a. More than two fills of a quantity of 60 each, within six months requires an approved
Prior authorization documenting the reason to exceed the prescribing limit.
b. Prior authorization approval will be for six months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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YY. GnRH Analogs
Therapeutic Class: GnRH Analogs
Last Reviewed by the DUR Board: April 26, 2018
GnRH Analogs are subject to prior authorization and quantity limits based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. This prior authorization criteria only applies to recipients who are under 18 years
of age. Approval of Lupron® (leuprolide) will be given if all the following criteria,
per individual diagnosis, are met and documented:
1. The recipient has a diagnosis of idiopathic or neurogenic central precocious
puberty (CPP), and
a. The requested dose and frequency is based on FDA-approved
guidelines; and
b. The medication is being prescribed by or in consultation with a
pediatric endocrinologist; and
c. There is an onset of secondary sex characteristics before age eight
years (females) or nine years (males); and
d. The recipient is currently less than 11 years of age (females) or 12
years of age (males).
2. The recipient has a diagnosis of gender dysphoria, formerly known as
gender identity disorder; and
a. The medication is being prescribed for suppression of puberty; and
b. The provider indicates a demonstrable knowledge what
gonadotropins medically can and cannot do and their social benefits
and risks; and
c. One of the following:
1. A documented real-life experience (living as the other
gender) for at least three months prior to the administration
of gonadotropin; or
2. A period of psychotherapy for a duration specified by the
mental health professional after the initial evaluation
(usually a minimum of three months).
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d. The member must meet the definition of gender dysphoria (see
definition below):
1. Gender Disphoria:
a. A strong and persistent cross-gender identification
(not merely a desire for any perceived cultural
advantages of being the other sex).
b. Persistent discomfort with his or her sex or sense of
inappropriateness in the gender role of that sex.
c. The disturbance is not concurrent with a physical
intersex condition.
d. The disturbance causes clinically significant distress
or impairment in social, occupational or other
important areas of functioning.
e. The transsexual identity has been present persistently
for at least two years.
f. The disorder is not a symptom of another mental
disorder or a chromosomal abnormality.
3. The recipient has a diagnosis of endometriosis, and
a. The requested dose and frequency is based on FDA-approved
guidelines; and
b. The recipient has had an inadequate response, adverse reaction or
contraindication to an NSAID; and
c. The recipient has had an inadequate response, adverse reaction or
contraindication to a hormonal contraceptive.
4. The recipient has a diagnosis of uterine leiomyomata (fibroids), and
a. The requested dose and frequency is based on FDA-approved
guidelines; and
b. The recipient is symptomatic; and
c. Documentation has been submitted of the anticipated surgery date
(or notation that surgery is planned once the fibroids shrink) or
clinical rational why surgical intervention is not required.
5. The recipient has a diagnosis of prostate cancer, and
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a. The requested dose and frequency is based on FDA-approved
guidelines.
2. Prior Authorization Guidelines
a. Prior authorization approval will be given for an appropriate length of therapy
based on the diagnosis, unless the prescriber indicates a shorter duration of
approval.
1. CPP: One year, or until the member reaches the age of 11 years (female) or
12 years (male).
2. Endometriosis: One year.
3. Uterine Leiomyomata (fibroids): One month or until the time of the
documented surgery (maximum of three months).
4. Prostate Cancer: One year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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ZZ. RESERVED
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MEDICAID SERVICES MANUAL
AAA. Narcolepsy Agents
Therapeutic Class: Narcolepsy Agents (non-stimulants)
Last Reviewed by the DUR Board: April 22, 2021
Narcolepsy Agents are subject to prior authorizations and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Approval will be given if the following criteria are met and documented:
1. Provigil® (modafinil), and Nuvigil® (armodafinil):
a. The recipient has a diagnosis of narcolepsy.
2. Xyrem® (sodium oxybate):
a. The recipient has tried and failed on Provigil® (modafinil) or
Nuvigil® (armodafinil); and/or
b. The recipient has a diagnosis of narcolepsy with cataplexy; and
c. The drug was prescribed by or in consultation with a neurologist or
sleep specialist.
3. Prior Authorization Guidelines
a. Prior authorization approvals will be for 12 months.
b. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
b. Sunosi® (solriamfetol)
1. For treatment of Narcolepsy
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a diagnosis of narcolepsy confirmed by sleep study
(unless the prescriber provides justification confirming that a sleep
study would not be feasible); and
2. The recipient has had trial and failure, contraindication, or
intolerance to both of the following:
a. modafinil; and
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b. armodafinil.
b. Recertification Request:
1. Documentation of positive clinical response to Sunosi® therapy.
c. Prior Authorization Guidelines:
1. Initial request will be approved for 12 months.
2. Recertification request will be approved for 12 months.
3. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. For treatment of Obstructive Sleep Apnea (OSA)
a. Approval will be given if all the following criteria are met and
documented:
1. The recipient must have a diagnosis of OSA defined by one of the
following:
a. The recipient has had 15 or more obstructive respiratory
events per hour of sleep confirmed by a sleep study (unless
the prescriber provides justification confirming that a sleep
study would not be feasible); or
b. Both the following:
1. Five or more obstructive respiratory events per hour
of sleep confirmed by a sleep study (unless the
prescriber provides justification confirming that a
sleep study would not be feasible); and
2. One of the following signs/symptoms are present:
a. Daytime sleepiness; or
b. Nonrestorative sleep; or
c. Fatigue; or
d. Insomnia; or
e. Waking up with breath holding, gasping, or
choking; or
f. Habitual snoring noted by a bed partner or
other observer; or
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g. Observed apnea; and
3. Both the following:
a. The recipient has used a standard
treatment(s) for the underlying obstruction
for one month or longer (e.g., CPAP,
BiPAP); and
b. The recipient is fully compliant with ongoing
treatment(s) for the underlying airway
obstruction; and
4. The recipient has had a trial and failure,
contraindication, or intolerance to both of the
following:
a. Modafinil; and
b. Armodafinil.
b. Recertification Request (recipient must meet all the criteria)
1. Documentation of positive clinical response to Sunosi® therapy;
and
2. The recipient continues to be fully compliant with ongoing
treatment(s) for the underlying airway obstruction. (e.g., CPAP,
BiPAP)
c. Prior Authorization Guidelines
1. Initial request will be approved for six months.
2. Recertification request will be approved for for six months.
3. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Wakix® (pitolisant)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient has a documented diagnosis of narcolepsy as confirmed by
sleep study (unless the prescriber provides justification confirming that a
sleep study would not be feasible); and
b. The recipient is 18 years of age and older.
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2. Recertification Requests:
a. The recipient must have documentation of positive clinical response to
Wakix® therapy.
3. Prior Authorization Guidelines:
a. Initial request will be approved for six months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization form are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. Xywav® (calcium, magnesium, potassium, and sodium oxybates)
1. Narcolepsy with Cataplexy (Narcolepsy Type 1).
a. Approval will be given if the following criteria are met and documented:
1. The recipient has a diagnosis of narcolepsy confirmed by sleep study
(unless the prescriber provides justification confirming that a sleep
study would not be feasible); and
2. The recipient has present symptoms of cataplexy; and
3. The recipient has symptoms of excessive daytime sleepiness (e.g.,
irrepressible need to sleep or daytime lapses into sleep); and
4. The medication is prescribed by or in consultation with either a
Neurologist, a Psychiatrist, or a Sleep Medicine Specialist.
b. Recertification Request:
1. The recipient has documentation demonstrating a reduction in the
frequency of cataplexy attacks associate with therapy; or
2. The recipient has documentation demonstrating a reduction in
symptoms of excessive daytime sleepiness associated with therapy.
c. Prior Authorization Guidelines:
1. Initial request will be approved for six months.
2. Recertification request will be approved for 12 months.
3. Prior Authorization form are available
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. Narcolepsy without Cataplexy (Narcolepsy Type 2)
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a. Aproval will be given if all the following criteria are met and documented:
1. The recipient has diagnosis of narcolepsy confirmed by sleep study
(unless the prescriber provides justification confirming that a sleep
study would not be feasible); and
2. The recipient symptoms of cataplexy are absent; and
3. The recipient has symptoms of excessive daytime sleepiness (e.g.,
irrepressible need to sleep or daytime lapses into sleep); and
4. The recipient has trial and failure, contraindication (e.g., safety
concerns, not indicated for patient’s age/weight), or intolerance to
generic modafinil or generic armodafinil and Sunosi®; and
5. One of the following:
a. The recipient has trial and failure, contraindication, or
intolerance to an amphetamine (e.g., amphetamine,
dextroamphetamine) or methylphenidate-based stimulant; or
b. The recipient has history of or potential for substance use
disorder; and
6. The medication is prescribed by or in consultation with either a
Neurologist, a Psychiatrist, or a Sleep Medicine Specialist.
b. Recertification Request:
1. The recipient has documentation demonstrating a reduction in
symptoms of excessive daytime sleepiness associated with therapy.
c. Prior Authorization Guidelines:
1. Initial request will be approved for six months.
2. Recertification request will be approved for 12 months.
3. Prior Authorization form are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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BBB. Vimovo® (naproxen/esomeprazole magnesium), Duexis® (ibuprofen/famotidine)
Therapeutic Class: Nonsteroidal Anti-inflammatory Drug/Anti-ulcer Agent Combinations
Last Reviewed by the DUR Board: April 23, 2015
Vimovo® (naproxen/esomeprazole magnesium), Duexis® (ibuprofen/famotidine) are subject to
prior authorizations and quantity limitations based on the Application of Standards in Section 1927
of the SSA and/or approved by the DUR Board. Refer to the Nevada Medicaid and Check Up
Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The drug is being used for an FDA approved indication; and
b. The recipient’s medical records documents one of the following risk factors for
developing a NSAID-related ulcer:
1. Previous history of a major gastrointestinal bleed, perforation or
obstruction; or
2. Previous history of a peptic ulcer, hemorrhagic gastritis, hemorrhagic
gastropathy or erosive esophagitis; or
3. Concomitant therapy for an anticoagulant or antiplatelet agent (including
aspirin) or chronic oral corticosteroids; or
4. The recipient has had gastric bypass surgery (Roux-en-Y gastric bypass);
and
c. The recipient is intolerant to a COX-2 inhibitor or has had a gastric or duodenal
ulcer while taking a COX-2 inhibitor; and
d. The recipient has experienced an NSAID-associated ulcer in the past while taking
a single-entity proton pump inhibitor (PPI) or prostaglandin agent concomitantly
with an NSAID or the recipient is intolerant to both PPIs and prostaglandin agents;
and
e. The recipient’s medical records document an inadequate response or adverse
reaction with concurrent therapy of an equivalent dose of the individual
components.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for one year.
b. Prior Authorization forms available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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CCC. Rayos® (prednisone delayed-release)
Therapeutic Class: Corticosteroid, Systemic
Last Reviewed by the DUR Board: April 23, 2015
Rayos® (prednisone delayed-release) is subject to prior authorizations based on the Application
of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
1. Coverage and Limitations
Approval will be given if all of the following criteria are met and documented:
a. The requested drug is being used for a FDA approved indication; and
b. The recipient’s medical records document an inadequate response or adverse
reaction to generic prednisone immediate–release tablets.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be:
1. Initial therapy: three months.
2. Recertification: one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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DDD. Corlanor® (ivabradine)
Therapeutic Class: Cardiovascular Agent
Last Reviewed by the DUR Board: September 3, 2015
Corlanor® (ivabradine) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. A diagnosis of chronic heart failure; and
b. A left ventricular ejection fraction (LVEF) < 35%; and
c. A resting heart rate > 70 bpm; and
d. The recipient is > 18 years of age; and
e. The prescriber is a cardiologist or there is documentation in the recipient’s medical
record that a cardiologist has been consulted regarding the diagnosis and treatment
recommendations; and
f. The recipient is in a normal sinus rhythm; and
g. The recipient is on a maximally tolerated dose of a beta-blocker or the recipient has
a contraindication to beta-blocker use.
2. Prior Authorization Guidelines
a. The extent of prior authorization approvals will be based on the appropriate use for
the individual agents.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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EEE. Anti-lipidemic Agents – PCSK9 Inhibitors
Therapeutic Class: AntilipemicAgent, PCSK9 Inhibitors
Last Reviewed by the DUR Board: July 23, 2020
Anti-lipidemic Agents – PCSK9 Inhibitors are subject to prior authorization and quantity
limitation based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Approval will be given if all the following criteria are met and document:
a. Initial Request:
1. The recipient has an FDA-approved diagnosis; and
2. The requested medication was prescribed by or in consultation with a
cardiologist or lipid specialist; and
3. The requested medication will be used as an adjunct to a low-fat diet and
exercise; and
4. For the treatment of homozygous familial hypercholesterolemia:
a. With alirocumab (Praluent®)
1. The recipient is 18 years of age or older; or
b. With evolocumab (Repatha®)
1. The recipient is 13 years of age or older.
5. And the recipient must meet one of the following (a, b, c, or d):
a. The recipient has had an inadequate response to high intensity
statintherapy defined as all of the following:
1. The recipient has received therapy with atorvastatin > 40 mg
or rosuvastatin > 20 mg for at least the past three months;
and
2. The recipient has received add-on therapy with ezetimibe to
the maximum tolerable dose of statin for at least the past two
weeks or the recipient has a contraindication to ezetimibe
therapy; and
3. The LDL-C after therapy for at least the past three months
was > 100 mg/dL (HeFH) for > 70 mg/dL (clinical
atherosclerotic cardiovascular disease); and
4. The statin therapy will be continued with PCSK-9 therapy.
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b. Or, the recipient has had an inadequate response to moderate
intensity statin therapy defined as all of the following:
1. The recipient has an intolerance or contraindication to high
intensity statin therapy; and
2. The recipient has received therapy with:
a. atorvastatin 10 to 20 mg; or
b. rosuvastatin 5 to 10 mg; or
c. simvastatin > 20 mg; or
d. pravastatin >40 mg; or
e. lovastatin 40 mg; or
f. fluvastatin XL 80 mg; or
g. fluvastatin 40 mg twice daily; or
h. pitavastatin > 2 mg
for at least the past three months; and
3. The recipient has received add-on therapy with ezetimibe to
the maximum tolerable dose of statin for at least the past two
weeks or the recipient has a contraindication to ezetimibe
therapy; and
4. The LDL-C after therapy for at least the past three months
was > 100 mg/dL (HeFH) or > 70 mg/dL (clinical
atherosclerotic cardiovascular disease); and
5. Statin therapy will be continued with PCSK-9 therapy.
c. Or the recipient experienced an adverse reaction to at least two
statins, the statins and adverse reactions must be documented in the
recipient’s medical record.
d. Or the recipient has a labeled contraindication to all statins, the
contraindication is documented in the recipient’s medical record.
2. Recertification Request (The recipient must meet all criteria (a-d))
a. The recipient has been adherent with PCSK-9 inhibitor therapy; and
b. The recipient has been adherent with statin therapy or the recipient has a labeled
contraindication to statin therapy; and
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c. The recipient is continuing a low-fat diet and exercise regimen; and
d. The recipient has achieved a reduction in LDL-C level.
3. Prior Authorization Guidelines
a. Initial authorization will be approved for six months.
b. Recertification approval will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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FFF. Invega Trinza® (paliperidone palmitate)
Therapeutic Class: Second Generation (Atypical) Antipsychotic
Last Reviewed by the DUR Board: November 5, 2015
Invega Trinza® (paliperidone palmitate) is subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented.
a. The recipient has a diagnosis of schizophrenia; and
b. The recipient has been stabilized on once-monthly paliperidone palmitrate injection
(Invega Sustenna®) for at least four months with the two most recent doses of the
once-monthly injection being the same strength; and
c. The recipient is 18 years of age or older; and
d. The requested dose is one injection every three months.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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GGG. Medications for Recipients on Hospice
Last Reviewed by the DUR Board: January 27, 2017
Previously reviewed: January 28, 2016
Medications for recipients on hospice are subject to prior authorization and quantity limits based
on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. For recipients 21 years of age or older:
1. The prescriber has verified the recipient is enrolled in the hospice program;
and
2. The requested medication is not being used to treat or manage symptoms of
the terminal hospice diagnosis; and
3. The requested medication is not being used for palliative care; and
4. The requested medication is unrelated to the terminal hospice diagnosis and
is medically necessary to treat the recipient; and
5. The requested medication is not providing a curative or long-term
prophylactic therapy.
b. For recipients 20 years of age or younger:
1. The prescriber has verified the recipient is enrolled in a hospice program;
and
2. The requested medication is not being used to treat or manage symptoms
of the terminal hospice diagnosis; and
3. The requested medication is not being used for palliative care.
4. Medically necessary curative medications for this age group are covered
by the DHCFP pursuant to Sections 1905(o)(1) and 2110(a)(23) of the
SSA.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for three months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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HHH. (RESERVED FOR FUTURE USE)
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III. Hetlioz® (tasimelteon)
Therapeutic Class: Sedative Hypnotic
Last Reviewed by the DUR Board: January 28, 2016
Hetlioz® (tasimelteon) is subject to prior authorization and quantity limits based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all following criteria are met and documented:
a. The recipient has a diagnosis of non-24-hour sleep-wake disorder; and
b. The recipient is totally blind; and
c. The medication is being prescribed by or in consultation with a sleep specialist; and
b. The recipient had an adverse reaction, contraindication or an inadequate response
(after at least four weeks of therapy) to a therapeutic dose of melatonin.
2. Prior Authorization Guidelines
a. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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JJJ. Entresto® (sacubitril/valsartan)
Therapeutic Class: Angiotension II Receptor Blocker
Last Reviewed by the DUR Board: January 24, 2019
Entresto® (sacubitril/valsartan) is subject to prior authorization based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of chronic heart failure NYHA Class II to IV; and
b. The recipient has reduced left ventricular ejection fraction (LVEF); and
c. The recipient is 18 years of age or older; and
d. The prescriber is a cardiologist or there is documentation in the recipient’s medical
record that a cardiologist has been consulted; and
e. The recipient has had a trial of an angiotensin converting enzyme (ACE) or an
angiotensin receptor blocker (ARB) for at least four weeks prior to the initiation of
therapy; and
f. The recipient will not concurrently receive an ACE inhibitor; and
g. The recipient is on an individualized dose of a beta blocker or the recipient has a
contraindication to beta blocker use; and
h. Entresto® will be given twice daily with a maximum dose of 97/103 mg.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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KKK. Neurokinin-1 Antagonists and Combinations
Therapeutic Class: Neurokinin-1 Antagonists and Combinations
Last Reviewed by the DUR Board: April 28, 2016
Neurokinin-1 antagonists and combinations are subject to prior authorization and quantity limits
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
For requests to exceed the quantity limits approval will be given if all the following criteria
are met and documented:
a. The requested medication is being used for an FDA-approved indication; and
b. The requested medication is being prescribed by an oncologist or in consultation
with an oncologist; and
c. The recipient must meet one of the following criteria:
1. The recipient is 18 years of age or older; or
2. The recipient is 12 years of age or older, the requested medication is
aprepitant (Emend®) and the recipient is diagnosed with nausea and
vomiting caused by chemotherapy.
d. And, it is medical necessity for the recipient to exceed the quantity limit (e.g.,
duration of chemotherapy cycle).
2. Prior Authorization Guidelines
a. Prior authorization approval will be for six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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LLL. RESERVED
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MMM. Duchenne Muscular Dystrophy (DMD) Agents
Therapeutic Class:Duchenne Muscular Dystrophy (DMD) Agents
Last Reviewed by the DUR Board: January 28, 2021
DMD agents are subject to prior authorization and quantity limitations based on the Application
of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Exondys 51® (eteplirsen)
a. Approval will be given if all the following criteria are met and documented:
1. Initial request:
a. The recipient has a diagnosis of Duchenne muscular dystrophy
(DMD); and
b. There is documentation of a confirmed mutation of the dystrophin
gene amenable to exon 51 skipping; and
c. The medication is prescribed by or in consultation with a neurologist
who has experience treating children; and
d. The prescribed dose does not exceed 30 milligrams per kilogram of
body weight once weekly.
2. Recertification Request (the recipient must meet all the following criteria).
a. The recipient has been on therapy for less than 12 months; and
b. The recipient has experienced clinically significant benefit; and
c. The recipient is tolerating therapy; and
d. The prescribed dose will not exceed 30 milligrams per kilogram of
body weight once weekly; and
e. The medication is prescribed by or in consultation with a neurologist
who has experience treating children, or all the following:
1. The recipient has been on therapy for 12 months or more;
and
2. The recipient has experienced a benefit from therapy (e.g.,
disease amelioration compared to untreated patients); and
3. The recipient has experienced clinically significant benefit;
and
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4. The recipient is tolerating therapy; and
5. The prescribed dose will not exceed 30 milligrams per
kilogram of body weight once weekly; and
6. The medication is prescribed by or in consultation with a
neurologist who has experience treating children.
b. Prior Authorization Guidelines
1. Initial authorization will be approved for six months.
2. Recertification request will be approved for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Emflaza® (deflazacort)
a. Approval will be given if all the following criteria are met and documented:
1. Initial request:
a. The recipient must have a diagnosis of (DMD); and
b. The recipient must be five years of age or older; and
c. The recipient must have received genetic testing for a mutation of
the dystrophin gene, and one of the following:
1. Documentation of a confirmed mutation of the dystrophin
gene; or
2. Muscle biopsy confirming an absence of dystrophin protein;
and
d. The medication must be prescribed by or in consultation with a
neurologist who has experience treating children; and
e. The recipient has had at least a three-month trial and failure of
prednisone (prednisolone or equivalent dose) or a documented
intolerance to prednisone (prednisolone or equivalent dose) given at
a dose of 0.75 mg/kg/day or 10 mg/kg/week; and
The dose will not exceed 0.9 milligrams per kilogram of body
weight once daily.
b. Recertification request (the recipient must meet all the following criteria):
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1. Documentation of positive clinical response to Emflaza® therapy (e.g.,
improvement or preservation of muscle strength); and
2. The dose will not exceed 0.9 milligrams per kilogram of body weight once
daily.
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be approved for 12 months.
2. Recertification request will be approved for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. Vyondys 53® (golodirsen)
a. Approval will be given if all the following criteria are met and documented:
1. Submission of medical records (e.g. chart notes, laboratory values)
documenting the following:
a. The recipient has a diagnosis of DMD; and
b. Documentation of a confirmed mutation of the dystrophin gene
amenable to exon 53 skipping; and
2. The medication is prescribed by or in consultation with a neurologist who
has experience treating children; and
3. The dose will not exceed 30 milligrams per kilogram of body weight infused
once weekly.
b. Recertification request (recipient must meet all criteria):
1. One of the following:
a. All the following:
1. The recipient has been on therapy for less than 12 months;
and
2. The recipient is tolerating therapy; and
3. Dose will not exceed 30 milligrams per kilogram of body
weight infused once weekly; and
4. The medication is prescribed by or in consultation with a
neurologist who has experience treating children; or
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b. All the following:
1. The recipient has been on therapy for 12 months or more;
and
2. Recipient experienced a benefit from therapy (e.g. disease
amelioration compared to untreated patients); and
3. Recipient is tolerating therapy; and
4. Dose will not exceed 30 milligrams per kilogram of body
weight infused once weekly; and
5. The medication is prescribed by or in consultation with a
neurologist who has experience in treating children.
c. Prior Authorization Guidelines:
1. Initial authorization will be approved for six months.
2. Recertification request will be approved for 12 months.
3. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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NNN. Qutenza® (capsaicin)
Therapeutic Class: Topical Neuropathic Pain Agents
Last Reviewed by the DUR Board: January 28, 2021
Qutenza® (capsaicin) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Approval will be given if all the following criteria is met and documented:
a. The recipient has a diagnosis of neuropathic pain associated with postherpetic
neuralgia; and
b. The recipient has history of failure or intolerance to over-the-counter capsaicin.
2. Recertification Request (recipient must meet all criteria):
a. At least three months have transpired since the last Qutenza®
application/administration; and
b. The recipient experienced pain relief with a prior course of Qutenza®; and
c. The recipient is experiencing a return of neuropathic pain.
3. Prior Authorization Guidelines:
a. Initial authorization will be approved for three months.
b. Recertification request will be approved for three months.
c. The Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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OOO. Austedo® (deutetrabenazine)
Therapeutic Class: Austedo® (deutetrabenazine)
Last Reviewed by the DUR Board: January 25, 2018
Austedo® (deutetrabenazine) is subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
Austedo® is indicated for the diagnosis of chorea associated with Huntington’s disease or Tardive
Dyskinesia.
1. Coverage and Limitations for Diagnosis of Chorea Associated with Huntington’s Disease
Approval will be given if all the following criteria are met and documented:
a. Initial request:
1. The recipient must have a diagnosis of chorea associated with Huntington’s
disease; and
2. The recipient must be 18 years of age or older; and
3. The medication is prescribed by or in consultation with a neurologist; and
4. Prior authorization will not be approved for recipients who are suicidal or
have untreated/inadequately treated depression, or hepatic impairment, or
are currently utilizing monoamine oxidase inhibitors (MAOIs), reserpine
or tetrabenazine.
b. Recertification request (the recipient must meet all of the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
a. Documentation of positive clinical response to Austedo® therapy.
2. Recertification will not be approved for recipients who are suicidal or have
untreated/inadequately treated depression, or hepatic impairment, or are
currently utilizing monoamine oxidase inhibitors (MAOIs), reserpine or
tetrabenazine.
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for 12 months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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2. Coverage and Limitations for Diagnosis of Tardive Dyskinesia (TD)
Approval will be given if all of the following criteria are met and documented:
a. Initial Request:
1. The recipient must have a confirmed diagnosis of TD; and
2. The recipient must be 18 years of age or older; and
3. At least 60 days of stable (drug, dose) neuroleptic medication exposure
(either typical or first-generation antipsychotic agents, atypical or second-
generation antipsychotic agents or certain dopamine receptor-blocking
drugs used in treatment of nausea and gastroparesis); and
4. Presence of involuntary athetoid or choreiform movements lasting at least
30 days; and
5. Must be prescribed by, or in consultation with, a neurologist or psychiatrist;
and
6. The recipient must have one of the following:
a. Persistent symptoms of TD despite a trial dose reduction, tapering
or discontinuation of the offending medication; or
b. The recipient is not a candidate for trial dose reduction, tapering or
discontinuation of the offending medication.
b. Recertification request (the recipient must meet all the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
a. Documentation of positive clinical response to Austedo® therapy.
2. Prior Authorization Guidelines
a. Initial prior authorization approval will be for three months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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PPP. Brineura® (cerliponase alfa)
Therapeutic Class: Brineura® (cerliponase alfa)
Last Reviewed by the DUR Board: October 19, 2017
Brineura® (cerliponase alfa) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Initial request:
1. The recipient must have a diagnosis of symptomatic late infantile neuronal
ceroid lipofuscinosis Type 2 (CLN2) also known as tripeptidyl peptidase 1
(TPP1) deficiency; and
2. The diagnosis must be confirmed by TPP1 enzyme detected by a dried
blood spot test and CLN2 genotype analysis; and
3. The recipient must be three years of age or older; and
4. The drug must be prescribed by or in consultation with a neurologist with
expertise in the diagnosis of CLN2; and
5. The drug must be administered by, or under the direction of, a physician
knowledgeable in intraventricular administration; and
6. The recipient must not have acute intraventricular access-related
complications (e.g., leakage, device failure or device-related infections);
and
7. The recipient must not have a ventriculoperitoneal shunt.
b. Recertification request (the recipient must meet all of the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
a. The recipient must not have acute intraventricular access-related
complications (e.g., leakage, device failure or device-related
infections); and
b. The recipient must not have a ventriculoperitoneal shunt; and
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c. Documentation of positive clinical response to Brineura®, (e.g.,
improvement in walking or crawling, or no evidence of disease
progression).
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for four months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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QQQ. Ingrezza® (valbenazine)
Therapeutic Class: Ingrezza® (valbenazine)
Last Reviewed by the DUR Board: October 19, 2017
Ingrezza® (valbenazine) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Initial request:
1. The recipient must have a diagnosis of tardive dyskinesia (TD) confirmed
by the most current edition of Diagnostic and Statistical Manual of Mental
Disorders (DSM), and the following:
a. At least 60 days of stable (drug, dose) neuroleptic medication
exposure (either typical or first generation antipsychotic agents
(such as, chlorpromazine, haloperidol or fluphenazine), atypical or
second-generation antipsychotic agents (such as, clozapine,
risperidone, olanzapine, quetiapine or aripiprazole, or certain
dopamine receptor-blocking drugs used in treatment of nausea and
gastroparesis (such as, prochlorperazine, promethazine or
metoclopramide)); and
b. The presence of involuntary athetoid or choreiform movements
lasting at least 30 days.
1. The recipient must be 18 years of age or older; and
2. The drug must be prescribed by or in consultation with a neurologist or
psychiatrist; and
3. The recipient must have persistent symptoms of TD despite a trial of dose
reduction, tapering or discontinuation of the offending medication; or
4. The recipient must not be a candidate for a trial of dose reduction, tapering
or discontinuation of the offending medication.
b. Recertification request (the recipient must meet all of the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
2. Documentation of positive clinical response to Ingrezza® therapy.
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c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for three months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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RRR. RESERVED FOR FUTURE USE
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SSS. Xadago® (safinamide)
Therapeutic Class: Xadago® (safinamide)
Last Reviewed by the DUR Board: October 19, 2017
Xadago® (safinamide) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Initial request:
1. The recipient must have a diagnosis of Parkinson’s disease; and
2. The recipient must be five years of age or older; and
3. Documented continued Levodopa and/or other dopaminergic treatments;
and
4. Recipient reports greater than 1.5 hours per day of “off” episodes (“off”
episodes refer to “end-of-dose wearing off” and unpredictable “on/off”
episodes); and
5. Recipient must not also be taking any of the following drugs: other MAOIs,
or other drugs that are potent inhibitors of MAOI (e.g., linezolid), opioid
drugs (e.g., tramadol, meperidine and related derivatives), selective
norepinephrine reuptake inhibitors (SNRIs), tri- or tetra-cyclic or
triazolopyridine antidepressants (TCAs), cyclobenzaprine,
methylphenidate, amphetamine and their derivatives, St. John’s wort or
dextromethorphan; and
6. The recipient must not have severe hepatic impairment (e.g., Child-Pugh
C).
b. Recertification request (the recipient must meet all of the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
a. Documentation of positive clinical response to Xadago® therapy;
and
b. Documented continued Levodopa and/or other dopaminergic
treatments.
c. Prior Authorization Guidelines
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1. Initial prior authorization approval will be for three months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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TTT. Codeine and Tramadol for Children
Therapeutic Class: Opioid Analgesic
Last Reviewed by the DUR Board: October 19, 2017
Codeine, codeine with acetaminophen and tramadol, tramadol with acetaminophen are subject to
prior authorization and quantity limitations based on the Application of Standards in Section 1927
of the SSA and/or approved by the DUR Board. Refer to the Nevada Medicaid and Check Up
Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Codeine, codeine with acetaminophen
1. All of the following criteria must be met:
a. The recipient must be 12 years of age or older; and
b. The lowest effective dose for the shortest period of time is being
requested; and
c. The recipient must not be obese (BMI > 30 kg/m²), have obstructive
sleep apnea, or severe lung disease; and
d. The recipient is not being prescribed the drug for post-surgical pain
following a tonsillectomy and/or adenoidectomy.
b. Tramadol, tramadol with acetaminophen
1. All of the following criteria must be met:
a. The recipient must be 12 years of age or older; and
b. The lowest effective dose for the shortest period of time is being
requested; and
c. The recipient must not be obese (BMI > 30 kg/m²), have obstructive
sleep apnea, or severe lung disease; and
d. The recipient is not being prescribed the drug for post-surgical pain
following a tonsillectomy and/or adenoidectomy; and
e. The prescribed dose does not exceed 200mg/day and does not
exceed a five day supply.
2. Tramadol Extended Release (ER) will not be approved for children under
18 years of age and will reject at point of sale.
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c. Prior Authorization Guidelines
1. Codeine, codeine with acetaminophen
a. Prior authorization approval will be given for the lowest effective
dose for the shortest period of time requested.
1. Prior authorization will be given for a one month time
period.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Tramadol, tramadol with acetaminophen
a. Prior authorization approval will be given for the lowest effective
dose for the shortest period of time requested.
b. Prior authorization will be given for a one month time period.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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UUU. High Dollar Claim
Last Reviewed by the DUR Board: April 26, 2018
A High Dollar Claim is defined as a single point-of-sale claim that exceeds $10,000. A High Dollar
Claim is subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits. If other prior authorization
criteria exists, it will supersede this criteria.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. One of the following:
1. The medication is being prescribed for a Food and Drug Administration
(FDA) approved indication; or
2. One of the following:
a. Diagnosis is supported as a use of American Society of Health-
System Pharmacists Drug Information (AHFS DI); or
b. Diagnosis is supported in the FDA Uses/Non-FDA Uses section in
DRUGDEX Evaluation and carries a Strength of Recommendation
rating of IIb or better (see DRUGDEX Strength of Recommendation
table); or
3. Both of the following:
a. Diagnosis is listed in the FDA Uses/Non-FDA Uses section in
DRUGDEX Evaluation and carries a Strength of Recommendation
rating of III or Class Indeterminant (see DRUGDEX Strength of
Recommendation table); and
b. Efficacy is rated as “Effective” or “Evidence Favors Efficacy” (see
DRUGDEX Efficacy Rating and Prior Authorization Approval
Status table); or
4. Diagnosis is supported in any other section in DRUGDEX; or
5. The use is supported by clinical research in two articles from major peer-
reviewed medical journals that present data supporting the proposed off-
label use or uses as generally safe and effective unless there is clear and
convincing contradictory evidence presented in a major peer-reviewed
medical journal.
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b. And one of the following:
1. The dosage/quantity/duration of the medication is reasonably safe and
effective based on information contained in the FDA approved labeling,
peer-reviewed medical literature or accepted standards of medical practice;
or
2. The dosage/quantity/duration of the medication is reasonably safe and
effective based on one of the following compendia:
a. American Hospital Formulary Service (AHFS) Compendium.
b. Thomson Reuters (Healthcare) Micromedex/DRUGDEX (not Drug
Points) Compendium.
c. Elsevier Gold Standard Clinical Pharmacology Compendium.
d. National Comprehensive Cancer Network Drugs and Biologics
Compendium.
c. Excluded:
1. Hemostatic coagulation factors used for the treatment of hemophilia are
excluded from this criteria.
d. Prior Authorization Guidelines
1. Prior authorization approval will be for 12 months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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VVV. (RESERVED FOR FUTURE USE)
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WWW. Botulinum Toxin
Therapeutic Class: Neurotoxic Protein
Last reviewed by the DUR Board: July 26, 2018
Botulinum toxins are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Policy
Botulinum toxin injections are a Nevada Medicaid covered benefit for certain spastic
conditions including, but not limited to cerebral palsy, stroke, head trauma, spinal cord
injuries and multiple sclerosis. The injections may reduce spasticity or excessive muscular
contractions to relieve pain, to assist in posturing and ambulation, to allow improved range
of motion, to permit better physical therapy and provide adequate perineal hygiene.
2. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. It is expected that physicians be familiar with and experienced in the use of
botulinum toxin products and utilize FDA-approved product labeling, compendia
and peer-reviewed scientific literature to select the appropriate drug and dose
regimen for each recipient condition. A complete list of covered indications can be
found within the “Provider Type 20, 24 and 77 Billing Guide” applicable to
botulinum toxins.
b. Documentation must be provided that the recipient has been unresponsive to
conventional methods of treatment (e.g., medication, physical therapy and other
appropriate methods used to control and/or treat spastic conditions); and
c. If maximum dose is reached and positive clinical response is not established,
treatment must be discontinued; and
d. Documentation of medical necessity is required for treatment more frequent than
every 90 days; and
e. Coverage will be approved for one injection per site. A site is defined as including
muscles of a single contiguous body part, such as a single limb, eyelid, face or neck.
f. Coverage will not be provided for injections given for cosmetic or for
investigational purposes.
3. Recertification Request (the recipient must meet all the following criteria):
a. Authorization for continued use shall be reviewed at least every 12 months when
the following criteria are met:
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1. Documentation of a positive clinical response to Botulinum Toxin therapy.
4. Prior Authorization Guidelines
a. Prior authorization approval will be for six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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XXX. Compounded Medications
Last Reviewed by the DUR Board: January 24, 2019
Compounded medications are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Each active ingredient in the compounded medication is FDA-approved or national
compendia supported for the condition being treated; and
b. The therapeutic amounts and combinations are supported by national compendia or
peer-reviewed literature for the condition being treated in the requested route of
delivery; and
c. If any prescription ingredients require prior authorization and/or step therapy, all
drug specific criteria must also be met; and
d. The compounded medication must not be used for cosmetic purpose; and
e. The compounded medication must not include any ingredient that has been
withdrawn or removed from the market due to safety reasons (drugs withdrawn
from the market due to safety or effectiveness); and
f. The recipient has tried and failed therapy or had an intolerance to at least two FDA-
approved, commercially available prescription therapeutic alternatives, one of
which is the same route of administration as the requested compound, unless one
of the following criteria are met:
1. The recipient has a contraindication to commercially available products; or
2. One or no other therapeutic alternatives are commercially available; or
3. Compound medication is prepared in a different dosage form for a recipient
who is unable to take the commercially available formulation (mixing or
reconstituting commercially available products based on the manufacturer’s
instructions or the product’s approved labeling does not meet this criteria);
or
4. The recipient has an allergy or sensitivity to inactive ingredients (e.g., dyes,
preservatives, sugars, etc.) that are found in commercially available
products.
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2. Prior Authorization Guidelines
a. Prior authorization approval will be for six months unless the provider requests for
a shorter length of therapy.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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YYY. Antibiotics
Last Reviewed by the DUR Board: July 26, 2018
Antibiotic medications are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
The outpatient antibiotic class criteria apply to the following:
Third Generation Fluoroquinolones Oxazolidinones
Cephalosporins
cefixime ciprofloxacin tedizolid
cefdinir levofloxacin linezolid
cefpodoxime delafloxacin
ceftibuten moxifloxacin
cefdotoren ofloxacin
If applicable, reference current Infectious Disease Society of America (IDSA) (or equivalent
organization) guidelines to support the use of the following:
1. Coverage and Limitations for Third Generation Cephalosporins and Fluoroquinolones
Approval will be given if the following criteria are met and documented:
a. Culture and sensitivity-proven susceptibilities and resistance to other agents
suggest the requested drug is necessary.
2. Coverage and Limitations for Oxazolidinones
a. Sivextro® (tedizolid)
Approval will be given if the following criteria are met and documented:
1. Recipient has diagnosis of Acute Bacterial Skin and Skin Structure
Infection; and
2. Infection is caused by methicillin-resistant Staphylococcus aureus
(MRSA); and
3. Recipient has had a trial of or has a contraindication to an alternative
antibiotic that the organism is susceptible to (depending on manifestation,
severity of infection and culture or local sensitivity patterns, examples of
alternative antibiotics may include, but are not limited to:
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trimethoprim/sulfamethoxazole (TMP/SMX), doxycycline, vancomycin,
daptomycin, telavancin, clindamycin); or
4. Recipient started treatment with intravenous antibiotic(s) in the hospital and
requires continued outpatient therapy.
b. Zyvox® (linezolid)
Approval will be given if the following criteria are met and documented:
1. Recipient has a diagnosis of vancomycin-resistant enterococcus (VRE)
faecium infection or diagnosis of MRSA infection; and
2. Recipient has had a trial of or has a contraindication to an alternative
antibiotic that the organism is susceptible to (depending on manifestation,
severity of infection and culture or local sensitivity patterns, examples of
alternative antibiotics may include, but are not limited to: TMP/SMX,
doxycycline, vancomycin, tetracycline, clindamycin); or
3. Recipient started treatment with intravenous antibiotic(s) in the hospital and
requires continued outpatient therapy.
3. Exception Criteria (applies to antibiotic medications)
a. Prescribed by an infectious disease specialist or by an emergency department
provider; or
b. Ceftriaxone prescribed as first line treatment for gonorrhea, pelvic inflammatory
disease, epididymo-orchitis and as an alternative to benzylpenicillin to treat
meningitis for those with a severe penicillin allergy; or
c. If cefixime is prescribed for gonococcal infection where ceftriaxone is unavailable;
or
d. The recipient resides in one of the following:
1. Acute Care
2. Long-term Acute Care (LTAC)
3. Skilled Nursing Facility (SNF)
4. Prior Authorization Guidelines
a. Prior authorization approval will be for a single course.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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5. References
a. CDC Antibiotic Prescribing and Use in Doctor’s Offices:
https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/index.html
b. CDC Improving Prescribing:
https://www.cdc.gov/antibiotic-use/community/improving-prescribing/index.html
c. IDSA Guidelines:
https://www.idsociety.org/practice-guidelines/#/score/DESC/0/+/
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ZZZ. Oral Oncology Agents
Therapeutic Class: Oral Oncology Agents
Last Reviewed by the DUR Board: January 24, 2019
Oral oncology agents are subject to prior authorization based on the Application of Standards in
Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada Medicaid and
Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations (this criteria only applies if other product-specific criteria is not
available in MSM Chapter 1200 – Prescribed Drugs)
Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis that is indicated in the FDA approved package insert
or listed in nationally recognized compendia, for the determination of medically
accepted indications; and
b. If the oral oncology medication is not indicated as a first line agent, either in the
FDA approved package insert or nationally recognized compendia, then
documentation of previous therapies tried and failed is required; and
c. The medication is prescribed by or in consultation with an oncologist or
hematologist; and
d. The recipient does not have any contraindications to the requested oral oncology
medication; and
e. The requested quantity and dosing regimen falls within the manufacturer’s
published dosing guidelines or nationally recognized compendia and is appropriate
for the recipient’s age; and
f. The medication must be used in combination with other chemotherapeutic or
adjuvant agents according to the FDA approved prescribing information; and
g. One of the following:
1. If an FDA-approved companion diagnostic test for the requested agent
exists, then documentation that the test was performed to confirm the
diagnosis is required; or
2. If a test with adequate ability to confirm a disease mutation exists, then
documentation that the test was performed to confirm the diagnosis is
required.
2. Recertification Request
a. Documentation of a positive clinical response to the oral oncology treatment.
June 3, 2019 PRESCRIBED DRUGS Appendix A Page 195
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3. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
June 3, 2019 PRESCRIBED DRUGS Appendix A Page 196
APPENDIX A - Coverage and Limitations
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AAAA. Pulmonary Arterial Hypertension Agents
Therapeutic Class: Pulmonary Arterial Hypertension Agents
Reviewed by the DUR Board: January 24, 2019
Pulmonary arterial hypertension (PAH) agents are subject to prior authorization based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient has a documented diagnosis of pulmonary arterial hypertension; or
b. The recipient has one of the following ICD-10 diagnosis codes submitted on the
pharmacy claim:
ICD-10 Description
127.20 Pulmonary Hypertension, Unspecified
127.21 Secondary Pulmonary Arterial Hypertension
127.22 Pulmonary Hypertension Due to Left Heart Disease
127.23 Pulmonary Hypertension Due to Lung Diseases and Hypoxia
127.9 Pulmonary Heart Disease, Unspecified
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
June 3, 2019 PRESCRIBED DRUGS Appendix A Page 197
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MEDICAID SERVICES MANUAL
BBBB. Anticonvulsants
Therapeutic Class: Anticonvulsants
Last Reviewed by the DUR Board: April 22, 2021
Anticonvulsants are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Cannabinoid
a. Epidiolex® (cannabidiol)
1. Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of Lennox-Gastaut syndrome, Dravet
Syndrome or Tuberous Sclerosis Complex (TSC); and
b. The recipient is one years of age or older; and
c. A recent serum transaminase (ALT and AST) and total bilirubin
level has been obtained and is within normal limits; and
d. The drug is prescribed by or in consultation with a neurologist; and
e. The total dose does not exceed 20 mg/kg/day (10mg/kg twice daily);
and
f. The medication will be used as adjunctive therapy (the recipient has
been taking one or more antiepileptic drugs and has chart notes
confirming the presence of at least four convulsive seizures per
month).
2. Recertification Request
a. Documentation of a positive clinical response to Epidiolex®
therapy; and
b. Serum transaminase (ALT and AST) and total bilirubin level has
been re-checked per package insert.
3. Prior Authorization Guidelines
a. Initial prior authorization will be for three months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
September 7, 2021 PRESCRIBED DRUGS Appendix A Page 198
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MEDICAID SERVICES MANUAL
4. For anticonvulsant criteria for children and adolescents, refer to Section N,
titled Psychotropic Medications for Children and Adolescents.
2. Nayzilam® (midazolam)
a. Approval will be given if the following criteria are met and documented:
1. The recipient has a diagnosis of acute intermittent seizures; and
2. The recipient is at least 12 years of age; and
3. The medication is prescribed by or in consultation with a Neurologist; and
4. The dose must not exceed two sprays per seizure cluster, no more than one
episode every three days and treat no more than five episodes per month.
b. Recertification Request
1. Documentation of positive clinical response to Nayzilam® therapy.
c. Prior Authorization Guidelines
1. Initial prior authorization will be for six months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Valtoco® (diazepam)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a diagnosis of epilepsy; and
2. The recipient is six years and older; and
3. The medication is prescribed for the acute treatment of intermittent,
stereotypic episodes of frequent seizure activity that are distinct from a
patient’s usual seizure pattern; and
4. The medication is prescribed by or in consultation with a neurologist; and
5. The quantity must not exceed five episodes per month.
b. Prior Authorization Guidelines:
1. Documentation of positive clinical response to Valtoco® therapy.
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c. Prior Authorization Guidelines:
1. Initial authorization will be approved for six months.
2. Recertification approval will be approved for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Fintepla® (fenfluramine)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a documented diagnosis of seizures associated with
Dravet Syndrome; and
2. The recipient is two years of age or older; and
3. The medication is prescribed by or in consultation with a neurologist.
b. Recertification Request:
1. The recipient has documentation of positive clinical response to Fintepla®
therapy.
c. Prior Authorization Guidelines:
1. Initial authorization will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
September 7, 2021 PRESCRIBED DRUGS Appendix A Page 200
APPENDIX B - Coverage and Limitations
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MEDICAID SERVICES MANUAL
2. MEDICATIONS WITH GENDER/AGE EDITS
A. Prenatal Vitamins
1. Payable only for female recipients.
October 1, 2015 PRESCRIBED DRUGS Appendix B Page 201
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B. Oral/Topical Contraceptives
1. Payable only for female recipients.
October 1, 2015 PRESCRIBED DRUGS Appendix B Page 202
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C. Gender Edits
1. Hormones
a. Estrogen – payable only for female recipients.
b. Progestins – payable only for female recipients.
c. Estrogen and Androgen Combinations – payable only for female recipients.
d. Estrogen and Progestin Combinations – payable only for female recipients.
e. Contraceptive Hormones – payable only for female recipients.
f. Transdermal Testosterone – payable only for male recipients.
g. Androgen Hormone Inhibitor – payable only for male recipients.
2. Exception to the above gender edits:
A diagnosis of Gender Dysphoria (formerly known as Gender Identity Disorder) will
bypass the gender edit if the appropriate ICD code is documented on the prescription and
transmitted on the claim.
November 4, 2019 PRESCRIBED DRUGS Appendix B Page 203
APPENDIX B - Coverage and Limitations
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MEDICAID SERVICES MANUAL
D. Vitamins with Fluoride
1. Payable only for recipients up to age 21 years.
October 1, 2015 PRESCRIBED DRUGS Appendix B Page 204
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MEDICAID SERVICES MANUAL
3. ANTIRETROVIRALS
Antiretrovirals for the treatment of HIV/AIDS are a covered benefit for Nevada Medicaid recipients. FDA
approved antiretrovirals whose manufacturers participate in the federal Drug Rebate Program and are not
DESI drugs, are covered.
October 1, 2015 PRESCRIBED DRUGS Appendix B Page 205
APPENDIX B– Standard Therapeutic Drug Classes
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MEDICAID SERVICES MANUAL
4. DIABETIC SUPPLY PROGRAM
Diabetic Supplies are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA Act and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
Prior authorization is required for preferred and non-preferred diabetic products (including insulin
delivery system and Continuous Glucose Monitor [CGM] receivers and readers).
Preferred diabetic product information is found at:
https://www.medicaid.nv.gov/providers/rx/diabeticsupplies.aspx
Preferred (including sensors and transmitters) and nonpreferred (including tubing, reservoirs for pumps
and transmitters and sensors for CGM’s) diabetic supplies do not require a prior authorization. These items
require a documented diagnosis of diabetes mellitus type I (DM1) or gestational diabetes and recipients
must meet all age restrictions stated on the manufacturer’s label.
Pharmacy benefit allows a 100-day supply for insulin system and CGM supplies.
1. Preferred Insulin Delivery System
a. Approval will be given if the following criteria are met and documented:
1. Recipient must have a documented diagnosis of Diabetes Mellitus Type I or
Gestational Diabetes; and
2. The product must be prescribed by or in consultation with an endocrinologist; and
3. The recipient must meet all age restrictions stated in the manufacturer’s label; and
4. The recipient must have been compliant on their current antidiabetic regimen for at
least the last six months and this regimen must include multiple day injections of
insulin (requiring at least three injections per day); and
5. One of the following:
a. Documented history of recurring hypoglycemia; or
b. Wide fluctuations in pre-meal blood glucose, history of severe glycemic
excursions or experiencing “Dawn” phenomenon with fasting blood
glucose exceeding 200 mg/dL, or
c. Prior use of an insulin pump with documented frequency of glucose self-
testing of at least four times per day in the month immediately prior to the
request.
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b. Prior Authorization Guidelines
1. Initial prior authorization approval will be for one year.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Recertification Request
1. Recertification of prior authorization approval will be given if the recipient has
documented positive clinical response to the product (including current HbA1C).
2. Recertification prior authorization approval will be for one year.
2. Non-Preferred Insulin Delivery System
a. Approval will be given if the following criteria are met and documented:
1. In addition to meeting the “Preferred Insulin Delivery System” criteria, the
recipient must also meet the following:
a. The recipient must have been trained to use the non-preferred product; and
b. The recipient must have benefited from use of the non-preferred product;
and
c. The recipient must have one of the following reasons/special
circumstances:
d. Recipient has had an allergic reaction to a preferred product or related
supply; or
e. Recipient has a visual impairment which requires the use of a non-
preferred product; or
f. Recipient has medical necessity justification (e.g. mental or physical
limitation) which requires them to stay on their current product.
3. Preferred Continuous Glucose Monitors (CGMs)
a. Approval will be given if the following criteria are met and documented:
1. Recipient must have a documented diagnosis of Diabetes Mellitus Type I or
Gestational Diabetes; and
2. Recipient must meet all age restrictions stated in the manufacturer’s label; and
3. Recipient must have been compliant on their current antidiabetic regimen for
PRESCRIBED DRUGS Appendix B Page 207
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MEDICAID SERVICES MANUAL
at least the last six months and this regimen must include multiple daily
injections of insulin (requiring at least three injections per day); and
4. One of the following:
a. Documented history of recurring hypoglycemia; or
b. Wide fluctuations in pre-meal blood glucose, history of severe
glycemic excursions or experiencing “Dawn” phenomenon with
fasting blood glucose exceeding 200 mg/dL; or
c. Recipient is currently using insulin pump therapy while continuing to
need frequent dosage adjustments or experiencing recurring episodes
of severe hypoglycemia (50 mg/dL).
b. Prior Authorization Guidelines
1. Initial prior authorization approval will be for one year.
2. Prior Authorization forms are available at:
http/www.medicaid.nv.gov/providers/rx/rxfor
ms.aspx.
4. Non-Preferred Continuous Glucose Monitor (CGM)
a. Approval will be given if the following criteria are met and documented:
1. In addition to meeting the Preferred CGM criteria, the recipient must also meet
the following:
a. Recipient has had an allergic reaction to a preferred product or related
supply; or
b. Recipient has a visual impairment which requires the use of a non-
preferred product; or
c. Recipient has medical necessity justification (e.g. mental or physical
limitation) which requires them to stay on their current product; or
d. The recipient must have been trained to use the non-preferred product;
and
e. The recipient must have benefited from use of the non-preferred
product.
5. Test Strips and Lancets
August 3, 2020 PRESCRIBED DRUGS Appendix B Page 208
APPENDIX B – Standard Therapeutic Drug Classes
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
a. Pharmacy Services billing information including Billing Manual and Quantity
Limits is available at: https://www.medicaid.nv.gov/providers/rx/billinginfo.aspx
*Blood Glucose monitors with special features (e.g. voice synthesizers) require a prior authorization.
For special blood glucose monitors, a diagnosis and a statement from the physician documenting the
impairment is required with a prior authorization.
August 3, 2020 PRESCRIBED DRUGS Appendix B Page 210
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
Zolgensma prior authorization criteria to follow
previously approved criteria by the DUR Board.
Appendix A Immunomodulator Revised and removed the use of symbols throughout
Section L. Drugs the section to improve readability. Corrected
grammatical errors throughout section and broken
web links.
Appendix A Exondys 51® Revised section title to “Duchenne Muscular
Section MMM. (eteplirsen) Dystrophy (DMD) Agents.” Revised last reviewed
date. Relocated clinical prior authorization criteria for
Emflaza® (deflazacort) within section. Added new
prior authorization criteria for Vyondys 53®
(golodirsen).
Appendix A Spinraza® Revised section title to “Qutenza® (capsaicin).”
Section NNN. (nusinersen) Revised last reviewed date. Relocated current
Spinraza® (nusinersen) within section K. Added new
clinical prior authorization criteria for Qutenza®
(capsaicin).
Appendix A Emflaza® Relocated current clinical prior authorization criteria
Section RRR. (deflazacort) for Emflaza® (deflazacort) within section MMM.
Revised section title to “RESERVED FOR FUTURE
USE.”
Appendix A Anticonvulsants Revised last reviewed date. Revised broken web
Section BBBB. links. Added new clinical prior authorization criteria
for Fintepla® (fenfluramine).
Page 2 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
PRESCRIBED DRUGS
1200 INTRODUCTION ................................................................................................................................ 1
1201 AUTHORITY ....................................................................................................................................... 1
1202 RESERVED .......................................................................................................................................... 1
1203 POLICY ................................................................................................................................................ 1
1203.1 COVERAGE AND LIMITATIONS .................................................................................................... 1
1203.1A PROVIDER RESPONSIBILITY.......................................................................................................... 8
1203.1B SERVICE DELIVERY MODEL ........................................................................................................ 12
1203.1C PRIOR AUTHORIZATION (PA) PROCEDURES ........................................................................... 19
1203.2 INTRAVENOUS (IV) THERAPY ..................................................................................................... 19
1204 HEARINGS .......................................................................................................................................... 1
APPENDIX A
TABLE OF CONTENTS .......................................................................................................................................... 1
Page 1
MTL 26/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1200
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
1200 INTRODUCTION
The Nevada Medicaid Pharmacy Services program pays for medically necessary prescription
services for eligible Medicaid recipients under the care of the prescribing practitioner. Such
services shall maintain a high standard of quality and shall be provided within the limitations and
exclusions hereinafter specified.
All providers participating in the Medicaid program must furnish services in accordance with the
rules and regulations of the Medicaid program. Conditions of participation are available from
Provider Services.
This Chapter describes covered services, service limitations and general reimbursement
methodology.
This manual obsoletes all previous policy and procedure manuals, bulletins and policy news.
All Medicaid policies and requirements (such as prior authorizations, etc.) are the same for Nevada
Check Up (NCU), with the exception of the four areas where Medicaid and NCU policies differ
as documented in the NCU Manual Chapter 1000.
October 1, 2015 PRESCRIBED DRUGS Section 1200 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1201
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
1201 AUTHORITY
A. The Code of Federal Regulations (CFR), Title 42, Public Health, Chapter IV, Center for
Medicare and Medicaid Services (CMS), Subchapter C Medical Assistance Programs,
Parts 430 through 456, states prescription drug coverage is an optional service under Title
XIX.
B. The Omnibus Budget Reconciliation Act (OBRA) of 1989 mandates additional preventive
health care services for infants, children and young adults (newborn through age 20)
eligible for Medicaid. These mandates provide that children and adolescents under age 21
receive follow-up services for a medically necessary condition discovered in a screening
examination, Early Preventative Screening and Diagnostic Testing (EPSDT), see Medicaid
Services Manual (MSM) Chapter 1500; this includes prescription services.
C. CFR Title 42 and Section 1927 of the Social Security Act (SSA), require states to provide
for a Drug Utilization Review (DUR) program for covered outpatient drugs in order to
assure that prescriptions are appropriate, medically necessary and not likely to result in
adverse medical results SSA, Title 19, (g)(1)(A)).
D. Section 1927 of the SSA allows a state to require a prior authorization on any covered
outpatient drug, providing the prior authorization program complies with the requirements
outlined in the act.
The SSA requires the establishment of a DUR board to monitor therapeutic
appropriateness, use of generic products, overutilization and underutilization of drugs and
quality of care consistent with protecting the health of program beneficiaries.
E. Chapter 422 of Nevada Revised Statute (NRS) amended by AB 384 to require the
Department of Health and Human Services (DHHS) to:
1. develop a list of preferred prescription drugs;
2. manage prescription drug use through the use of prior authorization and step
therapy; and
3. create the Pharmacy and Therapeutics Committee.
F. U.S. Troop Readiness, Veteran’s Health Care, Katrina Recovery and Iraq Accountability
Appropriations Act 2007, Section 7002(b) of the act requires Medicaid outpatient drugs
(defined in Section 1927(k)(2) of the SAA) will be reimbursable only if non-electronic
written prescriptions are executed on a tamper-resistant prescription pad.
G. The Deficit Reduction Act of 2005 requires Fee-for-Service (FFS) State Medicaid
programs to capture and report National Drug Codes (NDC) for outpatient drugs in order
for the state to receive federal financial participation.
November 14, 2016 PRESCRIBED DRUGS Section 1201 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1202
Subject:
MEDICAID SERVICES MANUAL RESERVED
1202 RESERVED
November 14, 2016 PRESCRIBED DRUGS Section 1202 Page 1
MTL 08/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1203
Subject:
MEDICAID SERVICES MANUAL POLICY
1203 POLICY
The Division of Health Care Financing and Policy (DHCFP), Nevada Medicaid, reimburses
pharmacies and practitioners for legend (prescription) and non-legend (over the counter)
pharmaceuticals dispensed or administered to Medicaid recipients. All prescribers must have a
license as a healthcare practitioner, such as a physician, podiatrist, osteopath, dentist, Advanced
Practice Registered Nurse (APRN), physician’s assistant, etc., keeping within the scope of their
practice. The DHCFP requires that pharmaceuticals are written, dispensed and prescribed in
accordance with the Nevada State Board of Pharmacy regulations and enforcement.
1203.1 COVERAGE AND LIMITATIONS
A. Covered drugs are subject to prior authorization and/or quantity limits and the following:
1. Section 1927(d)(1)(B)(i) of the SSA allows Medicaid to restrict coverage for an
outpatient drug if the prescribed drug is not for a medically accepted indication.
Section 1927(k)(6) defines a medically accepted indication as any use for a covered
outpatient drug, which is approved under the Federal Food, Drug and Cosmetic
Act, or the use of which is supported by one or more citations included or approved
for inclusion in any of the compendia:
a. American Hospital Formulary Service Drug Information;
b. United States Pharmacopeia;
c. DRUGDEX Information System; or
d. Peer-reviewed medical literature.
2. Pharmaceuticals must be manufactured by companies participating in the Federal
Medicaid Drug Rebate Program.
3. Medicaid is mandated by federal statute to require all written (non-electronic)
prescriptions for all outpatient drugs for Medicaid recipients to be on tamper-
resistant prescription pads. This requirement does not apply to e-prescriptions
transmitted to the pharmacy, prescriptions faxed to the pharmacy or prescriptions
communicated to the pharmacy by telephone by a prescriber. Refer to MSM
Addendum for more information on tamper-resistant prescription pads.
4. The Preferred Drug List (PDL) is a list of preferred outpatient drugs established by
the Silver State Scripts Board (formerly known as the Pharmacy and Therapeutics
(P&T) Committee). Reference Medicaid Operations Manual (MOM) Chapter 200
for the Silver State Scripts Board bylaws. Pharmaceuticals not on the PDL, but
within drug classes reviewed by the Silver State Scripts Board, require prior
March 2, 2020 PRESCRIBED DRUGS Section 1203 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1203
Subject:
MEDICAID SERVICES MANUAL POLICY
authorization, unless exempt under NRS or federal law or excluded through
recommendations of the Silver State Scripts Board or excluded by the DHCFP.
a. New pharmaceutical products not within reviewed PDL drug classes and
not excluded under the state plan or by NRS are covered without a Standard
Preferred Drug List Exception prior authorization until, or if, the Silver
State Scripts Board adds the drug class to the PDL and reviews the product
or evidence.
b. New Food and Drug Administration (FDA) approved drugs, or existing
pharmaceutical products within reviewed PDL drug classes, for which there
is new clinical evidence supporting its inclusion on the PDL and are not
excluded under state plan or by NRS, are covered with an approved
Standard Preferred Drug List Exception prior authorization until the Silver
State Scripts Board can review the new evidence or drug.
c. Pharmaceuticals may require prior authorization due to step therapy
protocols regardless of inclusion in the PDL.
d. If the Silver State Scripts Board determines that there are no significant
differences between drugs within specific classes based on clinical efficacy,
safety, and outcomes for patients, the DHCFP or its Quality Improvement
Organization (QIO)-like vendor, may consider cost in determining which
drugs are selected for inclusion on the PDL.
B. Standard Preferred Drug List Exception Criteria
Drugs that have a “non-preferred” status are a covered benefit for recipients if they meet
the coverage criteria.
1. Coverage and Limitations
a. Allergy to all preferred medications within the same class;
b. Contraindication to or drug-to-drug interaction with all preferred
medications within the same class;
c. History of unacceptable/toxic side effects to all preferred medications
within the same class;
d. Therapeutic failure of two preferred medications within the same class;
e. If there are not two preferred medications within the same class, therapeutic
failure only needs to occur on the one preferred medication;
f. An indication which is unique to a non-preferred agent, and is supported by
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Section:
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peer-reviewed literature or a FDA-approved indication;
g. Psychotropic, Antidepressant Medication – Continuity of Care;
Recipients discharged from an institution on non-preferred psychotropic
and/or non-preferred anti-depressant medication(s), their drugs will
continue to be covered by Medicaid for up to six months to allow the
recipient time to establish outpatient mental health services;
h. For atypical or typical antipsychotic, anticonvulsant and antidiabetic
medications, the recipient demonstrated therapeutic failure on one preferred
agent.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms/aspx
C. Excluded
The DHCFP will not reimburse for the following pharmaceuticals:
1. Agents used for weight loss.
2. Agents used to promote fertility.
3. Agents used for cosmetic purposes or hair growth.
4. Yohimbine.
5. Drug Efficacy Study Implementation (DESI) list “Less than Effective Drugs”: In
accordance with current policy, federal financial participation is not allowed for
any drug on the Federal Upper Limit (FUL) listing for which the FDA has issued a
notice of an opportunity for a hearing as a result of the DESI program which has
been found to be a less than effective or is identical, related or similar to the DESI
drug. The DESI drug is identified by the FDA or reported by the drug manufacturer
for purposes of the Medicaid Drug Rebate Program. This listing is available on the
Centers for Medicare and Medicaid Services (CMS) website at:
http://www.cms.gov/MedicaidDrugRebateProgram/12_LTEIRSDrugs.asp
This includes pharmaceuticals designated “ineffective” or “less than effective”
(including identical, related or similar drugs) by the FDA as to substance or
diagnosis for which prescribed.
6. Pharmaceuticals considered “experimental” as to substance or diagnosis for which
prescribed. Pharmaceuticals manufactured by companies not participating in the
federal Medicaid Drug Rebate Program unless rated “1-A” by the FDA.
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Subject:
MEDICAID SERVICES MANUAL POLICY
7. Agents used for impotence/erectile dysfunction.
D. Refills
A refill is a prescription subject to the limitations below:
1. Authorized refills are valid only from the pharmaceutical provider dispensing the
original prescription, pursuant to Nevada Administrative Code (NAC) Chapter 639.
2. Refill intervals must be consistent with the dosage schedule indicated on the
original prescription. If a prescription is for a 34-day supply, a consistent refill
would be filled in 30 days; an inconsistent refill date would be filled in 20 days
from the original fill. Lost medications: Nevada Medicaid does not pay for
replacement of lost, stolen or otherwise destroyed medications even if a physician
writes a new prescription for the medication. It is the responsibility of the recipient
to replace these medications. Prior authorization may be granted in life-threatening
situations and for maintenance medications only. See Maintenance Medications in
this section for more information on maintenance medications.
E. Early Refills
1. Nevada Medicaid only pays for up to a 34-day supply of medications (100-day
supply for maintenance medications) for recipients each month. A prescription
refill will be paid for by Nevada Medicaid only when 80% of the non-controlled
substance prescription, and 90% of the controlled substance prescription, is used in
accordance with the prescriber’s orders on the prescription and on the label of the
medication.
2. In the instance that a recipient will be out of town when a refill is due, the
pharmacist may enter the appropriate override code to allow an early refill. This
override will be monitored by Nevada Medicaid for misuse/abuse by the recipient
and/or provider.
3. Medicaid will not pay for an early prescription refill when gross negligence or
failure to follow prescriber’s prescription instructions has been displayed by the
recipient.
F. Maintenance Medications
1. Exceptions to the 34-day supply of medications are allowed for maintenance
medications.
2. Maintenance medications are required to be filled in three-month (100-day)
supplies.
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Subject:
MEDICAID SERVICES MANUAL POLICY
3. A one-time initial fill of less than three months will be allowed for the first fill to
assure tolerability and compliance.
4. Prescription quantities may be reviewed; in those cases where less than a 30-day
supply of maintenance drug is dispensed without reasonable medical justification,
the dispensing fee may be disallowed.
5. The following drug categories are considered maintenance medications and are
required to be filled in three-month (100-day) supplies:
a. Antianginals;
b. Antiarrhythmics;
c. Antidiabetics;
d. Antihypertensives;
e. Cardiac Glycosides;
f. Diuretics;
g. Estrogens; and
h. Progesterone.
6. Contraceptive drugs are considered maintenance medication. Contraceptive drugs
that are approved by the FDA are covered up to a 12-month supply.
a. This includes a drug for contraception or its therapeutic equivalent;
insertion of a device for contraception; removal of such a device that was
inserted while the insured was covered by the same policy of health
insurance; education and counseling relating to contraception; management
of side effects relating to contraception; and voluntary sterilization for
women.
b. Up to three months of contraception may be dispensed immediately, and up
to nine months of contraception may be dispensed at the subsequent visit.
c. For a refill following the initial dispensing of a contraceptive drug, the
provider may dispense up to a 12-month supply or any amount that covers
the remainder rolling year.
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d. If a prescription for a contraceptive drug is less than a one-year period, the
provider must dispense the contraceptive in accordance with the quantity
specified in the prescription order.
7. Anticonvulsants and thyroid preparations are considered maintenance medications,
but are not required to be filled in a three-month (100-day) supply.
8. Medications administered in a skilled nursing facility or physician’s office are
exempt from the three-month (100-day) supply requirement.
9. In long-term care facilities, if the prescriber fails to indicate the duration of therapy
for a maintenance drug, the pharmacy must estimate and provide at least a 30-day
supply. Exceptions may be based on reasonable stop orders. (For oral liquid
medications only, a 16 fluid ounce quantity will be considered sufficient to fulfill
the 30-day supply requirement.)
G. Emergency supply of medication
1. In an emergency situation, dispensing of up to a 96-hour supply of covered
outpatient drugs that require prior authorization will be allowed.
2. Nevada Medicaid requires prior payment authorization for medications identified
as requiring prior authorization.
3. The physician must indicate the diagnosis on the prescription (preferably with an
International Classification of Disease (ICD) code) to support the use of the
emergency policy.
4. As a follow-up to the dispensing of the emergency supply of medication, the
provider must contact the QIO-like vendor to obtain a verbal verification number.
5. An approved prior authorization (if required) will be necessary to get additional
medication.
H. Nevada Check Up (NCU)
All coverage and limitation policies and rules, including any prior authorization
requirements, outlined in this chapter apply to NCU recipients as well as Nevada Medicaid
FFS recipients. There are NO exceptions.
I. Vaccines
Nevada Medicaid recognizes the importance of preventative health care through vaccines
and immunizations. Unless otherwise stated in this chapter, vaccines are covered without
prior authorization. Reference Appendix A of this chapter.
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1. Childhood vaccines: All childhood vaccines are covered without prior
authorization under the Healthy Kids Program. Refer to MSM Chapter 1500,
Healthy Kids Program for more information on childhood vaccines.
2. Adult vaccines: Adult vaccines such as tetanus, flu vaccine and pneumococcal
vaccine are covered without prior authorization. For a list of covered adult vaccines,
please reference the Physician’s Fee Schedule at:
http://dhcfp.nv.gov/Resources/Rates/FeeSchedules/
3. Human Papillomavirus (HPV) Vaccine: The 9-valent HPV vaccine (for both males
and females) is covered for Medicaid eligible recipients ages nine years through 45
years, based on the US FDA approved indications. These may be accessed by
following the link: https://www.fda.gov/vaccines-blood-
biologics/vaccines/gardasil. The HPV vaccines are available through the State
Division of Public and Behavioral Health (DPBH) as part of the Vaccines for
Children (VFC) program for eligible females and males age nine through 18 years.
Please refer to MSM Chapter 1500 for more information on the VFC program.
4. Pharmacies may administer childhood and adult vaccines/immunizations.
a. Pharmacies must adhere to all Nevada State Board of Pharmacy (BOP)
regulations regarding vaccine/immunization administration including
certification to administer as documented in NAC Chapter 639.
b. Pharmacies must receive childhood vaccinations through the VFC Program.
The DHCFP or Nevada Medicaid and NCU do not reimburse for vaccines
included in the VFC Program.
c. Covered vaccinations not included in the VFC Program will be
reimbursable per the Nevada Medicaid and NCU Pharmacy Manual.
d. If the pharmacist administers the vaccinations, the dispensing fee will not
be reimbursed. An administration fee is paid instead.
J. Pharmacist Submitted Prior Authorizations
1. The DHCFP will allow pharmacists to submit a prior authorization if:
a. The requesting pharmacist has access to the recipient’s medical records.
K. Dispensing Practitioners:
1. Must have a current Certificate of Registration through the Nevada State Board of
Pharmacy. Refer to NRS 639.070 and NAC 639.390; and
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2. Must be enrolled with Nevada Medicaid provider enrollment as a Provider Type
(PT) 28; and
3. Dispensing practitioners’ offices must be located in the State of Nevada; and
4. All prior authorization criteria and quantity limitations apply to dispensing
practitioner claims; and
5. Only PT 28 can be reimbursed for a dispensing fee; and
6. All claims must be submitted in the National Council for Prescription Drug
Programs (NCPDP) format through Medicaid’s Point of Sale (POS) system; and
7. All dispensing practitioners must be compliant with all applicable BOP statutes and
regulations.
1203.1A PROVIDER RESPONSIBILITY
1. The pharmaceutical provider will maintain records for all prescriptions dispensed to
eligible recipients as may be required.
a. The provider will allow, upon request of proper representative, access to all records
that pertain to Medicaid recipients for fiscal review, audit or utilization review.
b. All fiscal records are to be maintained for a period of six years or as specified in
federal regulation.
2. Utilization Control
a. Prospective (Concurrent) Drug Utilization Review (Pro-DUR)
Pro-DUR functions will be carried out via the POS Systems.
1. Pro-DUR edits apply to POS claims.
2. Long Term Care (LTC) claims are subject to all Pro-DUR edits that apply
to retail.
3. Providers may submit override codes using the (NCPDP) standard
interactive DUR codes. Override codes may be submitted on the initial
claim. A denied claim does not have to be on file.
4. No long term override codes are issued, codes must be entered each time
errors occur. Reference the Nevada Medicaid and NCU Pharmacy Manual
for more information on the current Pro-DUR edits and override
procedures.
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5. All drugs are subject to quantity limitations. Refer to the Nevada Medicaid
and NCU Pharmacy Manual for established quantity limits.
b. Retro Drug Utilization Review (DUR)
Both recipient and provider profiles (i.e. claim payments) are reviewed to identify
patterns of excess. Verification of receipt of services is ongoing on a sample basis.
Providers may be audited on site.
c. Drug Utilization Review (DUR)
Nevada Medicaid policy and federal law allows the state appointed DUR Board to
conduct review of the information compiled about individual clients and providers
and allows the DUR Board to educate Medicaid providers about the changes in
drug therapeutics. Educational programs may include information such as drug
interactions between medications that physicians have prescribed for the clients and
medications they are prescribing that are unnecessarily expensive. In this case,
educational efforts will be directed to help providers improve their efficiency in the
allocation of the finite resources available for Medicaid clients.
d. Eligibility
Please refer to MSM Chapter 100 for information on Medicaid eligibility, eligibility
verification and the Eligibility Verification System (EVS).
e. Pharmacy Lock-In Program
The Pharmacy Lock-In Program is intended to prevent recipients from obtaining
excessive quantities of controlled substances through multiple visits to physicians,
clinics, and pharmacies.When a recipient has shown patterns of abuse/misuse of
Nevada Medicaid benefits, or the DHCFP has determined that the recipient requires
close medical management, the recipient may be “locked-in” to a specific
pharmacy. This means that Medicaid will only pay for controlled substance
prescriptions at a single pharmacy.
1. Pharmacy Lock-In Criteria.
a. The DHCFP conducts a comprehensive clinical review to determine
whether a recipient should be “locked-in” to a single pharmacy
using the following criteria:
1. The recipient has filled ten or more controlled substance
prescriptions in the past 60-day period (includes controlled
substance pharmaceuticals given in the emergency room);
and
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2. One of the following:
a. The recipient has utilized more than one pharmacy in
the past 60-day period; or
b. The recipient has utilized more than three physicians
in the past 60-day period; or
c. The recipient has utilized the emergency room(s) for
receiving controlled substances; or
d. The recipient has been diagnosed with a drug
dependency related condition; or
e. The dispensed quantity per prescription of controlled
substances appears excessive by the clinical review
team; or the recipient has other noted drug seeking
behaviors.
b. Recipients who are locked-in to one pharmacy are issued a written
Notice of Decision (NOD) 15 days prior to the implementation of
the pharmacy restriction. The NOD includes the individual’s right
to request a fair hearing within 90 days if he/she disagrees with the
findings and/or the DHCFP’s action.
c. The DHCFP assigns the pharmacy most frequently used by the
recipient for access of controlled substance prescriptions. Recipients
may change their locked-in pharmacy by contacting their Medicaid
District Office.
d. Upon implementation of pharmacy lock-in, the POS system will not
allow another pharmacy to bill for controlled substance
prescriptions, and a message will be given at the time of service to
notify the pharmacy that the recipient is locked-in. Any non-
controlled substance prescriptions can be filled at any pharmacy.
2. Duration of Lock-In Status.
a. Initially, a recipient remains in lock-in status for period lasting 36
months. Utilizing the pharmacy lock-in criteria, the DHCFP
conducts a clinical review not less than a month prior the 36-month
mark to determine whether the recipient will remain or may be
removed from lock-in status.
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1. A recipient may be placed on a second lock-in period lasting
108 months, if determined by the DHCFP that the recipient
is continuing to obtain excessive and/or inappropriate
controlled substance prescription or requires additional close
medical management or monitoring. Recipients placed on a
second lock-in period are re-evaluated at every 108-month
period to determine whether lock-in status still appropriate
or may be removed from lock-in status.
2. A written NOD is issued by the DHCFP 15 days prior the
effective date of continuation or removal of the pharmacy
restriction. The NOD includes the individual’s right to
request a fair hearing within 90 days if he/she disagrees with
the findings and/or the DHCFP action.
b. Recipients in lock-in status who are transitioning from a Nevada
Medicaid contracted Managed Care Organization (MCO) will start
a new initial 36-month lock-in period.
3. Pharmacy Lock-In Exemption
a. Some circumstances allow a recipient to receive medications from a
pharmacy other than their assigned locked-in pharmacy. A
Pharmacy may call the Technical Call Center to request an override
if:
1. The locked-in pharmacy is out of stock.
2. The locked-in pharmacy is closed.
3. The recipient is out of town and cannot access the locked-in
pharmacy.
3. Generic Substitution
Per NRS Chapter 639, if the practitioner has not indicated that generic substitution is
prohibited, the pharmacy provider must dispense, in substitution, another drug which is
available to him if the other drug:
a. is less expensive than the drug prescribed by brand name;
b. is biologically equivalent to the drug prescribed by brand name;
c. has the same active ingredient or ingredient of the same strength, quantity and form
of dosage as the drug prescribed by brand name; and
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d. is of the same generic type as the drug prescribed by brand name the least expensive
of the drugs that are available to him for substitution.
The pharmacy provider shall substitute the least expensive of the drugs available to him/her
for substitution.
4. Prescriber Brand Certification
Upper Limit cost limitations specified in this Chapter will not apply when a prescriber
certifies that a specific brand of medication is medically necessary for a particular patient.
The physician should document in the patient’s medical record the need for the brand name
product in place of the generic form. The procedure for certification must comply with the
following:
a. The certification must be in the physician's own handwriting.
b. Certification must be written directly on the prescription blank.
c. The phrase “Dispense as written” is required on the face of the prescription. For
electronically transmitted prescriptions “Dispense as written” must be noted. Not
acceptable: A printed box on the prescription blank checked by the prescriber to
indicate “brand necessary” or a handwritten statement transferred to a rubber stamp
and then stamped on the prescription.
d. A prior authorization is required to override genetic substitution.
e. Certification is not required if a generic is not manufactured.
f. A fax copy/verbal order may be taken by the pharmacist from the physician, but
the pharmacy must obtain an original printed copy and keep on file.
1203.1B SERVICE DELIVERY MODEL
For the rate and reimbursement methodology see MSM Chapter 700, Rates. For POS claims refer
to the Pharmacy Manual, and for Medicaid Management Information System (MMIS) claims refer
to the Nevada Medicaid and NCU Billing Manual (Billing Manual).
1. Institutional settings
a. Medical/Surgical, Specialty, Psychiatric Hospitals and free-standing inpatient
hospice facilities – All pharmacy services are included in the daily per diem rate
for inpatient services, which are billed through MMIS.
b. Long Term Care (LTC)
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1. Nursing Facilities (NF) – Legend (prescription) pharmaceutical services are
excluded from the daily per diem facility rate. This includes compound
prescriptions and Total Parenteral Nutrition (TPN) solution and additives.
Legend pharmaceuticals are billed separately directly by a licensed
pharmacy through POS.
Non-legend (over the counter) pharmaceuticals are not separately
reimbursable by the DHCFP.
2. Intermediate Care Facilities for Individuals with Intellectual Disabilities
(ICF/IID) – Legend and non-legend pharmaceuticals are excluded from the
facility rate. Pharmaceuticals are billed directly by a licensed pharmacy
through POS.
3. Hospice services in NFs, all drugs related to the documented terminal illness
and palliative, symptom relief are to be covered by the hospice and will not
be reimbursed by the DHCFP. Refer to MSM Chapter 3200, Hospice, for
more information.
2. Outpatient Pharmaceuticals
a. Covered outpatient drugs (COD(s)) are reimbursed separately from medical
services, in the following settings, in accordance with Section 1927 of the SSA.
1. Retail pharmacies (billed through POS).
2. Home Infusion Therapy (HIT)/Free Standing Infusion Clinics (billed
through POS).
a. Disposable supplies are billed separately with a 33 Provider Type
number (billed through MMIS).
b. Refer to the Nevada Medicaid and Check Up Pharmacy Billing
Manual.
3. COD(s) administered in an outpatient setting, such as a physician’s office
(NVPAD).
a. COD(s) are billed utilizing the appropriate National Drug Code
(NDC) and NDC quantity (billed through MMIS).
b. The administration of the drug is billed using the appropriate
Current Procedural Terminology (CPT) code (billed through
MMIS).
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4. Hospital based outpatient clinics.
a. COD(s) are billed utilizing the appropriate NDC and NDC quantity
(billed through MMIS).
b. The administration of the drug is billed using the appropriate CPT
code, (billed through MMIS).
5. End Stage Renal Disease (ESRD) Facilities.
a. Any COD(s) not included in the Prospective Payment System (PPS)
Rate are billed using the appropriate NDC and NDC quantity.
b. The administration of the drug is billed using the appropriate CPT
code, (billed through MMIS).
c. COD(s) included in the PPS Rate as documented in the CMS
Manual System, Publication # 100-04, Medicare Claims Processing,
Transmittal 2134 will deny if billed separately.
6. Emergency Rooms.
a. COD(s) are billed utilizing the appropriate NDC and NDC quantity
(billed through MMIS).
b. CODs are not reimbursed separately, in the following settings, in accordance with
1927(k)(2) of the SSA.
1. Ambulatory Surgical Centers (ASC). COD(s) are included in the facility
rate. COD(s) may not be billed separately.
2. Outpatient facilities/clinics/Federally Qualified Health Centers (FQHCs)
that are paid per encounter, cannot be reimbursed separately for CODs when
drugs are included in their encounter rate.
3. Outpatient hospice reimbursement for CODs related to the documented
terminal illness and palliative, symptom relief, are to be covered by the
hospice and will not be reimbursed by the DHCFP. Refer to MSM Chapter
3200, Hospice, for more information.
3. Disposable Medical Supplies
Please refer to MSM Chapter 1300, Durable Medical Equipment (DME), for instructions
on billing and any applicable limitations for these items.
4. Unit Dose (Repackage and Re-Stock) Repackage
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Nevada Medicaid provides reimbursement incentives for LTC providers who repackage
non-unit dose pharmaceuticals; An additional $0.43 per claim is given on pharmaceuticals
that are repackaged for unit dose dispensing. Pharmaceuticals that First Data Bank
classifies as unit dose products are not covered for this policy.
This incentive is available only to pharmacies supplying long-term care inpatients. The
pharmacy provider must apply to the QIO-like Vendor Pharmacy Department to enroll in
this incentive program.
In accordance with the CMS, State Medicaid Director Letter (SMDL) 06-005, repackaging
of pharmaceuticals must be in compliance with the Nevada State BOP. In addition, NFs
must properly credit the Medicaid program for the return of unused prescription medicines
upon discontinuance of the prescription or transfer, discharge or death of a Medicaid
beneficiary. This is to assure there is no double billing of the medication.
5. Coordination of Benefits (COB)
On-line COB (cost avoidance) is part of the Nevada Medicaid POS system.
a. If Nevada Medicaid is the recipient’s secondary carrier, claims for COB will be
accepted.
b. Nevada Medicaid is always the payer of last resort.
c. Other coverage will be identified by the presence of other carrier information on
the recipient eligibility file.
d. If the recipient shows other coverage, the claim will be denied. The POS system
will return a unique client-identified carrier code identifying the other carrier, the
recipient’s policy number and the carrier name in the additional message filed. It is
possible that a recipient may have more than one active other carrier; in that case,
the returned code will be from the first carrier, subsequent codes will be returned
until fully exhausted. Providers will be required to submit this code OTHER
PAYER ID (#340-7C) field as part of the override process.
e. Even if “no other insurance” is indicated on the eligibility file, the claim will be
processed as a Third Party Liability (TPL) claim if the pharmacy submits.
f. If other insurance is indicated on the eligibility file, the claim will be processed as
a TPL regardless of what TPL codes the pharmacy submits.
g. In all cases, the Nevada Medicaid “allowed amount” will be used when calculating
payment. In some cases, this may result in a “0” payment, when the insurance
carrier pays more than the Medicaid “allowable amount.”
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h. In order to facilitate the TPL/COB process, Nevada Medicaid will allow providers
to override “days supply limits” and/or “Drug Requires prior authorization”
conditions by entering a value of “5” (exemption from prescription limits) in the
PA/MC CODE field (NCPCP #416DG) if there are no prior authorization
requirements on these drugs from the primary insurer.
6. Pharmacy Billing Process
a. NCPDP Standard Billing Units
Nevada Medicaid reimburses for outpatient pharmaceuticals according to NCPDP
“Billing Unit Standard Format” guidelines. The standard provides for the billing of
pharmaceuticals in one of three billing units for all drug products. These units are
“each,” “milliliter (ml),” and “gram (g).” The following guidelines are to be used
when billing Nevada Medicaid for pharmaceuticals:
Tablets, Capsules, Suppositories, Pre-filled Syringes: must be billed by “each” or
by “mls.” For example, if 30 tablets of Metformin are dispensed, the quantity will
be 30.
Liquids, Liquid Orals, Suspensions, Solutions, Opthalmic/Otic Solutions: must be
billed by milliliters (mls). For example, if 560ml of guiafenesin is dispensed, the
quantity entered will be 560.
PLEASE NOTE:
Ounces must be converted to ml (1 ounce = 30ml).
Liters must be converted to ml (1L = 1000ml).
Ointments, Bulk Powders: must be billed by grams. For example, if a two ounce
tube of oxiconazole nitrate is dispensed, the quantity entered will be 60.
PLEASE NOTE:
Ounces must be converted to grams (1 ounce = 30g, ½ ounce = 15g). Oral
Contraceptives/Therapy packs: must be billed per “each” tablet dispensed, not the
number of packages. For example, Ortho Tri-Cyclen is a 28-day dial pack, the
quantity entered will be 28.
Transdermal Patches/Powder Packets: must be billed per “each” patch/packet
dispensed, regardless of whether they are pre-packaged in a box or come in
individual pouches/packets. For example, Catapress-TTS comes in a box of four
patches. If two of these boxes are dispensed, the quantity entered will be eight.
Inhalers and Aerosols: must be billed as either grams or ml, as specified by the
manufacturer on the labeling. For example a 90mcg(microgram)/inh Albuterol
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Inhaler has a total of 17gm in the canister. If one of these is dispensed, 17 will be
quantity entered.
Topical Products: must be billed as either grams or ml, as specified by the
manufacturer on the labeling.
PLEASE NOTE: Ounces must be converted to grams or ml.
1 ounce = 30ml
1 ounce = 30g
Reconstitutables (oral, otic, ophthalmic): must be billed per ml that are/will be in
the bottle after reconstitution according to the manufacturer’s instructions.
Liquid Injectables (vials, ampoules): must be billed by milliliters (ml). For
example, if a 10ml vial of Novolin 70/30 is dispensed, the quantity entered will be
10.
Powdered Injectables (vials): must be billed by “each” vial given per dose. For
example if the recipient receives Ampicillin 1g every six hours for one week, the
quantity entered will be 1, as only one vial is used per dose (assuming a 1gm vial
is used), and the number of doses entered will be 28 (four per day x seven days).
PLEASE NOTE: If the product is supplied with a diluent, the quantity entered is
only the number of powdered vials dispensed, the diluent is not factored in.
Intravenous Solutions: must be billed in ml administered per dose. For example, if
a recipient receives 250ml of Normal Saline four times per day, the quantity entered
will be 250, as that is the quantity per dose.
Blood Derived Products: products may vary in potency from batch to batch.
Anithemophilic products must be billed as the number of antihemophilic units
dispensed (each). Prolastin must similarly be billed as the number of milligrams
dispensed (each).
Kits: defined as products with at least two different or discreet items (excluding
diluents, applicators and activation devices) in the same package, intended for
dispensing as a unit. Kits carry only a single NDC. Kits are intended to be dispensed
as a unit and should be billed as a unit of each kit dispensed (each).
For further information, refer to the NCPDP Billing Unit Standard Format Official
Release.
b. Provider Numbers
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The state National Association of Boards of Pharmacy (NABP) provider number is
to be used and entered when billing online using the POS system or when using the
UCF.
7. State Maximum Allowable Cost (SMAC)
a. SMAC is the upper reimbursement limit for multi-source outpatient
pharmaceuticals established by the DHCFP or QIO-like vendor.
1. The DHCFP or QIO-like vendor will perform ongoing market analysis to
monitor pricing patterns and product availability.
2. The DHCFP or QIO-like vendor will perform monthly updates of the drugs
subject to the SMAC.
3. All drugs subject to the SMAC and updates will be posted on the following
website:
http://www.medicaid.nv.gov/providers/rx/MACinfo.aspx
b. Providers may appeal the current SMAC for a pharmaceutical product if a provider
determines that a particular multi-source drug is not available at the current SMAC
reimbursement.
1. The pharmacy must contact the QIO-like vendor technical call center to
initiate the appeal.
2. Information needed to make a decision will include the NDC number,
manufacturer, drug name, strength and price paid. A faxed copy of the
actual invoice for the drug may be requested.
3. Inquiries not resolved by the technical call center are forwarded to the QIO-
like vendor’s SMAC Coordinator for investigation and resolution.
4. If it is determined the SMAC is negatively impacting access to care for
recipients, the SMAC Coordinator has the authority to:
a. Adjust SMAC pricing for the particular claim being appealed; and
b. Make changes to the SMAC pricing file.
5. Appeals will be responded to within three working days of the referral to
the SMAC Coordinator.
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1203.1C PRIOR AUTHORIZATION PROCEDURES
1. Prior authorization requests may be done via phone, fax or via the internet. A facsimile
signature stamp is acceptable on faxed prior authorization requests.
2. Prior authorization requests must be submitted on the appropriate Prior Authorization
Request form. Pharmacy prior authorization forms can be found at the following web site:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. LTC drug claims are subject to prior authorization requirements.
4. The QIO-like vendor will process the prior authorization request within 24 hours of receipt.
a. The requesting practitioner will be advised of the prior authorization status
(approval, denial, pending further information) within 24 hours of the receipt.
b. For prior authorization requests in which the QIO-like vendor has pended the
request for further information, the prior authorization will deny if the practitioner
does not respond to a request for further information within three working days.
5. An approved prior authorization will be entered in the POS system prior to the dispensing
of the medication. There may be situations in which an authorization request is considered
after the fact (e.g. retroactive eligibility).
6. The Nevada Medicaid QIO-like vendor will send all Notice of Decision denial of service
letters. Reference MSM Chapter 3100 for the information on hearings.
7. Refer to the Nevada Medicaid and Check Up Pharmacy Billing Manual for more
information.
1203.2 INTRAVENOUS (IV) THERAPY
For specific instructions related to billing via the POS system, refer to the Nevada Medicaid Check-
Up Pharmacy Billing Manual.
A. Billing Guidelines
IV therapy is billed through the pharmacy POS system using the multi-ingredient
functionality. Drug coverage edits and prior authorization edits will be processed at the
individual ingredient level.
B. Long Term Care (LTC)
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1. For recipients in LTC, a daily dispensing fee of $10.17 will be applied to IV therapy
claims. This dispensing fee will be multiplied by the number of days the therapy
was provided
a. Non-Billable Items
IV hydration therapy of standard fluids without additives (e.g., antibiotics,
potassium and heparin) and supplies associated with IV therapy, enteral
nutrition and TPN administration are included in Nevada Medicaid’s
LTC/NF rate and may not be billed as a separate charge.
b. Billable Items
IV Drugs/TPN for recipients in LTC facilities may be billed as a separate
charge. Refer to MSM Chapter 500, Nursing Facilities, for further
information.
April 27, 2017 PRESCRIBED DRUGS Section 1203 Page 20
MTL 26/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1204
Subject:
MEDICAID SERVICES MANUAL HEARINGS
1204 HEARINGS
Please reference MSM Chapter 3100 for the Medicaid Hearings process.
October 1, 2015 PRESCRIBED DRUGS Section 1204 Page 1
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
DRUGS REQUIRING PRIOR AUTHORIZATION AND/OR QUANTITY LIMITATIONS............................... 6
A
ABSTRAL® (fentanyl citrate sublingual tablet) .................................................................................................... 19
ACTIQ® (fentanyl citrate transmucosal lozenge) .................................................................................................. 19
AGENTS USED FOR THE TREATMENT OF ATTENTION DEFICIT DISORDER (ADD)/ATTENTION
DEFICIT HYPERACTIVITY DISORDER (ADHD) .................................................................................. 8
AIMOVIG® (erenumab-aooe) ............................................................................................................................... 57
AJOVY® (fremanezumab-vfrm) ............................................................................................................................ 57
ALBUTEROL NEBULIZER.................................................................................................................................. 61
AMITIZA® (lubiprostone) ................................................................................................................................... 142
AMPYRIA® (dalfampridine) ................................................................................................................................. 75
ANTI-FUNGAL ONYCHOMYCOSIS.................................................................................................................. 22
ANTI-HEPATITIS AGENTS ................................................................................................................................. 90
ANTI-INSOMNIA AGENTS (Sedative Hypnotics) .............................................................................................. 63
ANTI-LIPIDEMIC AGENTS – PCSK9 INHIBITORS ....................................................................................... 158
ANTI-MIGRAINE MEDICATIONS ..................................................................................................................... 55
ANTIBIOTICS ..................................................................................................................................................... 191
ANTICONVULSANTS ........................................................................................................................................ 197
ANTIEMETICS ...................................................................................................................................................... 65
ANTIHEMOPHILIA AGENTS ............................................................................................................................. 88
AUSTEDO® (deutetrabenazine) .......................................................................................................................... 173
AUVI-Q® (epinephrine injection device) ............................................................................................................ 139
B
BENLYSTA® (belimumab) ................................................................................................................................... 24
BERINERT® (C1 esterase inhibitor) ................................................................................................................... 113
BEVYXXA® (betrixaban) ....................................................................................................................................... 7
BOTULINUM TOXIN ......................................................................................................................................... 187
BRILINTA® (ticagrelor) ...................................................................................................................................... 120
BRINEURA® (cerliponase alfa) .......................................................................................................................... 175
BUPRENORPHINE/NALOXONE ........................................................................................................................ 73
C
CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR INHIBITOR MEDICATIONS .................. 56
CANNABINOID ANTIEMETICS ......................................................................................................................... 65
CHRONIC IDIOPATHIC CONSTIPATION (CIC) AGENTS ........................................................................... 142
CINQAIR® (reslizumab)........................................................................................................................................ 43
CINRYZE® (C1 esterase inhibitor) ..................................................................................................................... 113
CODEINE AND TRAMADOL FOR CHILDREN .............................................................................................. 182
COLCHICINE (Colcrys®) ..................................................................................................................................... 84
COLONY STIMULATING FACTORS (POS CLAIMS ONLY) ....................................................................... 138
COMPOUNDED MEDICATIONS ...................................................................................................................... 189
CORLANOR® (ivabradine) ................................................................................................................................. 157
CYSTIC FIBROSIS AGENTS ............................................................................................................................. 116
D
DAKLINZA® (Daclatasvir) ................................................................................................................................... 90
DALIRESP® (roflumilast) ................................................................................................................................... 112
DOXEPIN TOPICAL ............................................................................................................................................. 64
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 1
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
DUCHENNE MUSCULAR DYSTROPHY (DMD) AGENTS .......................................................................... 168
DUEXIS® (ibuprofen/famotidine) ....................................................................................................................... 155
DUPIXENT® (dupilumab) ..................................................................................................................................... 47
E
EFFIENT® (prasugrel) ...............................................................................................................................................
120
ELIDEL® ............................................................................................................................................................... 36
EMGALITY® (galcanezumab-gnlm)..................................................................................................................... 57
EMFLAZA® (deflazacort) ................................................................................................................................... 169
ENTRESTO® (sacubitril/valsartan) ..................................................................................................................... 165
EPCLUSA® (sofosbuvir/velpatasvir) .................................................................................................................... 91
EPIDIOLEX® (cannabidiol) ................................................................................................................................ 197
EVENITY® (romosozumab-aqqg) ....................................................................................................................... 122
EVRYSDI® (risdiplam) ........................................................................................................................................ 26
EXONDYS 51® (eteplirsen) ................................................................................................................................ 168
F
FASENRA® (benralizamab) .................................................................................................................................. 46
FENTORA® (fentanyl citrate buccal tablet) .......................................................................................................... 19
FINTEPLA® (fenfluramine) ................................................................................................................................ 199
FIRAZYR® (icatibant) ......................................................................................................................................... 113
FORTEO® (Teriparatide) ..................................................................................................................................... 129
FUNCTIONAL GASTROINTESTINAL DISORDER AGENTS ....................................................................... 142
G
GnRH ANALOGS ................................................................................................................................................ 147
GONADOTROPIN RELEASING HORMONE RECEPTOR (GNRH) ANTAGONIST AND COMBINATIONS
................................................................................................................................................................... 134
GROWTH HORMONES........................................................................................................................................ 10
H
HARVONI® (Ledipasvir/sofosbuvir) .................................................................................................................... 92
HEMATOPOIETIC/HEMATINIC AGENTS ........................................................................................................ 20
HEREDITARY ANGIOEDEMA AGENTS ........................................................................................................ 113
HETLIOZ® (tasimelteon)..................................................................................................................................... 164
HIGH DOLLAR CLAIM ..................................................................................................................................... 184
HORMONES AND HORMONE MODIFIERS ..................................................................................................... 82
I
IMMEDIATE-RELEASE FENTANYL PRODUCTS ........................................................................................... 19
IMMUNOMODULATOR DRUGS ....................................................................................................................... 32
INCRETIN MIMETICS ....................................................................................................................................... 115
INGREZZA® (valbenazine) ................................................................................................................................. 177
INVEGA TRINZA® (paliperidone palmitate) ..................................................................................................... 161
IRRITABLE-BOWEL SYNDROME AGENTS .................................................................................................. 142
K
KALBITOR® (ecallantide) .................................................................................................................................. 113
KALYDECO® (ivacaftor).................................................................................................................................... 116
L
LAZANDA® (fentanyl citrate nasal spray) ........................................................................................................... 19
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 2
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
LEMTRADA® (alemtuzumab) .............................................................................................................................. 75
LIDODERM 5% PATCHES® ............................................................................................................................... 40
LINZESS® (linaclotide) ....................................................................................................................................... 142
LONG-ACTING NARCOTICS ............................................................................................................................. 53
LOTRONEX® (alosetron).................................................................................................................................... 143
LUCEMYRA™ (lofexidine) .................................................................................................................................. 73
MAVENCLAD® (cladribine) ................................................................................................................................ 77
MAVYRET® (glecaprevir/pibrentasvir) ................................................................................................................ 97
MEDICATIONS FOR RECIPIENTS ON HOSPICE .......................................................................................... 162
MEDICATIONS FOR THE TREATMENT OF ACNE ...................................................................................... 141
MONOCLONAL ANTIBODY AGENTS ............................................................................................................. 41
MOTEGRITY® (prucalopride) ............................................................................................................................ 141
MULTIPLE SCLEROSIS (MS) AGENTS ............................................................................................................ 75
N
NARCOLEPSY AGENTS ................................................................................................................................... 151
NAYZILAM® (midazolam) ................................................................................................................................. 198
NEBULIZER SOLUTION ..................................................................................................................................... 61
NEUROKININ-1 ANTAGONISTS AND COMBINATIONS ............................................................................ 166
NUCALA® (mepolizumab) ................................................................................................................................... 43
NUVIGIL® (armodafinil)..................................................................................................................................... 151
O
OCREVUS® (ocrelizumab) ................................................................................................................................... 78
OLYSIO® (simeprevir) ..............................................................................................................................................
100
OMONTYS® (Peginesatide) ................................................................................................................................ 137
ONSOLIS® (fentanyl citrate buccal film) .............................................................................................................. 19
OPIOIDS, OPIOID CONTAINING COUGH PREPARATIONS, OPIOIDS PRESCRIBED TO UNDER 18 .... 69
ORAL ONCOLOGY AGENTS ........................................................................................................................... 194
ORIAHNN® (elagolix, estradiol, and norethindrone) ......................................................................................... 135
ORILISSA® (elagolix) ......................................................................................................................................... 134
ORKAMBI® (lumacaftor/ivacaftor) .................................................................................................................... 116
OSTEOPOROSIS AGENTS ................................................................................................................................ 122
OVER-THE-COUNTER MEDICATIONS ............................................................................................................ 16
P
PLATELET INHIBITORS ................................................................................................................................... 120
PRALUENT® (alirocumab) ................................................................................................................................. 158
PROAIR® HFA ...................................................................................................................................................... 61
PROAIR RESPICLICK® ....................................................................................................................................... 61
PROLIA® (Denosumab) ...................................................................................................................................... 124
PROTON PUMP INHIBITORS (PPIs) .................................................................................................................... 6
PROTOPIC® .......................................................................................................................................................... 36
PROVENTIL® HFA .............................................................................................................................................. 61
PROVIGIL® (modafini) ....................................................................................................................................... 151
PULMONARY ARTERIAL HYPERTENSION AGENTS ................................................................................ 196
PSYCHOTROPIC MEDICATIONS FOR CHILDREN AND ADOLESCENTS ................................................. 37
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 3
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
Q__________________________________________________________________________________________
QUTENZA® (capsaicin)) 172
R
RAYOS® (prednisone delayed-release) ............................................................................................................... 156
REPATHA® (evolocumab) .................................................................................................................................. 158
S
SAVELLA® (milnacipran)..................................................................................................................................... 72
SEROSTIM® (somatropin) .................................................................................................................................... 13
SEROTONIN 5-HT1 RECEPTOR AGONISTS (triptans) .................................................................................... 55
SEROTONIN RECEPTOR ANTAGONISTS (5 HT3 antiemetics) ...................................................................... 65
SHORT-ACTING BRONCHODILATORS........................................................................................................... 61
SIVEXTRO® (tedizolid) ...................................................................................................................................... 191
SOMAVERT® (pegvisomant) ............................................................................................................................... 14
SOVALDI® (sofosbuvir) ..................................................................................................................................... 102
SPINAL MUSCULAR ATROPHY AGENTS ....................................................................................................... 25
SPINRAZA® (nusinersen) ..................................................................................................................................... 29
SPRAVATO™ (esketamine) ................................................................................................................................ 136
SUBSTANCE ABUSE AGENTS .......................................................................................................................... 73
SUBSYS® (fentanyl sublingual spray) .................................................................................................................. 19
SUNOSI® (solriamfetol) ...................................................................................................................................... 151
SYMDEKO® (tezacaftor/ivacaftor) ..................................................................................................................... 117
SYNAGIS® (Palivizumaub) .................................................................................................................................. 67
T
TECHNIVIE® (ombitasvir/paritaprevir/ritonavir) ............................................................................................... 105
THROMBIN INHIBITORS.................................................................................................................................... 87
TOBACCO CESSATION PRODUCTS ................................................................................................................ 60
TOPICAL ANDROGENS ...................................................................................................................................... 82
TOPICAL IMMUNOMODULATORS .................................................................................................................. 36
TORADOL® (ketorolac tromethamine) TABLETS .............................................................................................. 54
TRANSDERMAL FENTANYL ............................................................................................................................ 17
TRIKAFTA® (elexacaftor/tezacaftor/ivacaftor and ivacaftor) ............................................................................ 118
TRULANCE® (plecanatide) ................................................................................................................................ 142
TYMLOS® (abaloparatide) .................................................................................................................................. 131
U
UBRELVY® (ubrogepant) ..................................................................................................................................... 58
V
VALTOCO® (diazepam) ..................................................................................................................................... 198
VENTOLIN® HFA ................................................................................................................................................ 61
VIBERZI® (eluxadoline) ..................................................................................................................................... 143
VIEKIRA PAK®, VIEKIRA XR® (dasabuvir, ombitasvir, paritaprevir, ritonavir) ........................................... 106
VIMOVO® (naproxen/esomeprazole magnesium) .............................................................................................. 155
VIVITROL® (naltrexone) ...................................................................................................................................... 73
VOSEVI® (sofosbuvir/velpatasvir,voxilaprevir) ................................................................................................. 108
VYONDYS 53® (golodirsen) .............................................................................................................................. 170
W
WAKIX® (pitolisant) ........................................................................................................................................... 153
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 4
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
X
XADAGO® (safinamide) ..................................................................................................................................... 180
XARTEMIS® XR (oxycodone and acetaminophen) ........................................................................................... 146
XIFAXAN® (rifaximin) ....................................................................................................................................... 143
XOLAIR® (Omalizumab) ...................................................................................................................................... 41
XOPENEX®(Levalbuterol) .................................................................................................................................... 62
XYOSTED™ (testosterone enanthate) ................................................................................................................... 82
XYREM® (sodium oxybate) ................................................................................................................................ 151
Z
ZELNORM® (tegaserod) ..................................................................................................................................... 143
ZEPATIER® (elbasvir and grazoprevir) .............................................................................................................. 108
ZEPOSIA® (ozanimod).......................................................................................................................................... 79
ZOLGENSMA® (onasemnogene abeparvovec-xioi)............................................................................................. 30
ZORBTIVE®(somatropin) ..................................................................................................................................... 13
ZYVOX® (linezolid) ............................................................................................................................................ 192
All drugs in Appendix A may be subject to Quantity Limitations.
Check the Nevada Medicaid and Nevada Check Up Pharmacy Manual for a listing of the exact Quantity
Limitation.
January 6, 2019 PRESCRIBED DRUGS Appendix A Page 5
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
1. DRUGS REQUIRING A PRIOR AUTHORIZATION AND/OR QUANTITY LIMITATION
A. Proton Pump Inhibitors (PPIs)
Therapeutic Class: Proton Pump Inhibitors
Last Reviewed by the DUR Board: April 30, 2020
PPIs are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Approval will be given if the following criteria are met and documented:
a. The recipient is not exceeding once daily dosing (quantity limit of one
unit/day).
b. Requests for PPIs exceeding once daily dosing must meet one of the
following:
1. The recipient has failed an appropriate duration of once daily
dosing; or
2. The recipient has a diagnosis of a hypersecretory condition (e.g.,
Zollinger-Ellison Syndrome), esophagitis, Barrett’s esophagitis,
reflux esophagitis or treatment of an ulcer caused by H.Pylori
c. Prior Authorization Guidelines
1. Prior authorization approval will be for up to 12 months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
August 31, 2020 PRESCRIBED DRUGS Appendix A Page 5
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
B. Bevyxxa® (betrixaban)
Therapeutic Class: Oral Anticoagulants
Last Reviewed by the DUR Board: January 25, 2018
Bevyxxa® (betrixaban) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Initial request:
1. The recipient has a diagnosis of prophylaxis of venous thromboembolism
(VTE); and
2. The recipient must be 18 years of age or older; and
3. The recipient has received Bevyxxa® during hospitalization and will be
continuing Bevyxxa® therapy following discharge from the hospital; and
4. The recipient is at risk for thromboembolic complications due to moderate
or severe restricted mobility and has other risk factors of VTE; and
5. The recipient has not received a cumulative 42 days of Bevyxxa® therapy.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for:
1. Prior Authorization Request: Up to a total treatment duration of 42 days.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
July 2, 2018 PRESCRIBED DRUGS Appendix A Page 6
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
C. Agents Used for the Treatment of Attention Deficit Disorder (ADD)/Attention Deficit
Hyperactivity Disorder (ADHD)
Therapeutic Class: ADD/ADHD Agents
Last Reviewed by the DUR Board: April 25, 2019
Agents for the treatment of ADD/ADHD are subject to prior authorization and quantity limits
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria is met and documented:
a. General Criteria (Children and Adults)
1. A diagnosis of ADD/ADHD or other FDA approved diagnosis.
2. Only one long-acting stimulant (amphetamine and methylphenidate
products) may be used at a time.
3. A 30-day transitional overlap in therapy will be allowed.
4. Other treatable causes of ADD/ADHD have been ruled out.
b. ADD/ADHD Criteria (Children up to age 18 years)
1. The recipient is at least three years of age (short-acting stimulants) or at
least six years of age (long-acting stimulants, long-acting alpha agonists,
atomoxetine).
An initial evaluation or regular examination has been done within the past
12 months with the treating prescriber.
2. Exception Criteria
a. Prescriptions for ADD/ADHD medications do not require prior authorization for
children five years of age, up to 18 years of age, if the following criteria are met
and documented:
1. The recipient is at least five years of age for short acting stimulants or at
least six years of age for long-acting stimulants, long acting alpha agonists,
atomoxetine);
2. The medication is prescribed by a psychiatrist; and
3. An ICD code for ADD with or without hyperactivity is documented on the
prescription and transmitted on the claim.
September 2, 2019 PRESCRIBED DRUGS Appendix A Page 7
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
3. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
September 2, 2019 PRESCRIBED DRUGS Appendix A Page 8
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
D. Growth Hormones
Therapeutic Class: Growth Hormone
Last Reviewed by the DUR Board: July 23,2020
Growth Hormones are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA Act and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Approval will be given if the following criteria are met and documented:
1. Children (with open epiphyses and with remaining growth potential) must
meet all of the following:
a. The recipient has had an evaluation by a pediatric endocrinologist
or pediatric nephrologist with a recommendation for growth
hormone therapy; and
b. The recipient has had an evaluation ruling out all other causes for
short stature; and
c. The recipient is receiving adequate replacement therapy for any
other pituitary hormone deficiencies, such as thyroid,
glucocorticoids or gonadotropic hormones.
The recipient must then meet one of the following:
1. The recipient has a diagnosis of Noonan Syndrome, Prader-
Willi Syndrome or Turner Syndrome and their height is at
least two standard deviations below the mean or below the
fifth percentile for the patient’s age and gender and the bone
age is less than 16 years for male recipients or less than 14
years for female recipients; or
2. The recipient has a diagnosis of Prader-Willi Syndrome; or
3. The recipient has a diagnosis of Turner Syndrome, is female
and has a bone age of less than 14 years; or
4. The recipient has a diagnosis of chronic renal insufficiency
(<75 mL/minute), and their height is at least two standard
deviations below the mean or below the third percentile for
the recipient’s age and gender; or
November 30, 2020 PRESCRIBED DRUGS Appendix A Page 9
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
5. The recipient has a diagnosis of being small for gestational
age, the recipient is two years of age or older, and the height
is at least two standard deviations below the mean or below
the third percentile for the recipient’s age and gender; or
6. The recipient is a newborn infant with evidence of
hypoglycemia, and has low growth hormone level (<20
ng/mL), low for age insulin like growth factor (IGF)-1 or
IGF binding protein (BP) 3 (no stimulation test required for
infants); or
7. The recipient has a diagnosis of growth hormone deficiency
or hypothalamic pituitary disease (e.g., hypopituitarism due
to structure lesions/trauma to the pituitary including pituitary
tumor, pituitary surgical damage, trauma or cranial
irradiation), and their height is at least two standard
deviations below the mean or below the third percentile for
the patient’s age and gender and their bone age is less than
16 years for male or less than 14 years for female.
And recipient must meet one of the following:
a. The recipient has failed two growth hormone
stimulation tests (<10 ng/mL); or
b. The recipient has failed one growth hormone
stimulation test (<10 ng/mL) and one IGF-1 or
IGFBP-3 test; or
c. The recipient has failed one growth hormone
stimulation test (<10 ng/mL) or IGF-1 or IGFBP-3
test and they have deficiencies in three or more
pituitary axes (e.g., thyroid stimulating hormone
(TSH), luteinizing hormone (LH), follicle
stimulating hormone (FSH), adrenocorticotropic
hormone (ACTH) or antidiuretic hormone (ADH)).
2. Adults (with closed epiphyses, and no remaining growth potential) must
meet all of the following:
a. The recipient is being evaluated by an endocrinologist; and
b. The recipient is receiving adequate replacement therapy for any
other pituitary hormone deficiencies, such as thyroid,
glucocorticoids or gonadotropic hormones; and
c. The recipient has a diagnosis of growth hormone deficiency or
hypothalamic pituitary disease (e.g., hypopituitarism due to
October 1, 2015 PRESCRIBED DRUGS Appendix A Page 10
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
structure lesions/trauma to the pituitary including pituitary tumor,
pituitary surgical damage, trauma or cranial irradiation); and
The recipient must then meet one of the following:
1. The recipient has failed two growth hormone stimulation
tests (<5 ng/mL); or
2. The recipient has failed one growth hormone stimulation test
(<5 ng/mL) and one IGF-1 or IGFBP-3 test; or
3. The recipient has failed one growth hormone stimulation test
(<5 ng/mL) or IGFBP-3 test and has deficiencies in three or
more pituitary axes (i.e., TSH, LH, FSH, ACTH, ADH), and
has severe clinical manifestations of growth hormone
deficiency as evident by alterations in body composition
(e.g., decreased lean body mass, increased body fat),
cardiovascular function (e.g., reduced cardiac output, lipid
abnormalities) or bone mineral density.
3. Continued authorization will be given for recipients (up to age 21, with
remaining growth potential) who meet all of the following:
a. The recipient has a diagnosis of chronic renal insufficiency, growth
hormone deficiency, hypothalamic pituitary disease, newborn infant
with evidence of hypoglycemia, Noonan Syndrome, Prader-Willi
Syndrome, small for gestational age or Turner Syndrome; and
b. The recipient’s epiphyses are open; and
c. The recipient’s growth rate on treatment is at least 2.5 cm/year; and
d. The recipient does not have evidence of an expanding lesion or
tumor formation; and
e. The recipient has not undergone a renal transplant.
4. Continued authorization will be given for recipients (age 21 years and
older, with closed epiphyses and no remaining growth potential) who meet
all of the following:
a. The recipient has a diagnosis of growth hormone deficiency or
hypothalamic pituitary disease; and
b. There is documentation of improvement in clinical manifestations
associated with growth hormone deficiency
5. Prior Authorization Guidelines
November 30, 2020 PRESCRIBED DRUGS Appendix A Page 11
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
a. Initial prior authorization will be for six months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
b. Serostim® (somatropin)
1. Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of Human Immune Deficiency Virus
(HIV) with wasting or cachexia; and
b. The medication is indicated to increase lean body mass, body weight
and physical endurance; and
c. The recipient is receiving and is compliant with antiretroviral
therapy; and
d. The recipient has experienced an involuntary weight loss of >10%
pre-illness baseline or they have a body mass index of <20 kg/m²;
and
e. The recipient has experienced an adverse event, allergy or
inadequate response to megestrol acetate, or the recipient has a
contraindication to treatment with this agent; and
f. The recipient has experienced an adverse event, allergy or
inadequate response to an anabolic steroid (e.g., testosterone,
oxandrolone, nandrolone) or the recipient has a contraindication to
treatment with these agents.
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 12 weeks.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Zorbtive® (somatropin)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient has a diagnosis of short bowel syndrome; and
b. The recipient is age 18 years or older; and
November 30, 2020 PRESCRIBED DRUGS Appendix A Page 12
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
c. The medication is being prescribed by or following a consultation
with a gastroenterologist; and
d. The recipient is receiving specialized nutritional support (e.g., high
carbohydrate, low-fat diets via enteral or parenteral nutrition).
2. Prior Authorization Guidelines
a. Initial authorization will be approved for six months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. Somavert® (pegvisomant)
1. Approval will be given if all the following criteria are met and
documented:
a. The recipient has a diagnosis of acromegaly; and
b. The recipient is 18 years age or older; and
c. One of the following:
1. The recipient has an inadequate response to one of the
following:
a. Surgery; or
b. Radiation Therapy; or
c. Dopamine agonist (e.g. bromocriptine, cabergoline)
therapy; or
2. The recipient is not a candidate for all the following:
a. Surgery; and
b. Radiation Therapy; and
c. Dopamine agonist (e.g. bromocriptine, cabergoline)
therapy; and
d. The recipient has tried and failed, a contraindication, or intolerance
to generic octreotide (a somatostatin analogue); and
November 30, 2020 PRESCRIBED DRUGS Appendix A Page 13
APPENDIX A – Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
e. The medication is prescribed by or in consultation with an
endocrinologist.
2. Recertification Criteria:
a. The recipient must meet the following:
1. The recipient must have a documented positive clinical
response to Somavert® therapy (e.g. biochemical control;
decrease or normalization of IGF-1 levels).
3. Prior Authorization Guidelines:
a. Initial authorization will be approved for 12 weeks.
b. Recertification approval will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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E. Over-the-Counter Medications
Last Reviewed by the DUR Board: N/A
Over-the-Counter (OTC) medications are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Any more than two prescription requests for medications within the same therapeutic class
will require prior authorization.
A Prior Authorization form must be submitted to the Nevada QIO-like vendor. The QIO-
like vendor will request further information needed on a case by case basis to determine
the necessity of the medication for the recipient.
Note: Insulin will be exempt from any prior authorization requirements.
Approval will be for a one month time limit.
Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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F. Transdermal Fentanyl
Therapeutic Class: Analgesics, Narcotic
Last Reviewed by the DUR Board: April 25, 2019
Transdermal fentanyl, a narcotic agonist analgesic, is indicated in the management of chronic pain
in patients requiring continuous opioid analgesia for pain that cannot be managed by lesser means
such as acetaminophen-opioid combinations, non-steroidal analgesics or PRN dosing with short-
acting opioids. Transdermal fentanyl is subject to prior authorization and quantity limitations based
on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Because serious or life-threatening hypoventilation could occur, fentanyl transdermal is
contraindicated in management of acute or postoperative pain, mild or intermittent pain
responsive to PRN or non-opioid therapy or in doses exceeding 25 mcg/hr at the initiation
of opioid therapy. Therefore, patients must meet the following criteria in order to gain prior
authorization approval:
a. Patient cannot be managed by lesser means such as acetaminophen-opioid
combinations, nonsteriodal analgesics or PRN dosing with short-acting opioid.
b. Patient requires continuous opioid administration.
c. Prescribers are required to check the Nevada State BOPs Prescription Monitoring
Program (PMP) prior to prescribing narcotic analgesics. Refer to the PMP website
at http://bop.nv.gov/links/PMP/.
d. If transitioning from another opioid, daily morphine equivalent doses are used to
calculate the appropriate fentanyl patch dose.
1. Morphine 60-134 mg/day PO; initial Transdermal Fentanyl dose 25 mcg/hr.
2. Morphine 135-224 mg/day PO; initial Transdermal Fentanyl dose 50
mcg/hr.
3. Morphine 225-314 mg/day PO; initial Transdermal Fentanyl dose 75
mcg/hr.
4. Morphine 315-404 mg/day PO; initial Transdermal Fentanyl dose 100
mcg/hr.
5. Morphine 405-494 mg/day PO; initial Transdermal Fentanyl dose 125
mcg/hr.
6. Morphine 495-584 mg/day PO; initial Transdermal Fentanyl dose 150
mcg/hr.
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7. Morphine 585-674 mg/day PO; initial Transdermal Fentanyl dose 175
mcg/hr.
8. Morphine 675-764 mg/day PO; initial Transdermal Fentanyl dose 200
mcg/hr.
9. Morphine 765-854 mg/day PO; initial Transdermal Fentanyl dose 225
mcg/hr.
10. Morphine 855-944 mg/day PO; initial Transdermal Fentanyl dose 250
mcg/hr.
11. Morphine 945-1034 mg/day PO; initial Transdermal Fentanyl dose 275
mcg/hr.
12. Morphine 1035-1124 mg/day PO; initial Transdermal Fentanyl dose 300
mcg/hr.
2. Prior Authorization Guidlines
a. Prior authorization approval will be given for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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G. Immediate-Release Fentanyl Products
Therapeutic Class: Analgesics, Narcotic
Last Reviewed by the DUR Board: July 25, 2013
Immediate-Release Fentanyl Products are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Subsys® (fentanyl sublingual spray), Onsolis® (fentanyl citrate buccal film),
Fentora® (fentanyl citrate buccal tablet), Lazanda® (fentanyl citrate nasal spray),
Abstral® (fentanyl citrate sublingual tablet) and Actiq® (fentanyl citrate
transmucosal lozenge):
The recipient must meet all of the following:
1. The recipient is > 18 years of age or > 16 years of age if requesting fentanyl
citrate transmucosal lozenge (Actiq®); and
2. The recipient has pain resulting from a malignancy; and
3. The recipient is already receiving and is tolerant to opioid therapy; and
4. The recipient is intolerant of at least two of the following immediate-release
opioids: hydrocodone, hydromorphone, morphine or oxycodone.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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H. Hematopoietic/Hematinic Agents
Therapeutic Class: Erythropoiesis Stimulating Agents (ESAs)
Last Reviewed by the DUR Board: October 17, 2019
This policy applies in all settings with the exception of inpatient facilities. Hematopoietics and
Hematinics are subject to prior authorizations and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. The recipient has been evaluated for adequate iron stores; and
b. Recent laboratory results are required for prior authorization, i.e. serum
hemoglobin, within seven days of prior authorization request; and
c. Recipients must meet one of the following criteria for coverage:
1. Achieve and maintain hemoglobin levels in one of the following conditions:
a. Treatment of anemia secondary to myelosuppressive anticancer
chemotherapy, Hb levels should not exceed 10 g/dL.
b. Treatment of anemia related to zidovudine therapy in HIV-infected
patients. Hb levels should not exceed 12 g/dL.
c. Treatment of anemia secondary to ESRD. Hb levels should not
exceed 11 g/dL if on dialysis or 10 g/dL if not on dialysis.
d. Epoetin alfa (Epogen®) is indicated to reduce the need for allogenic transfusions
in surgery patients when a significant blood loss is anticipated. It may be used to
achieve and maintain hemoglobin levels within the range of 10 to 13 gm/dl.
Darbepoetin Alfa (Aranesp®) does not have this indication.
2. Non-Covered Indications
a. Any anemia in cancer or cancer treatment patients due to folate deficiency, B-12
deficiency, iron deficiency, hemolysis, bleeding or bone marrow fibrosis.
b. Anemia associated with the treatment of acute and chronic myelogenous leukemias
(CML, AML) or erythroid cancers.
c. Anemia of cancer not related to cancer treatment.
d. Any anemia associated only with radiotherapy.
e. Prophylactic use to prevent chemotherapy-induced anemia.
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f. Prophylactic use to reduce tumor hypoxia.
g. Patients with erythropoietin-type resistance due to neutralizing antibodies.
h. Anemia due to cancer treatment if patients have uncontrolled hypertension.
3. Prior Authorization Guidelines
a. Prior approval will be given for a one month period.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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I. Anti-Fungal Onychomycosis
Therapeutic Class: Antifungal Agents
Last Reviewed by the DUR: September 3, 2015
Anti-Fungal Onychomycosis Agents are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. The agent is U.S. FDA approved for the treatment of onychomycosis (tinea
unguium).
b. And one of the following:
d. The recipient is experiencing pain which limits normal activity; or
2. The recipient’s disease is iatrogenically-induced; or
3. The recipient’s disease is associated with immunosuppression; or
4. The recipient has diabetes; or
5. The recipient has significant peripheral vascular compromise.
c. And the requested length of therapy is appropriate, based on the agent and infection
location.
d. And the drug and/or formulation-specific criteria is met:
1. Terbinafine: no pre-existing liver disease.
2. Itraconazole: The recipient does not have a diagnosis of heart failure and
there is no evidence of ventricular dysfunction.
3. Oral granules dosage form: clinical rationale documenting why the recipient
cannot or should not use terbinafine tablets or itraconazole capsules.
e. Topical dosage forms:
1. Inadequate response after an appropriate length of therapy with ciclopirox
8% solution or an adverse reaction or contraindication to ciclopirox 8%
solution; and
2. Inadequate response after an appropriate length of therapy to either
terbinafine tablets or itraconazole capsules or an adverse reaction or a
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contraindication to terbinafine tablets or itraconazole capsules or a clinical
rationale why the recipient cannot use terbinafine tablets or itraconazole
capsules.
f. Onmel (itraconazole) tablets: Clinical rationale documenting why the recipient
cannot or should not use terbinafine tablets or itraconazole capsules.
2. Prior Authorization Guidelines
a. The extent of prior authorization approvals will be based on the appropriate use for
the individual agents.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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J. Benlysta® (belimumab)
Therapeutic Class: Benlysta® (belimumab)
Last Reviewed by the DUR Board: January 25, 2018
Benlysta® (belimumab) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Initial request:
1. The recipient has a diagnosis of active Systemic Lupus Erythematosus
(SLE); and
2. The recipient must be 18 years of age or older; and
3. Documentation confirms that the recipient is autoantibody positive (i.e.,
anti-nuclear antibody (ANA) and/or anti-double-stranded DNA (anti-
dsDNA)); and
4. The recipient is currently receiving at least one standard of care treatment
for active SLE that includes one or more of the following agents (unless all
agents are contraindicated): antimalarials (e.g., Plaquenil
(hydroxychloroquine)), corticosteroids (e.g., prednisone), glucocorticoids,
or immunosuppressants (e.g., methotrexate, Imuran (azathioprine),
mycophenolate); and
5. The medication is prescribed by or in consultation with a rheumatologist;
and
6. The recipient must not have active CNS Lupus; and
7. The recipient must not currently be receiving treatment for a chronic
infection; and
8. The recipient must not have evidence of severe renal disease.
b. Recertification Request (the recipient must meet all the following criteria):
1. Authorization for continued use shall be reviewed at least every six months
when the following criteria are met:
a. Documentation of positive clinical response to Benlysta® therapy.
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2. Prior Authorization Guidelines
a. Prior authorization approvals will be for:
1. Initial request: six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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K. Spinal Muscular Atrophy (SMA) Agents
Therapeutic Class: Spinal Muscular Atrophy Agents
Last Reviewed by the DUR Board: January 28, 2021
SMA agents are subject to prior authorization and quantity limitatons based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid Check Up Pharmacy Manual for specific quantity limits.
1. Evrysdi® (risdiplam)
a. Approval will be given if the following criteria are met and documented:
1. Recipient has a diagnosis of SMA type I, II, or III; and
2. Both the following:
a. Recipient has mutation or deletion of genes in chromosome 5q
resulting in one of the following:
1. Homozygous gene deletion or mutation (e.g., homozygous
deletion of exon 7 at locus 5q13); or
2. Compound heterozygous mutation (e.g., deletion of survival
motor neuron 1 (SMN1) exon 7 [allele 1] and mutation of
SMN1 [allele 2]); and
b. Recipient has at least two copies of SMN2; and
3. Recipient is not dependent on invasive ventilation or tracheostomy and non-
invasive ventilation beyond use for naps and nighttime sleep; and
4. Recipient is at least two months of age or older; and
5. At least one of the following exams (based on the recipient’s age and motor
ability) have been conducted to establish baseline motor ability:
NOTE: Baseline assessments for patients less than two months of age
requesting risdiplam proactively are not necessary to not delay access to
initial therapy in recently diagnosed infants. Initial assessments shortly
post-therapy can serve as baseline with respect to efficacy reauthorization
assessment.
a. Hammersmith Infant Neurological Exam (HINE) (infant to early
childhood); or
b. Hammersmith Functional Motor Scale Expanded (HFMSE); or
c. Upper Limb Module (ULM) Test (Non ambulatory); or
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d. Children’s Hospital of Philadelphia Infant Test of Neuromuscular
Disorders (CHOP INTEND); or
e. Motor Function Measure 32 (MFM-32) Scale; and
6. The medication is prescribed by or in consultation with a neurologist with
expertise in the diagnosis and treatment of SMA; and
7. Recipient is not to receive concomitant chronic SMN modifying therapy for
the treatment of SMA (e.g. Spinraza®); and
8. One of the following:
a. Recipient has not previously received gene replacement therapy for
the treatment of SMA (e.g. Zolgensma®); or
b. Recipient has previously received gene therapy for the treatment of
SMA (e.g. Zolgesma®) and the provider attest that there has been
an inadequate response to gene therapy (e.g. sustained decrease in
at least one motor test score over a period of six months).
b. Recertification Request (recipient must meet all criteria):
1. The recipient has documentation of positive clinical response to therapy
from pretreatment baseline status as demonstrated by the most recent results
from one of the following exams:
a. One of the following HINE-2 milestones:
1. Improvement or maintenance of previous improvement of at
least a 2-point (or maximal score) increase in ability to kick;
or
2. Improvement or maintenance of previous improvement of at
least a 1-point increase in any other HINE-2 milestone (e.g.,
head control, rolling, sitting, crawling, etc.), excluding
voluntary grasp; or
3. Recipient exhibited improvement, or maintenance of
previous improvement in more HINE motor milestones than
worsening, from pretreatment baseline (net positive
improvement); or
4. The recipient has achieved and maintained any new motor
milestones when they would otherwise be unexpected to do
so (e.g., sit unassisted, stand, walk); or
b. One of the following HFMSE milestones:
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1. Improvement or maintenance of a previous improvement of
at least a 3-point increase in score from pretreatment
baseline; or
2. Recipient has achieved and maintained any new motor
milestone from pretreatment baseline when they would
otherwise be unexpected to do so (e.g., sit unassisted, stand,
walk); or
c. One of the following ULM test milestones:
1. Improvement or maintenance of a previous improvement of
at least a 2-point increase in score from pretreatment
baseline; or
2. Recipient has achieved and maintained any new motor
milestone from pretreatment baseline when they would
otherwise be unexpected to do so (e.g., sit unassisted, stand,
walk); or
d. One of the following CHOP INTEND milestones:
1. Improvement or maintenance of a previous improvement of
at least a 4-point increase in score from pretreatment
baseline; or
2. Recipient has achieved and maintained any new motor
milestone from pretreatment baseline when they would
otherwise be unexpected to do so (e.g., sit unassisted, stand,
walk); or
e. One of the following MFM-32 milestones:
1. Improvement or maintenance of a previous improvement of
at least a 3-point increase in score from pretreatment
baseline; or
2. Recipient has achieved and maintained any new motor
milestone from pretreatment baseline when they would
otherwise be unexpected to do so (e.g., sit unassisted, stand,
walk); and
2. Recipient remains not be dependent on invasive ventilation or tracheostomy
and use of non-invasive ventilation beyond use for naps and nighttime sleep;
and
3. The medication is prescribed by or in consultation with a neurologist with
expertise in the diagnosis and treatment of SMA; and
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4. Recipient is not to receive concomitant chronic SMN modifying therapy for
the treatment of SMA (e.g. Spinraza®); and
5. One of the following:
1. Recipient has not previously received gene replacement therapy for
the treatment of SMA (e.g. Zolgensma®); or
2. Recipient has previously received gene therapy for the treatment of
SMA (e.g. Zolgesma®) and the provider attest that there has been
an inadequate response to gene therapy (e.g. sustained decrease in
at least one motor test score over a period of six months).
c. Prior Authorization Guidelines:
1. Initial authorization will be approved for 12 months.
2. Recertification request will be approved for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Spinraza® (nusinersen)
a. Approval will be given if the following criteria are met and documented:
1. Initial request:
a. The recipient has a diagnosis of SMA, and
b. The medication is prescribed by or in consultation with a neurologist
who has experience treating SMA.
2. Recertification Request (the recipient must meet all the following criteria):
a. The recipient has been on therapy for less than 12 months; and
b. The recipient is maintaining neurological status; and
c. The recipient is tolerating therapy; and
d. The medication is prescribed by or in consultation with a neurologist
who has experience treating SMA, or all the following:
1. The recipient has been on therapy for 12 months or more;
and
2. The recipient has experienced a benefit from therapy (e.g.,
disease amelioration compared to untreated patients); and
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3. The recipient is maintaining neurological status; and
4. The recipient is tolerating therapy; and
3. Prior Authorization Guidelines
a. Initial request will be approved for 12 months.
b. Recertification request will be approved for 12 months.
c. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. Zolgensma® (onasemnogene abeparvovec-xioi)
a. Approval will be given if the following criteria are met and documented:
1. The recipient must be two years of age or younger; and
a. The recipient must have the mutation or deletion of genes in
chromosome 5q in one of the following: homozygous gene deletion
or mutation of SMN1 gene (e.g., homozygous deletion of exon 7 at
locus 5q13); or
b. Compound heterozygous mutation of SMN1 gene (e.g., deletion of
SMN1, exon 7 [allele 1] and mutation of SMN1 [allele 2]); and
1. The recipient has a diagnosis of SMA confirmed by a
neurologist with expertise in the diagnosis of SMA; or
2. The recipient has a diagnosis of SMA based on the results of
SMA newborn screening with three copies or less of SMN
2; and
c. The recipient is not dependent on either invasive ventilation or
tracheostomy or use of non-invasive ventilation beyond use of naps
and nighttime sleep; and
d. Submission of medical records (e.g., chart notes, laboratory values)
documenting the recipient’s anti-AAV9 antibody titers are less than
or equal to 1:50; and
e. The recipient is not to receive concomitant SMN modifying therapy
(e.g. Spinraza®); and
f. The medication is prescribed by a neurologist with expertise in the
diagnosis of SMA; and
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g. The recipient has never received Zolgensma® treatment in their
lifetime.
b. Prior Authorization Guidelines
1. Prior authorization approval is limited to once in a lifetime.
2. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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L. Immunomodulator Drugs
Therapeutic Class: Immunomodulators
Last Reviewed by the DUR Board: October 18, 2018
Actemra® (tocilizumab) Ilaris® (canakinumab) Remicade® (infliximab)
Amevive® (alefacept) Ilumya® (tildrakizumab) Renflexis® (infliximab)
Arcalyst® (rilonacept) Infle ctra® (infliximab) Siliq® (brodalumab)
Cimzia® (certolizumab pegol) Kevzara® (sarilumab) Simponi® (golimumab)
Consentyx® (secukinumab) Kineret® (ankinra) Simponi® ARIA™ (golimumab)
Enbrel® (etanercept) Olumiant® (baricitinib) Stelara® (ustekinumab)
Entyvio® (vedolizumab) Orencia® (abatacept) Taltz® (ixekizumab)
Humira® (adalimumab) Otezla® (apremilast) Xeljanz® (tofacitinib)
Immunomodulator Drugs are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. For all recipients:
1. The recipient has had a negative tuberculin test; and
2. The recipient does not have an active infection or a history of recurring
infections; and
3. The approval will not be given for the use of more than one biologic at a
time (combination therapy); and
4. Each request meets the appropriate diagnosis-specific criteria (b-j).
b. Rheumatoid Arthritis (RA):
1. The recipient has a diagnosis of moderately to severely active RA; and
2. The recipient is 18 years of age or older; and
3. The recipient has had a rheumatology consultation, including the date of the
visit; and one of the following:
a. The recipient has had RA for less than six months (early RA) and
has high disease activity; and an inadequate or adverse reaction to a
disease modifying antirheumatic drug (DMARD) (methotrexate,
hydroxychloroquine, leflunomide, minocycline and sulfasalazine);
or
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b. The recipient has had RA for greater than or equal to six months
(intermediate or long-term disease duration) and has moderate
disease activity and has an inadequate response to a DMARD
(methotrexate, hydroxychloroquine, leflunomide, minocycline or
sulfasalazine); or
c. The recipient has had RA for greater than or equal to six months
(intermediate or long-term disease duration) and has high disease
activity.
a. Psoriatic Arthritis:
1. The recipient has a diagnosis of moderate or severe psoriatic arthritis; and
2. The recipient is 18 years of age or older; and
3. The recipient has had a rheumatology consultation including the date of the
visit or a dermatology consultation including the date of the visit; and
4. The recipient had an inadequate response or a contraindication to treatment
with any one nonsteroidal anti-inflammatory (NSAID) or to any one of the
following DMARDs: methotrexate, leflunomide, cyclosporine or
sulfasalazine.
b. Ankylosing Spondylitis:
1. The recipient has a diagnosis of ankylosing spondylitis; and
2. The recipient is 18 years or older; and
3. The recipient has had an inadequate response to NSAIDs; and
4. The recipient has had an inadequate response to any one of the DMARDs
(methotrexate, hydroxychloroquine, sulfasalazine, leflunomide,
minocycline).
c. Juvenile Rheumatoid Arthritis/Juvenile Idiopathic Arthritis:
1. The recipient has a diagnosis of moderately or severely active juvenile RA
or juvenile idiopathic arthritis; and
2. The recipient is at an appropriate age, based on the requested agent, and:
a. Abatacept: Six years of age or older
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b. Adalimumab, canakinumab, etanercept, tocilizumab: Two years of
age or older.
3. And the recipient has at least five swollen joints; and
4. The recipient has three or more joints with limitation of motion and pain,
tenderness or both; and
5. The recipient has had an inadequate response to one DMARD.
d. Plaque Psoriasis:
1. The recipient has a diagnosis of chronic, moderate to severe plaque
psoriasis; and
2. The recipient is 18 years of age of older; and
3. The agent is prescribed by a dermatologist; and
4. The recipient has failed to adequately respond to a topical agent; and
5. The recipient has failed to adequately respond to at least one oral treatment.
g. Crohn’s Disease:
1. The recipient has a diagnosis of moderate to severe Crohn’s Disease; and
2. The recipient is at an appropriate age, based on the requested agent:
a. Adalimumab, infliximab: Six years of age or older.
b. All others: 18 years of age or older.
3. And the recipient has failed to adequately respond to conventional therapy
(e.g. sulfasalazine, mesalamine, antibiotics, corticosteroids, azathioprine, 6-
mercaptopurine, leflunomide); or
4. The recipient has fistulizing Crohn’s Disease.
h. Ulcerative Colitis:
1. The recipient has a diagnosis of moderate to severe ulcerative colitis; and
2. The recipient is at an appropriate age, based on the requested agent:
a. Infliximab: Six years of age or older.
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b. All others: 18 years of age or older.
3. And the recipient has failed to adequately respond to one or more of the
following standard therapies:
a. Corticosteroids;
b. 5-aminosalicylic acid agents;
c. Immunosuppressants; and/or
d. Thiopurines.
i. Cryopyrin-Associated Periodic Syndromes (CAPS): Familial Cold
Autoinflammatory Syndromes (FCAS) or Muckle-Wells Syndrome (MWS):
1. The recipient has a diagnosis of FCAS or MWS; and
2. The recipient is at an appropriate age, based on the requested agent:
a. Canakinumab: Four years of age or older.
b. Rilonacept: 12 years of age or older.
j. Cryopyrin-Associated Periodic Syndromes (CAPS): Neonatal-Onset Multisystem
Inflammatory Disease (NOMID):
1. The recipient has a diagnosis of NOMID.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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M. Topical Immunomodulators
Therapeutic Class: Topical Immunomodulators
Last Reviewed by the DUR Board: October 17, 2019
Topical Immunomodulators drugs are a subject to prior authorization and quantity limitations and
quantity limitations based on the Application of Standards in Section 1927 of the SSA and/or
approved by the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for
specific quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. Patient has a documented diagnosis of Atopic Dermatitis:
1. Elidel® for mild to moderate, for ages > two years.
2. Eucrisa® for mild to moderate, for ages ≥ two years.
3. Protopic® 0.03%; moderate to severe, for ages > two years.
4. Protopic® 0.1%; moderate to severe, for ages > 16 years.
b. Not for chronic use.
c. Elidel® is not recommended for use on patients with Netherton’s syndrome due to
the potential for systemic absorption.
d. Not recommended for use in immunocompromised patients.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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N. Psychotropic Medications for Children and Adolescents
Therapeutic Class: Psychotropic Agents
Last Reviewed by the DUR Board: July 23, 2020
Psychotropic medications for children and adolescents are subject to prior authorization based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for billing information.
Authorization will be given if the following criteria are met and documented.
1. Coverage and Limitations
The DHCFP requires prior authorization approval for children and adolescents for the
psychotropic therapeutic classes below and medication combinations considered to be
polypharmacy. The DHCFP has adopted the following practice standards to strengthen
treatment outcomes for our children and adolescents.
a. The psychotropic therapeutic classes subject to this policy are:
1. Antipsychotics
2. Antidepressants
3. Mood Stabilizers (including lithium and anticonvulsants used for behavioral
health indications.)
4. Sedative hypnotics
5. Antianxiety agents
b. For all children under 18 years of age, the following must be documented in the
medical record for authorization.
1. For psychotropic medications in this age group, when possible, be
prescribed by or in consultation with a child psychiatrist.
2. Psychotropic medication must be part of a comprehensive treatment plan
that addresses the education, behavioral management, living home
environment and psychotherapy.
3. Physician and/or prescriber monitoring is required while the recipient is
utilizing any psychotropic medication.
a. For recipients who are in initial treatment (have not received any
doses previously) or are continuing therapy but are considered
unstable (has had a dose change in the last three months), medical
documentation must support a monthly or more frequent visit with
the physician and/or prescriber. If the recipient was discharged from
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an institution on the medication, the follow-up visit(s) can be with
their treating physician and/or prescriber.
b. For recipients who are considered stable in their medication therapy,
medical documentation must support visits with the treating
physician at least every three months.
c. Polypharmacy: Each psychotropic medication prescribed must be independently
treating a specific symptom and/or diagnosis.
1. Polypharmacy (intra-class) is defined as more than one drug within the same
therapeutic class within a 60-day time period.
a. Prior authorization approval is required for two or more drugs in the
same therapeutic class within a 60-day period.
2. Polypharmacy (inter-class) is defined as more than one drug across different
therapeutic classes within a 60-day time period.
a. Prior authorization approval is required for four or more drugs
across all psychotropic therapeutic classes listed in this policy
within a 60-day time period.
3. Approval for polypharmacy may be given in situations where the requested
medication(s) will be used for cross tapering and situations where the
recipient will be discontinuing the previously prescribed agent. A 30-day
cross-taper will be allowed.
4. Approval for polypharmacy may be given for a medication to augment the
effect of another psychotropic medication as long as the purpose of the poly-
pharmacy is clearly documented in the recipient’s medical record and each
agent is supported by individual authorizations.
5. The recipient must have a trial of each individual medication alone. The
reasons for an inadequate response must be documented in the medical
record.
6. For intra-class and inter-class polypharmacy, all psychotropic medications
must be utilized for a medically accepted indication as established by the
FDA, and/or peer reviewed literature.
7. Polypharmacy rules will be bypassed for antidepressants, antipsychotics,
anticonvulsants, and mood stabilizers, if the medication is prescribed by a
board-certified child psychiatrist.
d. For children under six years of age, in addition to the Coverage and Limitation
requirements, all psychotropic medications require a prior authorization approval
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and must be utilized for a medically accepted indication as established by the FDA
and/or peer-reviewed literature.
e. Continuity of Care. In an effort to improve recipient safety and quality of care:
1. For recipients under 18 years of age, who have been discharged from an
institutional facility, they will be allowed to remain on their discharge
medication regimen for up to six months to allow the recipient time to
establish outpatient mental health services. The initial prior authorization
after discharge must document the name of the discharge institution and the
date of discharge.
2. For all other recipients under the age of 18, a six month prior authorization
will be granted to cover current medication(s) when it is documented that
the recipient has been started and stabilized. This will allow the recipient
time to establish services if necessary and to transition to medication(s) per
Nevada Medicaid policy.
2. Exceptions to Criteria for Anticonvulsants and ADD/ADHD Medications:
a. Treatment for seizure disorders with anticonvulsants are not subject to this policy.
The ICD Codes for Epilepsy and/or Convulsions will bypass the prior authorization
requirement at the pharmacy POS if the correct ICD Code is written on the
prescription and transmitted on the claim. Or the prior authorization requirement
will be overridden for anticonvulsant medications when the prescriber has a
provider Specialty Code of 126, neurology or 135, pediatric neurology, in the POS
system.
b. The current policy for treatment of ADD/ADHD is to be followed. Refer to this
Chapter’s Appendix A.
3. Prior Authorization Guidelines
a. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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O. Lidoderm 5% Patches®
Therapeutic Class: Topical, Local Anesthetics
Last Reviewed by the DUR Board: October 17, 2019
1. Coverage and Limitations
Topical Lidoderm Patches® are subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the
DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
Authorization will be given if one of the following criteria are met and documented:
a. If an ICD code for herpes zoster is documented on the prescription; or
b. Completion of a prior authorization documenting a diagnosis of Post Herpetic
Neuralgia/Neuropathy.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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P. Monoclonal Antibody Agents
Therapeutic Class: Respiratory Monoclonal Antibody Agents
Last Reviewed by the DUR Board: January 23, 2020
Monoclonal Antibody Agents are subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Xolair® (Omalizumab)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient will not use the requested antiasthmatic monoclonal
antibody in combination with other antiasthmatic monoclonal
antibodies.
2. All the following criteria must be met and documented for a
diagnosis of moderate to severe persistent asthma:
a. The recipient must be six years of age or older; and
b. The recipient must have a history of a positive skin test or
Radioallergosorbent (RAST) test to a perennial
aeroallergen; and
c. The prescriber must be either a pulmonologist or allergist/
immunologist; and
d. The recipient must have had an inadequate response, adverse
reaction or contraindication to inhaled, oral corticosteroids;
and
e. The recipient must have had an inadequate response, adverse
reaction or contraindication to a leukotriene receptor
antagonist; and
f. The recipient must have had a pretreatment serum total
Immunoglobulin E (IgE) level between 30 IU/mL and 700
IU/mL; and
g. The recipient's current weight must be recorded; and
h. The requested dose is appropriate for the recipient’s pre-
treatment serum IgE and body weight (see Table 1).
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2. All the following criteria must be met and documented for diagnosis of
chronic idiopathic urticaria (CIU):
a. The recipient is 12 years of age or older; and
b. The recipient must have had an inadequate response, adverse
reaction or contraindication to two different oral second-generation
antihistamines; and
c. The recipient must have had an inadequate response, adverse
reaction or contraindication to an oral second-generation
antihistamine in combination with a leukotriene receptor antagonist;
and
d. The prescriber must be either an allergist/immunologist,
dermatologist or a rheumatologist or there is documentation in the
recipient’s medical record that a consultation was done by an
allergist/immunologist, dermatologist or a rheumatologist regarding
the diagnosis and treatment recommendations; and
e. The requested dose is:
1. Initial therapy: 150 mg every four weeks or 300 mg every
four weeks and clinical rationale for starting therapy at 300
mg every four weeks has been provided.
2. Continuation of therapy: 150 mg or 300 mg every four
weeks.
3. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
Table 1: Dosing for Xolair® (omalizumab)*
Pre-treatment Body Weight (kg)
Serum IgE 30-60 >60-70 >70-90 >90-150
(IU/mL)
≥30-100 150 mg 150 mg 150 mg 300 mg
>100-200 300 mg 300 mg 300 mg 225 mg
>200-300 300 mg 225 mg 225 mg 300 mg
>300-400 225 mg 225 mg 300 mg
>400-500 300 mg 300 mg 375 mg
>500-600 300 mg 375 mg
>600-700 375 mg DO NOT DOSE
Every 2 Weeks Dosing
Every 4 Weeks Dosing
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b. Nucala® (mepolizumab), Cinqair® (reslizumab)
1. All the following criteria must be met and documented:
a. The recipient will not use the requested antiasthmatic monoclonal
antibody in combination with other antiasthmatic monoclonal
antibodies; and
b. The recipient must have a diagnosis of severe eosinophilic-
phenotype asthma; and
c. The recipient must be of FDA indicated appropriate age:
1. Mepolizumab: six years of age or older
2. Reslizumab: 18 years of age or older
d. And, the prescriber must be either a pulmonologist or allergist/
immunologist; and
e. The recipient must be uncontrolled on current therapy including
high dose corticosteroid and/or on a secondary asthma inhaler; and
f. There is documentation of the recipient’s vaccination status; and
g. The requested dose is appropriate:
1. Mepolizumab: 100 mg subcutaneously every four weeks.
2. Reslizumab: 3 mg/kg via intravenous infusion of 20 to 50
minutes every four weeks.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
c. Nucala® (mepolizumab) for the treatment of severe asthma
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of severe asthma; and
b. The asthma is an eosinophilic phenotype as defined by one of the
following:
1. Baseline (pre-treatment) peripheral blood eosinophil level
greater than or equal to 150 cells/microliter; or
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2. Peripheral blood eosinophil levels were greater than or equal
to 300 cells/microliter within the past 12 months; and
c. One of the following:
1. The recipient has had at least one or more asthma
exacerbations requiring systemic corticosteroid within the
past 12 months; or
2. The recipient has had prior intubation for an asthma
exacerbation; or
3. The recipient has had prior asthma-related hospitalization
within the past 12-months; and
d. The recipient is currently being treated with one of the following
(unless there is a contraindication or intolerance to these
medications)
1. Both the following:
a. High-dose inhaled corticosteroid (ICS) (e.g., greater
than 500 mcg fluticasone propionate
equivalent/day); and
b. Additional asthma controller medication (e.g.,
leukotriene receptor antagonist, long acting beta-2
agonist [LABA], theophylline); or
2. One maximally dosed combination ICS/LABA product
(e.g., Advair [fluticasone propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
e. The recipient age is greater than or equal to six years; and
f. The medication must be prescribed by or in consultation with one of
the following:
1. Pulmonologist; or
2. Allergist/Immunologist
2. Recertification request (the recipient must meet all the criteria)
a. Documentation of positive clinical response to therapy (e.g.
reduction in exacerbations, improvement in forced expiratory
volume in one second [FEV1], decreased use of rescue
medications); and
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b. The recipient is currently being treated with one of the following
unless there is a contraindication or intolerance to these
medications:
1. Both the following:
a. ICS; and
b. Additional asthma controller medication (e.g.,
leukotriene receptor antagonist, long acting beta-2
agonist [LABA], theophylline); or
2. A combination ICS/LABA product (e.g., Advair [fluticasone
propionate/salmeterol], Dulera [mometasone/formoterol],
Symbicort [budesonide/formoterol]); and
c. The medication must be prescribed by or in consultation with one of
the following:
1. Pulmonologist; or
2. Allergist/Immunologist
3. Prior Authorization Guidelines
a. Initial authorization will be approved for six months.
b. Recertification will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
d. Nucala® (mepolizumab) for the treatment of Eosinophilic Granulomatosis with
Polyangiitis (EGPA)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of EGPA; and
b. The recipient’s disease has relapsed or is refractory to standard of
care therapy (i.e. corticosteroid treatment with or without
immunosuppressive therapy); and
c. The recipient is currently receiving corticosteroid therapy; and
d. The medication must be prescribed or in consultation with one of
the following:
1. Pulmonologist; or
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2. Rheumatologist; or
3. Allergist/Immunologist.
2. Recertification Requests (the recipient must meet the following criteria)
a. Documentation of positive clinical response to therapy (e.g. increase
in remission time).
3. Prior Authorization Guidelines
a. Initial authorization will be approved for 12 months.
b. Recertification request will be approved 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
e. Fasenra® (benralizumab)
1. All the following criteria must be met and documented:
a. The recipient must be 12 years of age or older; and
b. The recipient will not use the requested antiasthmatic monoclonal
antibody in combination with other antiasthamtic monoclonal
antibodies; and
c. The recipient must have a diagnosis of severe eosinophilic
phenotype asthma; and
d. One of the following:
1. Patient has had at least two or more asthma exacerbations
requiring systemic corticosteroids within the past 12 months;
or
2. Any prior intubation for an asthma exacerbation; or
3. Prior asthma-related hospitalization within the past 12
months.
e. Patient is currently being treated with one of the following unless
there is a contraindication or intolerance to these medications:
1. Both a high-dose ICS (e.g., greater than 500 mcg fluticasone
propionate equivalent/day) and an additional asthma
controller medication (e.g., leukotriene receptor antagonist,
long-acting beta-2 agonist (LABA), theophylline); or
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2. One maximally dosed combination ICS/LABA product
(e.g., Advair (fluticasone propionate/salmeterol), Dulera
(mometasone/formoterol), Symbicort (budesonide/
formoterol)).
f. Prescribed by or in consultation with one of the following:
1. Pulmonologist; or
2. Allergy/Immunology specialist.
2. Recertification Request: Authorization for continued use shall be reviewed
at least every 12 months when the following criteria are met:
a. There is documentation of a positive clinical response (e.g.,
reduction in exacerbation).
b. Patient is currently being treated with one of the following unless
there is a contraindication or intolerance to these medications:
1. Both an ICS (5,E) and an additional asthma controller
medication (e.g., leukotriene receptor antagonist, long-
acting beta-2 agonist (LABA), theophylline); or
2. A combination ICS/LABA product (e.g., Advair (fluticasone
propionate/salmeterol), Dulera (mometasone/formoterol),
Symbicort (budesonide/formoterol)).
c. Prescribed by or in consultation with one of the following:
1. Pulmonologist; or
2. Allergy/Immunology specialist.
3. Prior Authorization Guidelines
a. Initial prior authorization will be for 12 months.
b. Recertification request will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
d. Dupixent® (dupilumab)
1. Atopic Dermatitis
a. Approval will be given if all the following criteria are met and
documented:
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1. The recipient must have a diagnosis of moderate to severe
atopic dermatitis; and
2. One of the following:
a. Trial and failure, contraindication, or intolerance to
one medium to high potency topical
corticosteroid(e.g. betamethasone, tramcinolone); or
b. Trial and failure or intolerance to one of the
following, unless the recipient is not a candidate for
therapy (e.g. immunocompromised)
1. Elidel® (pimecrolumus) topical cream; or
2. Tacrolimus topical ointment; and
3. The medication must be prescribed by or in consultation
with one of the following:
1. Dermatologist; or
2. Allergist/Immunologist
b. Recertification request (the recipient must meet all criteria)
1. Documentation of positive clinical response to Dupixent®
therapy.
c. Prior Authorization Guidelines
1. Initial authorization approval will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Eosinophilic Asthma
a. Approval will be given if all the following criteria are met and
documented:
1. The recipient has a diagnosis of moderate to severe asthma;
and
2. Asthma is an eosinophilic phenotype as defined by a
baseline (pre-treatment) peripheral blood eosinophil level
greater than or equal to 150 cells per microliter; and
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3. Age is greater or equal to 12 years; and
4. One of the following:
a. The recipient has had at least one or more asthma
exacerbations requiring systematic corticosteroid
within the past 12 months; or
b. The recipient has had prior intubation for an asthma
exacerbation; or
c. The recipient has had prior asthma-related
hospitalization within the past 12 months; and
5. The recipient is currently being treated with one of the
following unless there is a contraindication or ntolerance to
these medications:
a. Both the following:
1. High-dose ICS [e.g., greater than 500 mcg
fluticasone propionate equivalent/day]; and
2. Additional asthma controller medication
[e.g., leukotriene receptor antagonist, long
acting beta-2 agonist (LABA), theophylline];
or
b. One maximally dosed combination ICS/LABA
product (e.g., Advair [fluticasone
propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
6. The medication must be prescribed by or in consultation
with one of the following:
1. Pulmonologist; or
2. Allergist/Immunologist.
b. Recertification request (recipient must meet all the criteria):
1. Documentation of a positive clinical response to Dupixent
therapy (e.g., reduction in exacerbations, improvement in
FEV1, decreased use of rescue medications); and
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2. The recipient is currently being treated with one of the
following unless there is a contraindication or intolerance to
these medications:
a. Both the following:
1. Inhaled corticosteroid (ICS); and
2. Additional asthma controller medication
[e.g., leukotriene receptor antagonist, long
acting beta-2 agonist (LABA), theophylline];
or
b. A combination ICS/LABA product (e.g., Advair
[fluticasone propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
3. The medication is prescribed by or in consultation with one
of the following:
a. Pulmonologist; or
b. Allergist/Immunologist
c. Prior Authorization Guidelines
1. Initial prior authorization will be for six months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Oral Corticosteroid Dependent Asthma
a. Approval will be given if all the following criteria are met and
documented
1. The recipient must have a diagnosis of moderate to severe
asthma; and
2. The recipient is greater or equal to 12 years of age; and
3. The recipient is currently dependent on oral corticosteroids
for the treatment of asthma; and
4. The recipient is currently being treated with one of the
following unless there is a contraindication or intolerance to
these medications:
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a. Both the following:
1. High-dose ICS [e.g., greater than 500 mcg
fluticasone propionate equivalent/day]; and
2. Additional asthma controller medication
[e.g., leukotriene receptor antagonist, long
acting beta-2 agonist (LABA), theophylline];
or
b. One maximally dosed combination ICS/LABA
product (e.g., Advair [fluticasone
propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
5. The medication must be prescribed by or in consultation
with one of the following:
a. Pulmonologist; or
b. Allergist/Immunologist.
b. Recertification Request (the recipient must meet all criteria)
1. Documentation of a positive clinical response to Dupixent®
therapy (e.g., reduction in exacerbations, improvement in
FEV1, reduction in oral corticosteroid dose); and
2. The recipient is currently being treated with one of the
following unless there is a contraindication or intolerance to
these medications:
a. Both the following:
1. ICS; and
2. Additional asthma controller medication
[e.g., leukotriene receptor antagonist, long
acting beta-2 agonist (LABA), theophylline];
or
b. A combination ICS/LABA product (e.g., Advair
[fluticasone propionate/salmeterol], Dulera
[mometasone/formoterol], Symbicort
[budesonide/formoterol]); and
3. The medication must be prescribed by or in consultation
with one of the following:
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a. Pulmonologist; or
b. Allergist/Immunologist.
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for six months.
2. Recertification approval will be 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)
a. Approval will be given if all the following criteria are met and
documented:
1. The recipient must have a diagnosis of CRSwNP; and
2. Unless contraindicated, the recipient has had an inadequate
response to two months of treatment with an intranasal
corticosteroid (e.g., fluticasone, mometasone) [Document
drug(s), dose, duration and date of trial]; and
3. The medication will not be used in combination with another
agent for CRSwNP; and
4. The medication must be prescribed by or in consultation
with an Allergist/Immunologist
b. Recertification request (the recipient must meet all criteria)
1. Documentation of a positive clinical response to therapy;
and
2. The medication will not be used in combination with another
agent for CRSwNP; and
3. The medication is prescribed by or in consultation with an
allergist/Immunologist.
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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Q. Long-Acting Narcotics
Therapeutic Class: Analgesics, Narcotic
Last Reviewed by DUR Board: April 28, 2016
Long-Acting Narcotics are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
The current criteria for the use of fentanyl transdermal patches (Appendix A, (F.)) or
oxycodone/acetaminophen ER tablets (Appendix A, (XX.)) is to be met.
For all other long-acting narcotics requests that exceed the quantity limit, the following
criteria must be met and documented:
a. The recipient has a diagnosis of terminal cancer; or
b. All the the following criteria must be met:
1. The recipient is 18 years of age or older; and
2. The requested agent will be used for the management of pain severe enough
to require daily, around-the-clock, long-term opioid treatment; and
3. There is documentation in the recipient’s medical record that alternative
agents (e.g., non-opioid analgesics or immediate-release opioids) are
ineffective, not tolerated or would be otherwise inadequate to provide
sufficient management of pain.
2. Prior Authorization Guidelines
a. The prior authorization approval will be for three months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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R. Toradol® (ketorolac tromethamine) tablets
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Last Reviewed by the DUR Board: April 30, 2020
Toradal® is subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Ketorolac is indicated for the short-term (up to five days) management of moderately
severe acute pain that requires analgesia at the opioid level. It is not indicated for minor or
chronic painful conditions. The following criteria must be met:
a. Oral treatment must be indicated only as continuation therapy to IV/IM therapy;
and
b. Oral treatment must not not to exceed five days; and
c. Oral treatment must not exceed 40 mg/day.
2. Prior Authorization Guidelines
a. Initial request will be approved for up to five days.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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S. Anti-Migraine Medications
Therapeutic Class: Serotonin 5-HT1 receptor agonists (triptans)
Last Reviewed by the DUR Board: July 25, 2019
Therapeutic Class: Calcitonin Gene-Related Peptide (CGRP) Receptor Inhibitor Medications
Last Reviewed by the DUR Board: April 30, 2020
Serotonin 5-HT1 receptor agonists commonly referred to as “triptans” and CGRP Receptor
Inhibitor medications or anti-migraine medications are subject to prior authorization and quantity
limitations based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Serotonin 5-HT1 Receptor Agonists (triptans)
a. An approved prior authorization is required for any prescription exceeding the
quantity limits. Approval for additional medication beyond these limits will be
considered only under the following circumstances:
1. The recipient’s current medication history documents the use of
prophylactic medications for migraine headache or the medical provider
agrees to initiate such therapy which includes beta-blockers, tricyclic
antidepressants, anticonvulsants, Selective Serotonin Reuptake Inhibitors
(SSRIs) and/or calcium channel blockers; or
2. The medical provider is aware of and understands the implications of daily
use and/or overuse of triptans and agrees to counsel the patient on this issue
in an effort to taper the quantity of triptan medication required monthly.
a. Recipient’s current medication history must NOT have Monoamine
Oxidase (MAO) Inhibitors present for approval of Imitrex®
(sumitriptan), Maxalt® (rizatriptan) or Zomig® (zolmitriptan).
b. Recipients whose current medication history indicates the use of
propranolol will NOT be granted prior authorization of Maxalt®
(rizatriptan) 10mg tablet or 10mg orally disintegrating tablet.
c. Prior authorization will NOT be given to patients with ischemic
heart disease.
b. Prior Authorization Guidelines
1. Approval for exceeding the quantity limits on triptans will be provided for
a two-month time period.
2. The prior authorization must be initiated by the prescriber. The approved
prior authorization must be available if requested.
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3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Calcitonin Gene-Related Peptide (CGRP) Receptor Inhibitor Medications
a. Approval will be given if the following criteria are met and documented:
1. CGRP General Criteria
a. The recipient must have one of the following:
1. Both the following:
a. The recipient has a diagnosis of episodic migraines;
and
b. The recipient has four to 14 migraine days per month,
but not more than headache days per month; or
2. All the following:
a. The recipient has a diagnosis of chronic migraines;
and
b. The recipient has greater than or equal to 15
headache days per month, of which at least eight
must be migraine days for at least three months; and
c. The recipient has been considered for medication
overuse headache (MOH) and potentially offending
medication(s) have been discontinued; and
b. The recipient is 18 years of age or older; and
c. The medication must be prescribed by or in consultation with either
a Neurologist or a Pain Specialist; and
d. The recipient must meet two of the following:
1. One of the following:
a. The recipient has documented history of failure (after
at least a two-month trial) or intolerance to Elavil®
(amitriptyline) or Effexor® (venlafaxine); or
b. The recipient has a contraindication to Elavil®
(amitriptyline) and Effexor® (venlafaxine); or
2. One of the following:
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a. The recipient has documented history of failure (after
at least a two-month trial) or intolerance to
Depakote®/Depakote® ER (divalproex sodium) or
Topamax® (topiramate); or
b. The recipient has a contraindication to both
Depakote®/Depakote® ER (divalproex sodium) and
Topamax® (topiramate); or
3. One of the following:
a. The recipient has documented history of failure (after
at least a two-month trial) or intolerance to one of the
following beta blockers:
1. Atenolol; or
2. Propranolol; or
3. Nadolol; or
4. Timolol; or
5. Metoprolol; or
b. The recipient has a contraindication to all the
following beta blockers:
1. Atenolol; or
2. Propranolol; or
3. Nadolol; or
4. Timolol; or
5. Metoprolol.
2. Recertification Request:
a. The recipient must have a documented positive response to
Aimovig® (erenumab-aooe), Ajovy® (fremanezumab-vfrm) or
Emgality® (galcanezumab-gnlm) therapy, demonstrated by a
reduction in headache frequency and/or intensity; and
b. The recipient has had a decrease in use of acute migraine
medications (e.g. NSAIDs, triptans) since the start of CGRP
therapy; and
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c. The medication must be prescribed by or in consultation with either
a Neurologist or a Pain Specialist; and
d. For chronic migraine only: The recipient continues to be monitored
for MOH.
3. Prior Authorization Guidelines:
a. Initial request will be approved for six months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Acute Migraines
a. Ubrelvy® (ubrogepant)
1. Approval will be given if all the following criteria are met and documented:
a. Recipient must have a diagnosis of acute migraine with or without
aura; and
b. Recipient is 18 years of age or older; and
c. The prescribed dose will not exceed two doses per migraine and
treating no more than eight migraine episodes per 30 days; and
d. The recipient has had at least one trial and failure of triptan agent;
and
e. The medication must be prescribed by or in consultation with either
a Neurologist or a Pain Specialist.
2. Recertification Request:
a. The recipient must have a documented positive response to the
Ubrelvy® therapy; and
b. The medication must be prescribed by or in consultation with either
a Neurologist or a Pain Specialist.
3. Prior Authorization Guidelines:
a. Initial request will be approved for six months.
b. Recertification request will be approved for 12 months.
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c. Prior authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Episodic Cluster Headache
a. Emgality® (galcanezumab-gnlm)
1. Approval will be given if all the following criteria are met
and documented
a. The recipient has a diagnosis of episodic cluster
headache; and
b. The recipient has experienced at least two cluster
periods lasting from seven days to 365 days,
separated by pain-free periods lasting at least three
months.
c. The recipient is 18 years of age or older.
d. The medication must be prescribed by or in
consultation with either a Neurologist or a Pain
Specialist.
2. Recertification Request:
a. The recipient has documented positive response to
Emgality® therapy, demonstrated by a reduction in
headache frequency and/or intensity; and
b. The medication must be prescribed by or in
consultation with either a Neurologist or a Pain
Specialits.
3. Prior Authorization Guidelines:
a. Initial request will be approved for three months.
b. Recertification request will be approved for 12
months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.a
spx.
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T. Tobacco Cessation Products
Therapeutic Class: Tobacco Cessation Agents
Last Reviewed by the DUR Board: April 30, 2020
Smoking cessation products, including patches, gums, lozenges and inhalers (based on the
recipients’ route of choice), are subject to quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
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U. Short-Acting Bronchodilators
Therapeutic Class: Beta Adrenergic Agents
Last Reviewed by the DUR Board: January 24, 2019
Short-Acting Bronchodilators are subject to PA and quantity limitations based on the Application
of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. This criteria applies to, but is not limited to, the following list:
Proventil® HFA ProAir® HFA ProAir RespiClick®
Ventolin® HFA Albuterol Nebulizer Nebulizer Solution
a. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
1. Quantity Limits:
a. Albuterol Metered Dose Inhalers (MDI): two units per month.
b. Albuterol Nebulizer Solution: three bottles of 20ml each or 125
nebulizer units per month.
2. In order to exceed the quantity limit, a recipient must meet all of the
following:
a. The recipient must have a diagnosis of asthma; and
b. The recipient has been assessed for causes of asthma and external
triggers have been removed or reduced where possible.
3. For recipients 18 years of age or younger the following criteria must be met:
a. The recipient has a diagnosis of asthma; and
b. The recipient requires an additional inhaler unit for school or
equivalent program.
b. Prior Authorization Guidelines
1. Prior authorization approval will be for 12 months.
2. Prior authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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2. Xopenex®
a. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
1. Authorization only for recipients experiencing side effects on one other
beta-adrenergic agent of any formulation.
2. Authorization for patients whose cardiovascular status is considered to be
in severe deteriorating condition.
b. Prior Authorization Guidelines
Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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V. Anti-Insomnia Agents (Sedative Hypnotics)
Therapeutic Class: Anxiolytics, Sedatives and Hypnotics
Last Reviewed by the DUR Board: September 3, 2015
See Section N of this Appendix for criteria for Sedatives and Hypnotics when prescribed for a
psychotropic indication.
Sedatives Hypnotics are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented.
a. An FDA approved ICD diagnosis code, such as insomnia, is documented on the
prescription and transmitted on the claim; or
b. A PA with an FDA approved diagnosis, such as insomnia, is submitted.
2. Prior Authorization Guidelines
a. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms/aspx
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W. Doxepin Topical
Therapeutic Class: Other Topical Anti-Pruiritics
Last Reviewed by DUR Board: October 22, 2020
Doxepin Topical is subject to prior authorization and quantity limits based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for billing information.
1. Authorization will be given if the following criteria are met and documented:
a. The recipient has a documented diagnosis of pruritus with atopic dermatitis or
lichen simplex chronicus; and
b. The recipient is 18 years of age or older; and
c. Treatment must not exceed eight days.
2. Prior Authorization Guidelines:
a. Prior Authorization approval will be given for eight days.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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X. Antiemetics
Therapeutic Class: Antiemetics, (Serotonin Receptor Antagonists (5 HT3 Antiemetics))
Last Reviewed by the DUR Board: October 28, 2010
Therapeutic Class: Antiemetic (Cannabinoid Antiemetics)
Last Reviewed by DUR Board: October 18, 2018
Antiemetics are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
An approved prior authorization is required for any prescription exceeding the quantity limits.
Approval for additional medication beyond these limits will be considered only under the
following circumstances:
Serotonin Receptor Antagonists (5 HT3 Antiemetics)
1. Coverage and Limitations
a. The recipient has failed on chemotherapy-related antiemetic therapy at lower doses;
or
b. The recipient is receiving chemotherapy treatments more often than once a week;
or
c. The recipient has a diagnosis of Acquired Immune Deficiency Syndrome (AIDS)
associated nausea and vomiting; or
d. The recipient has a diagnosis of hyperemesis gravidarum and has failed at least one
other antiemetic therapy or all other available therapies are medically
contraindicated.
2. Prior Authorization Guidelines
A prior authorization to override the quantity limits to allow for a 30-day fill for these drugs
may be effective for up to six months.
Cannabinoid Antiemetics
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Nabilone
1. The recipient has a diagnosis of chemotherapy-induced nausea and/or
vomiting; and
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2. The recipient has experienced an inadequate response, adverse event or has
a contraindication to at least one serotonin receptor antagonist; and
3. The recipient has experienced an inadequate response, adverse event or has
a contraindication to at least one other antiemetic agent; and
4. The prescriber is aware of the potential for mental status changes associated
with the use of this agent and will closely monitor the recipient.
b. Dronabinol
1. The recipient has a diagnosis of chemotherapy-induced nausea and/or
vomiting; and
a. The recipient has experienced an inadequate response, adverse event
or has a contraindication to at least one serotonin receptor
antagonist; and
b. The recipient has experienced an inadequate response, adverse event
or has a contraindication to at least one other antiemetic agent; and
c. The prescriber is aware of the potential for mental status changes
associated with the use of this agent and will closely monitor the
recipient; or
2. The recipient has been diagnosed with Acquired Immune Deficiency
Syndrome (AIDS) and has anorexia associated with weight loss; and the
recipient has experienced an inadequate response, adverse event or has a
contraindication to megestrol (Megace®); and
a. The prescriber is aware of the potential for mental status changes
associated with the use of this agent and will closely monitor the
recipient.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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Y. Synagis® (palivizumaub)
Therapeutic Class: Antiviral Monoclonal Antibodies
Last Reviewed by the DUR Board: January 22, 2015
Synagis® (palivizumab) injections are subject to prior authorization and quantity limitations based
on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
For consideration outside these guidelines, a prior authorization may also be submitted with
supporting medical necessity documentation.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Recipients younger than 12 months of age at the start of Respiratory Syncytial Virus
(RSV) season, must meet one of the following criteria:
1. The recipient was born at 28 weeks, six days of gestation or earlier; or
2. The recipient has a diagnosis of chronic lung disease (CLD) of prematurity;
or
3. The recipient has hemodynamically significant congenital heart disease; or
4. The recipient has congenital abnormalities of the airways or neuromuscular
disease; or
5. The recipient has a diagnosis of cystic fibrosis; and
a. The recipient has clinical evidence of CLD and/or nutritional
compromise.
b. Recipients younger than two years of age at the start of RSV season must meet one
of the following criteria:
1. The recipient has a diagnosis of CLD of prematurity; and
a. The recipient has required medical therapy (e.g., bronchodilator,
diuretics, oxygen, coritcosteroids) within six months to the start of
RSV season; or
2. The recipient has had a cardiac transplant; or
3. The recipient is severely immunocompromised (solid organ or
hematopoietic stem cell transplant, chemotherapy or other conditions)
during the RSV season; or
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4. The recipient has had a cardiopulmonary bypass and continues to require
prophylaxis after surgery or at the conclusion of extracorporeal membrane
oxygenation; or
5. The recipient has a diagnosis of cystic fibrosis; and
a. The recipient has had manifestations of severe lung disease
(previous hospitalization for pulmonary exacerbation in the first
year of life or abnormalities on chest radiography or chest computed
tomography that persists when stable) or weight for length less than
the tenth percentile.
2. Prior Authorization Guidelines
a. Prior authorization approval will be up to five doses per RSV season for recipients
meeting criteria.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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Z. Opioids, Opioid Containing Cough Preparations, Opioids Prescribed to Under Age 18
Therapeutic Class: Opioids, Last reviewed by the DUR Board: July 26, 2018
Opioid Containing Cough Preparations Last reviewed by the DUR Board: July 26, 2018
Opoids Prescribed to Under Age 18: Last Reviewed by the DUR Board: October 18, 2018
Opioids, Opioid Containing Cough Preparations and Opioids Prescribed to Under Age 18 are
subject to prior authorization and quantity limitations based on the Application of Standards in
Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada Medicaid and
Check Up Pharmacy Manual for specific quantity limits.
Opioids
1. Coverage and Limitations
a. Opioids will be covered without prior authorization:
1. For initial prescriptions of seven days or less; and
2. For a total of 13 seven-day prescriptions in any rolling 12 month period;
and
3. For prescriptions of 60 mg morphine equivalents or less per day.
b. Recipients currently on chronic opioid medications will not be subject to the seven-
day requirement for an opioid(s) they have been receiving in the past 45 days.
c. Prior Authorization Criteria: To exceed the number of seven-day prescriptions, or
to exceed the seven-day limit, or to exceed the 60 mg morphine equivalents or less
per day:
1. All of the following criteria must be met and documented:
a. The recipient has chronic pain or requires an extended opioid
therapy and is under the supervision of a licensed prescriber; and
b. Pain cannot be controlled through the use of non-opioid therapy
(acetaminophen, NSAIDs, antidepressants, anti-seizure
medications, physical therapy, etc.); and
c. The lowest effective dose is being requested; and
d. A pain contract is on file.
d. Exceptions to this policy:
1. Recipients with cancer/malignancy related pain; or
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2. Recipients who are post-surgery with an anticipated prolonged recovery
(greater than three months); or
3. Recipients receiving palliative care; or
4. Recipients residing in a long-term care facility; or
5. Recipients receiving treatment for HIV/AIDS; or
6. Prescriptions written by or in consultation with a pain specialist.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. CDC Guidance:
a. http://www.cdc.gov/drugoverdose/prescribing/guideline.html.
4. Opioid Containing Cough Preparations
a. The recipient must be 18 years of age or older.
b. Prior authorization approval will be for six months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. For references purposes, codeine and tramadol for children prior authorization
criteria can also be found within this chapter in Section TTT.
5. Opioids Prescribed to Under Age 18
a. Short Acting Opioids will be covered without PA for:
1. Initial prescription of three days or less; and
2. A total of 13 three-day prescriptions in any rolling 12-month period; and
3. Prescriptions of 60 morphine milligram equivalents (MME) or less per day.
b. Recipients currently on chronic opioid medications will not be subject to the three-
day requirement for an opioid(s) they have been receiving in the past 45 days.
c. To exceed the number of three-day prescriptions, or to exceed the three-day limit,
or to exceed the 60 MME or less per day:
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1. All of the following criteria must be met and documented:
a. The recipient has chronic pain or requires an extended opioid
therapy and is under the supervision of a licensed prescriber; and
b. Pain cannot be controlled through the use of non-opioid therapy
(acetaminophen, NSAIDs, antidepressants, anti-seizure
medications, physical therapy, chiropractic treatment, etc.); and
c. The lowest effective dose is being prescribed; and
d. A pain contract is on file.
d. Exceptions:
1. Recipients with cancer/malignancy related pain, recipients who are post-
surgery with an anticipated prolonged recovery (greater than three months),
recipients residing in a long-term care facility, recipients receiving
treatment for HIV/AIDS, hospice, palliative care or end-of-life care.
2. Prescriptions written by or in consultation with a pain specialist.
e. Prior Authorization Guidelines
1. Prior authorization approval will be for three months.
f. Prescribing Guidance:
1. CDC Guidance:
https://www.cdc.gov/drugoverdose/prescribing/guideline.html
2. HHS Opioids and Adolescents: https://www.hhs.gov/ash/oah/adolescent-
development/substance-use/drugs/opioids/index.html
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AA. Savella® (milnacipran)
Therapeutic Class: Fibromyalgia Agents: Serotonin-Norepinephrine Reuptake Inhibitor
Last Reviewed by DUR Board: July 23, 2020
Savella® (milnacipran) is subject to prior authorization.
1. Approval will be given if all of the following criteria are met and documented:
a. The recipient has a diagnosis of Fibromyalgia:
1. If an ICD code for Myalgia and Myositis unspecified is documented on the
prescription; or
2. Completion of a prior authorization documenting a diagnosis of
Fibromyalgia and/or Myalgia and Myositis, unspecified.
2. Prior Authorization Guidelines:
a. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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BB. Substance Abuse Agents
Therapeutic Class: Narcotic Withdrawal Therapy Agents
Last Reviewed by the DUR Board: July 23, 2020
Buprenorphine/Naloxone and Buprenorphine are subject to prior authorization and quantity
limitations based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Coverage and Limitations
a. Buprenorphine/Naloxone and Buprenorphine
1. Approval will be given if all of the following criteria are met and
documented:
a. Prior authorization approval will be required for all prescriptions
over 24 mg.
b. Requires diagnosis of opioid dependence.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
b. Lucemyra™ (lofexidine)
1. Approval will be given if all of the following criteria are met and
documented:
a. The recipient has a diagnosis of opioid withdrawal with symptoms
due to abrupt opioid discontinuation; and
b. The requested quantity must not exceed 2.88 mg/day for up to 14
days.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 14 days.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
c. Vivitrol® (naltrexone)
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1. Coverage and Limitations Approval will be given if the following criteria
are met and documented:
a. The drug is being used for an FDA approved indication; and
b. The drug must be delivered directly to the prescriber’s office; and
c. The drug is only to be administered once per month; and
d. Routine urine screening and monitoring is recommended.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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CC. Multiple Sclerosis (MS) Agents
Therapeutic Class: Agents for the treatment of Neuromuscular Transmission Disorder
Last Reviewed by the DUR Board: January 23, 2020
MS Agents are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Ampyria® (dalfampridine)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient must have a diagnosis of MS; and
2. The medication is being used to improve the recipient’s walking speed; and
3. The medication is being prescribed by or in consultation with a neurologist;
and
4. The recipient is ambulatory and has an EDSS score between 2.5 and 6.5;
and
5. The recipient does not have moderate to severe renal dysfunction (CrCL
less than 50 ml/min); and
6. The recipient does not have a history of seizures; and
7. The recipient is not currently pregnant or attempting to conceive.
b. Prior Authorization Guidelines
1. Initial prior authorization approval will be for three months.
2. Request for continuation of therapy will be approved for one year.
2. Relapsing Forms of MS Agents:
a. Approval will be given if all the following criteria are met and documented:
1. The recipient must have a diagnosis of a relapsing form of MS (e.g.,
relapsing-remitting MS, secondary-progressive MS with relapses).
b. Lemtrada® (alemtuzumab)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of a relapsing form of MS; and
one of the following:
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1. Both the following:
a. The recipient has not been previously treated with
alemtuzumab; and
b. The recipient has had failure after a trial of at least
four weeks; a contraindication, or intolerance to two
of the following disease-modifying therapies for MS:
1. Aubagio (teriflunomide)
2. Avonex (interferon beta-1a)
3. Betaseron (interferon beta-1b)
4. Copaxone/Glatopa (glatiramer acetate)
5. Extavia (interferon beta-1b)
6. Gilenya (fingolimod)
7. Mavenclad (cladrivine)
8. Mayzent (siponimod)
9. Ocrevus (ocrelizumab)
10. Plegridy (peginterferon beta-1a)
11. Rebif (interferon beta-1a)
12. Tecfidera (dimethyl fumarate)
13. Tysabri (natalizumab); or
14. Zinbryta (daclizumab)
c. Both the following:
a. The recipient has previously received
treatment with alemtuzumab; and
b. The recipient has had at least 12 months
elapsed or will have elapsed since the most
recent treatment course with
alemtuzumab; and
2. The medication will not be used in combination with another
disease-modifying therapy for MS.
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2. Prior Authorization Guidelines
a. Initial authorization approval will be for 12 months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Mavenclad® (cladribine)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of a relapsing form of MS (e.g.,
relapsing-remitting MS, secondary-progressive MS with relapses);
and one of the following:
1. Both the following:
a. The recipient has not been previously treated with
cladribine; and
b. The recipient has had failure after a trial of at least
four weeks; contraindication, or intolerance to two of
the following disease-modifying therapies for
MS:
1. Aubagio (teriflunomide)
2. Avonex (interferon beta-1a)
3. Betaseron (interferon beta-1b)
4. Copaxone/Glatopa (glatiramer acetate)
5. Extavia (interferon beta-1b)
6. Gilenya (fingolimod)
7. Lemtrada (alemtuzumab)
8. Mayzent (siponimod)
9. Ocrevus (ocrelizumab)
10. Plegridy (peginterferon beta-1a)
11. Rebif (interferon beta-1a)
12. Tecfidera (dimethyl fumarate)
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13. Tysabri (natalizumab); or
14. Zinbryta (daclizumab)
2. Both the following:
a. The recipient has previously received treatment with
cladribine; and
b. The recipient has not already received the FDA-
recommended lifetime limit of two treatment courses
(or four treatment cycles total) of cladribine; and
b. The medication will not be used in combination with another
disease-modifying therapy for MS.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one month.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. Ocrevus® (ocrelizumab)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient has a diagnosis of a relapsing form of MS (e.g.,
relapsing-remitting MS, secondary-progressive MS with relapses);
and
b. The medication must not be used in combination with another
disease-modifying therapy for MS; and
c. The medication must not be used in combination with another B-
cell targeted therapy (e.g., rituximab [Rituxan], belimumab
[Benlysta], ofatumumab [Arzerra]); and
d. The medication must not be used in combination with another
lymphocyte trafficking blocker (e.g., alemtuzumab [Lemtrada],
mitoxantrone).
2. Recertification Request (the recipient must meet all criteria):
a. Documentation of a positive clinical response to Ocrevus®
therapy; and
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b. The medication must not be used in combination with another
disease-modifying therapy for MS; and
c. The medication must not be used in combination with another B-
cell targeted therapy (e.g., rituximab [Rituxan], belimumab
[Benlysta], ofatumumab [Arzerra]); and
d. The medication must not be used in combination with another
lymphocyte trafficking blocker (e.g., alemtuzumab [Lemtrada],
mitoxantrone).
3. Prior Authorization Guidelines
a. Initial prior authorization approval will be 12 months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
e. Zeposia® (ozanimod)
1. Approval will be given if all the following criteria is met and documented:
a. The recipient has a documented diagnosis of a relapsing form of MS
(e.g., relapsing-remitting MS, secondary-progressive MS with
relapses); and
b. One of the following:
1. The agent is used for continuation of therapy; or
2. The recipient has had failure after a trial of at least 4 weeks,
contraindication, or intolerance to at least two of the
following disease-modifying therapies for MS:
a. Avonex (interferon beta-1a)
b. Betaseron (interferon beta-1b)
c. Copaxone/Glatopa (glatiramer acetate)
d. Tecfidera (dimethyl fumarate); and
c. The medication is prescribed by or in consultation with a
neurologist.
2. Recertification Criteria (the recipient must meet all criteria):
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a. The recipient has documentation of positive clinical response to
therapy (e.g., improvement in radiologic disease activity, clinical
relapses, disease progression); and
b. The medication is prescribed by or in consultation with a
neurologist.
3. Prior Authorization Guidelines:
a. Prior authorization approval will be for 12 months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Primary Progressive Forms of Multiple Sclerosis (PPMS) Agents:
a. Ocrevus® (ocrelizumab)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient must have a diagnosis of PPMS; and
b. The medication must not be used in combination with another
disease-modifying therapy for MS; and
c. The medication must not be used in combination with another B-
cell targeted therapy (e.g., rituximab [Rituxan], belimumab
[Benlysta], ofatumumab [Arzerra]); and
d. The medication must not be used in combination with another
lymphocyte trafficking blocker (e.g., alemtuzumab [Lemtrada],
mitoxantrone).
2. Recertification Request (the recipient must meet all criteria):
a. Documentation of a positive clinical response to Ocrevus® therapy;
and
b. The medication must not be used in combination with another
disease-modifying therapy for MS; and
c. The medication must not be used in combination with another B-
cell target therapy (e.g., rituximab [Rituxan], belimumab [Benlysta],
ofatumumab [Arzerra]); and
d. The medication must not be used with another lymphocyte
trafficking blocker (e.g., alemtuzumab [Lemtrada], mitoxantrone).
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3. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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DD. Hormones and Hormone Modifiers
Therapeutic Class: Androgenic Agents
Last Reviewed by the DUR Board: April 25, 2019
Topical Androgens
1. Coverage and Limitations
Recipients must meet all of the criteria for coverage:
2. Criteria for approval
a. Recipient is a male;
b. Use is for the FDA approved indication:
Primary (congenital or acquired) or secondary (congenital or acquired)
hypogonadism with an ICD code for hypogonadism;
c. The patient has two morning pre-treatment testosterone levels below the lower limit
of the normal testosterone reference range of the individual laboratory used;
d. The patient does not have breast or prostate cancer, a palpable prostate nodule or
induration, prostate-specific antigen greater than 4 ng/ml or severe lower urinary
symptoms with an International Prostate Symptom Score (IPSS) > 19;
e. The patient does not have a hematocrit > 50%;
f. The patient does not have untreated severe obstructive sleep apnea; and
g. The patient does not have uncontrolled or poorly controlled heart failure.
3. Prior Authorization Guidelines
a. Prior authorization approval will be for up to one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
Xyosted™ (testosterone enanthate)
1. Coverage and Limitations with Diagnosis of Hypogonadism
a. Diagnosis of hypogonadism (e.g. testicular hypofunction, male hypogonadism,
ICD-10 E29.1); and
b. The recipient is a male patient at birth; and
c. One of the following:
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1. Two pre-treatment serum total testosterone levels less than 300 ng/dL (<
10.4 nmol/L) or less than the reference range for the lab; or both of the
following:
a. Recipient has a condition that may cause altered sex hormone
binding globulin (SHBG) (e.g. thyroid disorder, HIV, liver disorder,
diabetes, obesity); and
b. One pre-treatment calculated free or bioavailable testosterone level
less than 5 ng/dL (< 0.17 nmol/L) or less than the reference range
for the lab; or
2. Recipient has a history of one of the following: bilateral orchiectomy,
panhypopituitarism or a genetic disorder known to cause hypogonadism
(e.g. congenital anorchia, Klinefelter’s syndrome).
2. Coverage and Limitation with Diagnosis of Gender Dysphoria
a. Diagnosis of gender dysphoria, as defined by the current version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM); and
b. The recipient is using the hormones to changes their physical characteristics; and
c. The recipient is a female-to-male transsexual.
3. Prior Authorization Guidelines
a. Length of prior authorization approval with diagnosis of hypogonadism will be for
one year.
b. Length of prior authorization approval with diagnsosis of gender dysphoria will be
for six months for recipients new to testosterone therapy or for 12 months for
recipients continuing testosterone therapy without a current authorization on file
with OptumRx.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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EE. Colchicine (Colcrys®)
Therapeutic Class: Antigout Agents
Last Reviewed by the DUR Board:January 28, 2016
Colchicine (Colcrys®) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Colchicine Tablets
1. The recipient has a diagnosis of acute gout (does not require prophylaxis)
and the recipient must meet all of the following:
a. The recipient is 16 years of age or older; and
d. The recipient has had an inadequate response, adverse reaction or
contraindication to an NSAID (indomethacin, naproxen, ibuprofen,
sulindac or ketoprofen); and
e. The recipient has had an inadequate response, adverse reaction or
contraindication to a corticosteroid (oral or intra-articular).
2. For prophylaxis of chronic gout:
a. The recipient is 16 years of age or older and must meet one of the
following:
1. There is documentation that the recipient will be treated with
colchicine in combination with allopurinol, Uloric®
(febuxostat) or probenecid; or
2. There is documentation that the recipient will be treated with
colchicine monotherapy and the recipient must meet all of
the following:
a. The recipient has had an inadequate response to
allopurinol at a dose of 600 mg/day for at least two
weeks or had an adverse reaction or contraindication
to allopurinol; and
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b. The recipient has had an inadequate response to
Uloric® (febuxostat) at a dose of 80 mg/day for at
least two weeks or has had an adverse reaction or
contraindication to Uloric® (febuxostat).
3. For Familial Mediterranean Fever (FMF):
a. The recipient is four years of age or older.
4. Requests exceeding the quantity limit may be approved for colchicine
tablets if all of the following are met and documented:
a. The recipient is 12 years of age or older; and
b. The recipient has a diagnosis of FMF; and
c. The recipient’s dose is ≤ 2.4 mg daily (120 tablets/30 days); and
d. Medical necessity must be provided and documented in the
recipient’s medical record that the recipient had an inadequate
response to 1.8 mg daily (90 tablets/30 days).
b. Colchicine Capsules
1. For Prophylaxis of chronic gout:
a. The recipient is 18 years of age or older and the recipient must meet
one of the following:
1. There is documentation that the recipient will be treated with
colchicine in combination with allopurinol, Uloric®
(febuxostat) or probenecid; or
2. There is documentation that the recipient will be treated with
colchicine monotherapy, and the recipient must meet all of
the following:
a. The recipient has had an inadequate response to
allopurinol at a dose of 600 mg/day for at least two
weeks or had an adverse reaction or contraindication
to allopurinol; and
b. The recipient has had an inadequate response to
Uloric® (febuxostat) at a dose of 80 mg/day for at
least two weeks or has had an adverse reaction or
contraindication to Uloric® (febuxostat).
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2. Prior Authorization Guidelines
a. Prior authorization approval will be given based on diagnosis.
1. For FMF and chronic gout: one year.
2. For acute gout: two months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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FF. Thrombin Inhibitors
Therapeutic Class: Thrombin Inhibitors
Last Reviewed by the DUR Board: January 22, 2015
Thrombin Inhibitors are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA Act and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. A diagnosis code associated with the FDA approved indication(s) is documented
on the prescription and transmitted on the claim; and
b. There are no contraindications to prescribing this medication; or
c. An approved Prior Authorization documenting the recipient meeting all of the
criteria above (1.) (a. and b.).
2. Prior Authorization Guidelines
a. Prior authorization approval will be for up to one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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GG. Antihemophilia Agents
Therapeutic Class: Antihemophilia Agents
Last Reviewed by the DUR Board: July 26, 2018
Antihemophilia Agents are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. The medication being prescribed must be for an FDA approved indication; or
b. One of the following:
1. The diagnosis is supported as a use of American Hospital Formulary Service
Drug Information (AHFS DI); or
2. The diagnosis is supported in the FDA Uses/Non-FDA Uses section in
DRUGDEX Evaluation with a Strength of Recommendation rating of IIb or
better (see DRUGDEX Strength of Recommendation table); or
3. Both of the following:
a. Diagnosis is listed in the FDA Uses/Non-FDA Uses section in
DRUGDEX Evaluation with a Strength of Recommendation rating
of III or Class Indeterminant (see DRUGDEX Strength of
Recommendation table); and
b. Efficacy is rated as “effective” or “evidence favors efficacy” (see
DRUGDEX Efficacy Rating and Prior Authorization Approval
Status table); or
4. Diagnosis is supported in any other section of DRUGDEX; or
5. The use is supported by clinical research in two articles from major peer
reviewed medical journals that present data supporting the proposed off-
label use or uses as generally safe and effective unless there is clear and
convincing contradictory evidence presented in a major peer-reviewed
medical journal; and
a. One of the following:
1. The dosage quantity/duration of the medication is
reasonably safe and effective based on information
contained in the FDA approved labeling, peer-reviewed
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medical literature or accepted standards of medical practice;
or
2. The dosage/quantity/duration of the medication is
reasonably safe and effective based on one of the following
compendia:
a. AHFS Compendium;
b. Thomson Reuters (Healthcare) Micromedex/
DRUGDEX (not Drug Points) Compendium;
c. Elsevier Gold Standard’s Clinical Pharmacology
Compendium;
d. National Comprehensive Cancer Network Drugs and
Biologics Compendium; and
c. The dispensing provider will monitor the amount of product a recipient has left to
avoid over-stock; and
d. The prescriber is a specialist in treating hemophilia; and
e. A new prior authorization will be required for any dose adjustment in excess of 5%
(increase or decrease).
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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HH. Anti-Hepatitis Agents
Therapeutic Class: Anti-Hepatitis Agents
Last Reviewed by the DUR Board: July 26, 2018
Anti-Hepatitis Agents are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA Act and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Daklinza® (daclatasvir) for genotype 1 or 3
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
1 or genotype 3 (submission of medical records e.g., chart notes, laboratory
values); and
2. The medication is used in combination with Sovaldi® (sofosbuvir); and
3. One of the following:
a. The recipient is without decompensated cirrhosis and is not a liver
transplant recipient; or
b. Both of the following:
1. The recipient has decompensated cirrhosis and/or is a liver
transplant recipient; and
2. The medication is used in combination with Ribavirin.
4. The recipient has not failed a prior HCV NS5A-containing regimen (e.g.,
Daklinza); and
5. The medication must be prescribed by or in consultation with one of the
following:
a. Hepatologist
b. Gastroenterologist
c. Infectious Disease Specialist
d. HIV Specialist (certified through the American Academy of HIV
Medicine)
6. Prior authorization approval will be for 12 weeks.
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b. Epclusa® (sofosbuvir and velpatasvir)
1. The following are required for all Epclusa® treatment:
a. The recipient is not receiving Epclusa® (sofosbuvir and velpatasvir)
in combination with another HCV direct acting antiviral agent (e.g.,
Sovaldi®, Olysio®); and
b. The medication must be prescribed by or in consultation with one of
the following:
1. Hepatologist
2. Gastroenterologist
3. Infectious Disease Specialist
4. HIV Specialist (certified through the American Academy of
HIV Medicine)
2. Genotype 1, 2, 3, 4, 5 or 6, without decompensated liver disease
a. The recipient has a documented diagnosis of chronic hepatitis C
virus genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g.,
chart notes, laboratory values); and
b. The recipient must not have decompensated liver disease; and
c. Epclusa® must be used alone; and
d. The request is FDA approved for recipient weight and age; and
e. Prior authorization approval will be for 12 weeks.
3. Genotype 1, 2, 3, 4, 5 or 6 with decompensated liver disease
a. The recipient has a documented diagnosis of chronic hepatitis C
virus genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g.,
chart notes, laboratory values); and
b. The recipient has decompensated liver disease; and
c. Epclusa® is being used in combination with Ribavirin; and
d. The request is FDA approved for recipient weight and age; and
e. Prior authorization approval will be for 24 weeks.
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4. Genotype 1, 2, 3, 4, 5 or 6 Ribavirin intolerance/ineligible or prior Sovaldi®
(sofosbuvir) or NS5A-based treatment failure.
a. The recipient has a documented diagnosis of chronic hepatitis C
virus genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g.,
chart notes, laboratory values); and
b. The recipient has decompensated liver disease; and
1. One of the following:
a. The recipient is Ribavirin intolerant or ineligible; or
b. Both of the following:
1. The recipient has had prior failure (defined as
viral relapse, breakthrough while on therapy,
or is a non-responder to therapy) to Sovaldi®
or NS5A-based treatment; and
2. Epclusa® is used in combination with
Ribavirin®.
c. Prior authorization approval will be for 24 weeks.
c. Harvoni® (ledipasvir/sofosbuvir)
1. The following are required for all Harvoni® treatment:
a. The recipient is not receiving Harvoni® in combination with another
HCV direct acting antiviral agent (e.g., Sovaldi®, Olysio®); and
b. The medication must be prescribed by or in consultation with one of
the following:
1. Hepatologist
2. Gastroenterologist
3. Infectious Disease Specialist
4. HIV Specialist (certified through the American Academy of
HIV Medicine)
2. Genotype 1, treatment naïve, without cirrhosis and pre-treatment HCV
RNA is less than six million IU/mL
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a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient does not have cirrhosis; and
c. The recipient is treatment naïve; and
d. Medical records documenting pre-treatment HCV RNA less than six
million IU/mL must be submitted; and
e. Prior authorization approval will be for eight weeks.
3. Genotype 1, treatment naïve, without cirrhosis and pre-treatment HCV
RNA is greater than or equal to six million IU/mL
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient does not have cirrhosis; and
c. The recipient is treatment naïve; and
d. Medical records documenting pre-treatment HCV RNA greater than
or equal to six million IU/mL must be submitted; and
e. Prior authorization approval will be for 12 weeks.
4. Genotype 1, treatment naïve with compensated cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has cirrhosis; and
c. The recipient is treatment naïve; and
d. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
e. Prior authorization approval will be for 12 weeks.
5. Genotype 1, treatment experienced without cirrhosis
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a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient does not have cirrhosis; and
c. One of the following:
1. The recipient has experienced treatment failure with a
previous treatment regimen that included peginterferon plus
Ribavirin or an HCV protease inhibitor (e.g., Incivek®
(telaprevir), Olysio® (simeprevir), Victrelis® (boceprevir))
plus peginterferon plus Ribavirin; or
2. Both of the following:
a. The recipient has experienced treatment failure with
a previous treatment regimen that included Sovaldi®
(sofosbuvir) except in combination with Olysio®
(simeprevir); and
b. The medication is used in combination with
Ribavirin.
d. Prior authorization approval will be for 12 weeks.
6. Genotype 1, Ribavirin eligible, treatment experienced and with
compensated cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has cirrhosis; and
c. The recipient has experienced treatment failure with a previous
treatment regimen that included peginterferon plus Ribavirin or an
HCV protease inhibitor (e.g., Incivek® (telaprevir), Olysio®
(simeprevir), Victrelis® (boceprevir)) plus peginterferon plus
Ribavirin; and
d. The medication is used in combination with Ribavirin; and
e. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
f. Prior authorization approval will be for 12 weeks.
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7. Genotype 1, Ribavirin ineligible, treatment experienced and with
compensated cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has cirrhosis; and
c. The recipient has experienced treatment failure with a previous
treatment regimen that included peginterferon plus Ribavirin or an
HCV protease inhibitor (e.g., Incivek® (telaprevir), Olysio®
(simeprevir), Victrelis® (boceprevir)) plus peginterferon plus
Ribavirin; and
d. The recipient is Ribavirin ineligible; and
e. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
f. Prior authorization approval will be for 24 weeks.
8. Genotype 1, 4, 5 or 6, decompensated cirrhosis or post-liver transplant
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1, 4, 5 or 6 (submission of medical records e.g., chart
notes, laboratory values); and
b. One of the following:
1. Submission of medical records (e.g., chart notes, laboratory
values) documenting that the recipient has decompensated
cirrhosis (e.g., Child-Pugh class B or C); or
2. Both of the following:
a. The recipient is a liver transplant recipient; and
b. The recipient is without decompensated liver disease
(e.g., Child-Pugh class B or C); and
c. The medication is used in combination with Ribavirin; and
d. Prior authorization approval will be for 12 weeks.
9. Genotype 1,4, 5, or 6, decompensated cirrhosis, Ribavirin ineligible or prior
failure of Sovaldi® or NS5A based regimen
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a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1, 4, 5 or 6 (submission of medical records e.g., chart
notes, laboratory values); and
b. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has decompensated cirrhosis (e.g.,
Child-Pugh class B or C); and
c. One of the following:
1. The recipient is Ribavirin ineligible; or
2. Both of the following:
f. The recipient has experienced treatment failure with
a previous treatment regimen that included Sovaldi®
(sofosbuvir) or an NS5A inhibitor (e.g., Daklinza®
(daclatasvir)); and
g. The medication is used in combination with
Ribavirin; and
d. Prior authorization approval will be for 24 weeks
10. Genotype 4, treatment naïve or treatment experienced (peginterferon plus
Ribavirin)
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 4 (submission of medical records e.g., chart notes,
laboratory values); and
b. One of the following:
1. The recipient is treatment naïve; or
2. One of the following:
a. The recipient has experienced failure with a previous
treatment regimen that included peginterferon plus
Ribavirin and is without cirrhosis; or
b. Both of the following:
1. The recipient has experienced failure with a
previous treatment regimen that included
peginterferon plus Ribavirin and has
compensated cirrhosis (Child-Pugh class A);
and
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2. The medication is used in combination with
Ribavirin; and
c. Prior authorization approval will be for 12 weeks.
11. Genotype 5 or 6, treatment naïve or treatment experienced (peginterferon
plus Ribavirin)
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 5 or 6 (submission of medical records e.g., chart notes,
laboratory values); and
b. One of the following:
1. The recipient is treatment naïve; or
2. The recipient has experienced failure with a previous
treatment regimen that included peginterferon plus
Ribavirin; and
c. Prior authorization approval will be for 12 weeks.
d. Mavyret® (glecaprevir/pibrentasvir)
1. The following are required for all Mavyret® treatment:
a. The recipient is not receiving Mavyret® in combination with
another HCV direct acting antiviral agent (e.g., Harvoni®
(ledipasvir/sofosbuvir), Zepatier® (elbasvir/grazoprevir)); and
b. The medication must be prescribed by or in consultation with one of
the following:
1. Hepatologist
2. Gastroenterologist
3. Infectious Disease Specialist
4. HIV Specialist (certified through the American Academy of
HIV Medicine)
2. Genotype 1, 2, 3, 4, 5 or 6, treatment naïve without cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart
notes, laboratory values); and
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b. The recipient is treatment naïve; and
c. The recipient is without cirrhosis; and
d. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
e. Prior authorization approval will be for eight weeks.
3. Genotype 1, 2, 3, 4, 5 or 6, treatment naïve with compensated cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart
notes, laboratory values); and
b. The recipient is treatment naïve; and
c. The recipient has compensated cirrhosis (Child-Pugh class A); and
d. Prior authorization approval will be for 12 weeks.
4. Genotype 1, treatment experienced (prior failure to an NS3/4A protease
inhibitor), without decompensated cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient has experienced failure with a previous treatment
regimen that included an HCV NS3/4A protease inhibitor (e.g.,
Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)); and
c. The recipient has had no previous treatment experience with a
treatment regimen that included an NS5A inhibitor (e.g., Daklinza®
(daclatasvir)); and
d. The recipient is without decompensated cirrhosis (Child-Pugh class
B or C); and
e. Prior authorization approval will be for 12 weeks.
5. Genotype 1, treatment experienced (prior failure to an NS5A inhibitor),
without decompensated cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
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b. The recipient has experienced failure with a previous treatment
regimen that included an NS5A inhibitor (e.g., Daklinza®
(daclatasvir)); and
c. The recipient has had no previous treatment experience with a
treatment regimen that included an HCV NS3/4A protease inhibitor
(e.g., Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)); and
d. The recipient is without decompensated cirrhosis (Child-Pugh class
B or C); and
e. Prior authorization approval will be for 16 weeks.
6. Genotype 3, treatment experienced (interferon or Sovaldi® based regimen),
without decompensated cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 3 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient has experienced failure with a previous treatment
regimen that included interferon, peginterferon, Ribavirin, and/or
Sovaldi® (sofosbuvir); and
c. The recipient has had no previous treatment experience with a
treatment regimen that included an HCV NS3/4A protease inhibitor
(e.g., Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) or an NS5A inhibitor (e.g., Daklinza® (daclatasvir));
and
d. The recipient is without decompensated cirrhosis (Child-Pugh class
B or C); and
e. Prior authorization approval will be for 16 weeks.
7. Genotype 1, 2, 4, 5 or 6, treatment experienced (interferon or Sovaldi®
based regimen), without cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1, 2, 4, 5 or 6 (submission of medical records e.g., chart
notes, laboratory values); and
b. The recipient has experienced failure with a previous treatment
regimen that included interferon, peginterferon, Ribavirin, and/or
Sovaldi® (sofosbuvir); and
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c. The recipient has had no previous treatment experience with a
treatment regimen that included an HCV NS3/4A protease inhibitor
(e.g., Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) or an NS5A inhibitor (e.g., Daklinza® (daclatasvir));
and
d. The recipient is without cirrhosis; and
e. Prior authorization approval will be for eight weeks.
8. Genotype 1, 2, 4, 5 or 6, treatment experienced (interferon or Sovaldi®
based regimen), with compensated cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1, 2, 4, 5 or 6 (submission of medical records e.g., chart
notes, laboratory values); and
b. The recipient has experienced failure with a previous treatment
regimen that included interferon, peginterferon, Ribavirin, and/or
Sovaldi® (sofosbuvir); and
c. The recipient has had no previous treatment experience with a
treatment regimen that included an HCV NS3/4A protease inhibitor
(e.g., Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) or an NS5A inhibitor (e.g., Daklinza® (daclatasvir));
and
d. The recipient has compensated cirrhosis (e.g., Child-Pugh class A);
and
e. Prior authorization approval will be for 12 weeks.
e. Olysio® (simeprevir)
1. Submission of medical records (e.g., chart notes, laboratory values)
documenting one of the following:
a. Both of the following:
1. Diagnosis of chronic hepatitis C genotype 1a; and
2. The recipient does not have the NS3 Q8K polymorphism; or
b. The recipient has a diagnosis of chronic hepatitis C genotype 1b; or
c. The recipient has a diagnosis of chronic hepatitis C genotype 4; and
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2. The recipient has not experienced failure with a previous treatment regimen
that includes Olysio® or other HCV NS3/4A protease inhibitors (e.g.,
Incivek® (telaprevir), Victrelis® (boceprevir)); and
3. The recipient is without decompensated liver disease (e.g., Child-Pugh class
B or C); and
4. The medication is used in combination with peginterferon alfa and
Ribavirin; and
5. The medication must be prescribed by or in consultation with one of the
following:
a. Hepatologist
b. Gastroenterologist
c. Infectious Disease Specialist
d. HIV Specialist (certified through the American Academy of HIV
Medicine)
6. Genotype 1 without cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient is without cirrhosis; and
c. The medication is used in combination with Sovaldi® (sofosbuvir);
and
d. Prior authorization approval will be for 12 weeks.
7. Genotype 1 with cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. Submission of medical records (e.g., chart notes, laboratory values
documenting that the recipient has cirrhosis; and
c. The medication is used in combination with Sovaldi® (sofosbuvir);
and
d. Prior authorization approval will be for 24 weeks.
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f. Sovaldi® (sofosbuvir)
1. The following is required for all Sovaldi® treatment:
a. The medication must be prescribed by or in consultation with one of
the following:
1. Hepatologist
2. Gastroenterologist
3. Infectious Disease Specialist
4. HIV Specialist (certified through the American Academy of
HIV Medicine)
2. Genotype 1 or 4, without decompensated liver disease
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 or 4 (submission of medical records e.g., chart notes,
laboratory values); and
b. The medication is used in combination with peginterferon alfa and
Ribavirin; and
c. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
d. The recipient has not experienced failure with a previous treatment
regimen that includes Sovaldi®; and
e. Prior authorization approval will be for 12 weeks.
3. Genotype 3, without decompensated liver disease
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 3 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient must be 18 years of age or older; or
c. Both of the following:
1. The recipient has a documented diagnosis of chronic
hepatitis C virus (HCV) genotype 3 (submission of medical
records e.g., chart notes, laboratory values); and
2. The recipient is 12 to 17 years of age; or both of the
following:
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a. The recipient weighs at least 35 kg; and
b. The recipient is less than 12 years of age; and
d. The medication is used in combination with Ribavirin; and
e. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
f. The recipient has not experienced failure with a previous treatment
regimen that includes Sovaldi®; and
g. Prior authorization approval will be for 24 weeks.
4. Genotype 2, without decompensated liver disease
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 2 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient must be 18 years of age or older; or
c. Both of the following:
1. The recipient has a documented diagnosis of chronic
hepatitis C genotype 2 (submission of medical records e.g.,
chart notes, laboratory values); and
2. The recipient is 12 to 17 years of age; or both of the
following:
a. The recipient weighs at least 35 kg; and
b. The recipient is less than 12 years of age; and
d. The medication is used in combination with Ribavirin; and
e. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
f. The recipient has not experienced failure with a previous treatment
regimen that includes Sovaldi®; and
g. Prior authorization approval will be for 12 weeks.
5. Genotype 1, without cirrhosis
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a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. The medication is used in combination with Olysio® (simeprevir);
and
c. The recipient is without cirrhosis; and
d. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
e. The recipient has not experienced failure with a previous treatment
regimen that includes Olysio® or other HCV NS3/4A protease
inhibitors (e.g., Incivek® (telaprevir), Victrelis® (boceprevir)); and
f. Prior authorization approval will be for 12 weeks.
6. Genotype 1, with cirrhosis
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. The medication is used in combination with Olysio® (simeprevir);
and
c. The recipient has cirrhosis; and
d. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
e. The recipient has not experienced failure with a previous treatment
regimen that includes Olysio® or other HCV NS3/4A protease
inhibitors (e.g., Incivek® (telaprevir), Victrelis® (boceprevir)); and
f. Prior authorization approval will be for 12 weeks.
7. Genotype 1
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. The medication is used in combination with Daklinza®
(daclatasvir); and
c. The recipient has not experienced failure with a previous HCV
NS5A treatment regimen (e.g., Daklinza® (daclatasvir)); and
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d. One of the following:
1. The recipient is without decompensated cirrhosis and is not
a liver transplant recipient; or
2. Both of the following:
a. The recipient has decompensated cirrhosis and/or is
a liver transplant recipient; and
b. The medication is used in combination with
Ribavirin.
e. Prior authorization approval will be for 12 weeks.
8. Genotype 3
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 3 (submission of medical records e.g., chart notes,
laboratory values); and
b. The medication is used in combination with Daklinza®
(daclatasvir); and
c. The recipient has not experienced failure with a previous HCV
NS5A treatment regimen (e.g., Daklinza® (daclatasvir)); and
d. One of the following:
1. The recipient is without cirrhosis and is not a liver transplant
recipient; or
2. Both of the following:
a. The recipient has cirrhosis (compensated or
decompensated) and/or is a liver transplant recipient;
and
b. The medication is used in combination with
Ribavirin.
e. Prior authorization approval will be for 12 weeks.
g. Technivie® (ombitasvir, paritaprevir and ritonavir) for genotype 4
1. The recipient has a documented diagnosis of chronic hepatitis C genotype
4 (submission of medical records e.g., chart notes, laboratory values); and
2. One of the following:
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a. The recipient is without cirrhosis; or
b. The recipient has compensated cirrhosis; and
3. The medication is used in combination with Ribavirin; and
4. The recipient is not receiving Technivie® in combination with another
HCV direct acting agent (e.g., Harvoni® (ledipasvir), Sovaldi®
(sofosbuvir), Olysio® (simeprevir)); and
5. The recipient does not have moderate to severe hepatic impairment (e.g.,
Child-Pugh class B or C); and
6. The medication must be prescribed by or in consultation with one of the
following:
a. Hepatologist
b. Gastroenterologist
c. Infectious Disease Specialist
d. HIV Specialist (certified through the American Academy of HIV
Medicine)
7. Prior authorization approval will be for 12 weeks.
h. Viekira Pak®, Viekira XR® (ombitasvir, paritaprevir, ritonavir tablets, dasabuvir
tablets)
1. The following is required for all Viekira Pak®, Viekira XR® treatment:
a. The recipient has not experienced failure with a previous treatment
regimen that includes HCV NS3/4A protease inhibitor (e.g.,
Incivek® (telaprevir), Olysio® (simeprevir), Victrelis®
(boceprevir)) or an NS5A inhibitor (Daklinza® (daclatasvir)); and
b. The recipient is not receiving Viekira® in combination with another
HCV direct acting antiviral agent (e.g., Harvoni® (ledipasvir),
Sovaldi® (sofosbuvir), Olysio® (simeprevir)); and
c. The medication must be prescribed by or in consultation with one of
the following:
1. Hepatologist
2. Gastroenterologist
3. Infectious Disease Specialist
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4. HIV Specialist (certified through the American Academy of
HIV Medicine)
2. Genotype 1a or mixed genotype 1, without cirrhosis and without liver
transplant
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1a or mixed genotype 1 (submission of medical records
e.g., chart notes, laboratory values); and
b. The recipient is without cirrhosis; and
c. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
d. The medication is used in combination with Ribavirin; and
e. Prior authorization approval will be for 12 weeks.
3. Genotype 1a or mixed genotype 1, with cirrhosis and without liver
transplant
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1a or mixed genotype 1 (submission of medical records
e.g., chart notes, laboratory values); and
b. Submission of medical records (e.g., chart notes, laboratory values)
documenting that the recipient has cirrhosis; and
c. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
d. The medication is used in combination with Ribavirin; and
e. Prior authorization approval will be for 24 weeks.
4. Genotype 1b, without liver transplant
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1b (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
c. Prior authorization approval will be for 24 weeks.
5. Genotype 1 (regardless of sub genotype), with liver transplant
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a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1 (submission of medical records e.g., chart notes,
laboratory values); and
b. Submission of documentation that the recipient is a liver transplant
recipient; and
c. Submission of medical records (e.g., chart notes or laboratory
values) documenting normal hepatic function and mild fibrosis (e.g.,
METAVIR fibrosis score less than or equal to F2); and
d. The medication is used in combination with Ribavirin; and
e. Prior authorization approval will be for 24 weeks.
i. Vosevi® (sofosbuvir/velpatasvir/voxilaprevir)
1. The following is required for all Vosevi® treatment:
a. The recipient is without decompensated liver disease (e.g., Child-
Pugh class B or C); and
b. The recipient is not receiving Vosevi® in combination with another
HCV direct acting antiviral agent (e.g., Harvoni® (ledipasvir),
Zepatier® (elbasvir/grazoprevir)); and
c. The medication must be prescribed by or in consultation with one of
the following:
1. Hepatologist
2. Gastroenterologist
3. Infectious Disease Specialist
4. HIV Specialist (certified through the American Academy of
HIV Medicine)
2. Genotype 1, 2, 3, 4, 5 or 6; without decompensated cirrhosis, prior relapse
to NS5A based regimen
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1, 2, 3, 4, 5 or 6 (submission of medical records e.g., chart
notes, laboratory values); and
b. The recipient is a previous relapser to an NS5A based regimen (e.g.,
Daklinza® (daclatasvir), Epclusa® (ledipasvir/sofosbuvir),
Mavyret® (glecaprevir/pibrentasvir), Technivie® (ombitasvir/
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paritaprevir/ ritonavir), Viekira® (ombitasvir/ paritaprevir/
ritonavir/dasabuvir), Zepatier® (elbasvir/grazoprevir); and
c. Submission of medical records (e.g., chart notes or laboratory
values) documenting normal hepatic function and mild fibrosis (e.g.,
METAVIR fibrosis score less than or equal to F2); and
d. Prior authorization approval will be for 12 weeks.
3. Genotype 1a, without decompensated cirrhosis, prior relapse to sofosbuvir
based regimen without an NS5A inhibitor
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1a (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient is a previous relapser to a sofosbuvir based regimen
without an NS5A inhibitor; and
c. Prior authorization approval will be for 12 weeks.
4. Genotype 3, without decompensated cirrhosis, prior relapse to sofosbuvir
based regimen without an NS5A inhibitor
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 3 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient is a previous relapser to a sofosbuvir based regimen
without an NS5A inhibitor; and
c. Prior authorization approval will be for 12 weeks.
j. Zepatier® (elbasvir/grazoprevir)
1. The following is required for all Zepatier® treatment:
a. The recipient does not have moderate to severe hepatic impairment
(e.g., Child-Pugh class B or C); and
b. The recipient is not receiving Zepatier® in combination with
another HCV direct acting antiviral agent (e.g., Sovaldi®
(sofosbuvir), Olysio® (simeprevir)); and
c. The medication must be prescribed by or in consultation with one of
the following:
1. Hepatologist
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2. Gastroenterologist
3. Infectious Disease Specialist
4. HIV Specialist (certified through the American Academy of
HIV Medicine)
2. Genotype 1a, treatment naïve, or PegIFN/RBV experienced or
PegIFN/RBV/protease inhibitor experienced, without NS5A
polymorphisms
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1a (submission of medical records e.g., chart notes,
laboratory values); and
b. One of the following:
1. The recipient is treatment naïve; or
2. The recipient has had prior failure to peginterferon alfa plus
Ribavirin treatment; or
3. The recipient has had prior failure to treatment with
peginterferon alfa plus Ribavirin plus an HCV NS3/4A
protease inhibitor (e.g., boceprevir, simeprevir or
telaprevir); and
c. Both of the following:
1. The recipient has been tested for the presence of NS5A
resistance associated polymorphisms; and
2. The recipient has baseline NS5A resistance associated
polymorphisms (e.g., polymorphisms at amino acid
positions 28, 30, 31, or 93); and
d. The medication is used in combination with Ribavirin; and
e. Prior authorization approval will be for 16 weeks.
3. Genotype 1b, treatment naïve, or PegIFN/RBV experienced or
PegIFN/RBV/protease inhibitor experienced
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 1b (submission of medical records e.g., chart notes,
laboratory values); and
b. One of the following:
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1. The recipient is treatment naïve; or
2. The recipient has had prior failure to peginterferon alfa plus
Ribavirin treatment; or
3. Both of the following:
a. The recipient has had prior failure to treatment with
peginterferon alfa plus Ribavirin plus an HCV
NS3/4A protease inhibitor (e.g., boceprevir,
simeprevir or telaprevir); and
b. The medication is used in combination with
Ribavirin; and
c. Prior authorization approval will be for 12 weeks.
4. Genotype 4, treatment naïve
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 4 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient is treatment naïve; and
c. Prior authorization approval will be for 12 weeks.
5. Genotype 4, PegIFN/RBV experienced
a. The recipient has a documented diagnosis of chronic hepatitis C
genotype 4 (submission of medical records e.g., chart notes,
laboratory values); and
b. The recipient has had prior failure to peginterferon alfa plus
Ribavirin; and
c. The medication is used in combination with Ribavirin; and
d. Prior authorization approval will be for 16 weeks.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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II. Daliresp® (roflumilast)
Therapeutic Class: Phosphodiesterase-4 Inhibitors.
Last Reviewed by the DUR Board: October 17, 2019
Daliresp® (roflumilast) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. The recipient has experienced an inadequate response, adverse event or has a
contraindication to a long-acting anticholinergic agent;
b. The recipient has experienced an inadequate response, adverse event or has a
contraindication to a long-acting beta () agonist;
c. The recipient has experienced an inadequate response, adverse event or has a
contraindication to an inhaled corticosteroid;
d. The recipient has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD);
and
e. The recipient has a history of COPD exacerbations.
2. Contraindication
a. Daliresp (roflumilast) may not be approved for a recipient with a diagnosis of
moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment.
3. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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JJ. Hereditary Angioedema Agents
Therapeutic Class: Hereditary Angioedema Agents
Last Reviewed By DUR Board: July 25, 2013
Hereditary angioedema agents are subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Cinryze® (C1 esterase inhibitor)
The recipient must meet all of the following:
1. The recipient has a diagnosis of hereditary angioedema; and
2. The medication is being prescribed by or in consultation with an allergist or
immunologist; and
3. The medication is being used as prophylaxis for hereditary angioedema
attacks; and
4. The recipient has experienced an inadequate response or adverse event with
an attenuated androgen (e.g. danazol, stanozolol) or antifibrinolytic (e.g.
tranexamic acid, aminocaproic acid) agent or has a contraindication to all
agents in these classes; and
5. The recipient routinely experiences more than one hereditary angioedema
attack per month, or the recipient has a history of laryngeal attacks.
b. Berinert® (C1 esterase inhibitor), Kalbitor® (ecallantide) and Firazyr® (icatibant)
The recipient must meet all of the following:
1. The recipient has a diagnosis of hereditary angioedema; and
2. The medication is being prescribed by or in consultation with an allergist or
immunologist; and
3. The medication is being used to treat acute hereditary angioedema attacks.
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2. Prior Authorization Guidelines
a. Initial prior authorization approval will be for six months.
b. Prior authorization requests for continuation therapy will be approved for one year.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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KK. Incretin Mimetics
Therapeutic Class: Incretin Mimetics
Last Reviewed by the DUR Board: January 26, 2017
Previously reviewed by the DUR Board: July 26, 2012
Incretin Mimetics are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. An ICD code for Type 2 Diabetes Mellitus is documented on the prescription and
transmitted on the claim; or
b. A prior authorization documenting a diagnosis of Type 2 Diabetes Mellitus has
been submitted.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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LL. Cystic Fibrosis Agents
Therapeutic Class: Cystic Fibrosis Agents
Last Reviewed by the DUR Board: April 30, 2020
Cystic Fibrosis (CF) Agents are subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Approval will be given for a single agent concomitantly if the following criteria are met
and documented:
A. Kalydeco® (ivacaftor)
1. Approval will be given if the following criteria are met and documented:
a. The recipient is six months of age or older; and
b. The recipient has a diagnosis of CF; and
c. There is documentation that the recipient has had an FDA-approved
cystic fibrosis mutation test confirming the presence of one of the
gene mutations listed in the FDA-approved package insert; and
d. The medication is prescribed by or in consultation with a
pulmonologist or a specialist affiliated with a CF care center.
2. Recertification Request (the recipient must meet all the following criteria)
1. Documentation of a positive clinical response to Kalydeco®
therapy.
3. Prior Authorization Guidelines
a. Initial request will be approved for 12 months.
b. Recertification request will be for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
B. Orkambi® (lumacaftor/ivacaftor)
1. Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of cystic fibrosis; and
b. The recipient is two years of age or older; and
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c. The recipient is homozygous for the F508del mutation in the cystic
fibrosis transmembrane conductance regulator (CFTR) gene; and
d. The requested dose is two tablets every 12 hours; or
e. The requested dose is one tablet every 12 hours in the presence of
severe hepatic impairment.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for one year.
b. Prior Authorizaition forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
C. Symdeko® (tezacaftor/ivacaftor)
1. Approval will be given if the following criteria are met and documented:
a. Initial Request:
1. The recipient is six years of age or older; and
2. The recipient has a documented diagnosis of CF; and
3. The medication must be prescribed by or in consultation
either a Pulmonolist or a specialist associated with a CF care
center.
4. One of the following:
a. The recipient is homozygous for the F508del
mutation as detected by an FDA cleared CF mutation
test or Clinical Laboratory Improvement
Amendments (CLIA) approved facility; or
b. The recipient has one of the FDA approved package
insert listed mutations on at least one allele in the
(CFTR) gene as detected by FDA cleared CF
mutation test or CLIA approved facility.
b. Recertification Request (the recipient must meet the following
criteria):
1. Documentation of a positive clinical response to Symdeko®
(tezacaftor/ivacaftor) therapy (e.g., improvement in lung
function or decreased number of pulmonary exacerbations).
2. Prior Authorization Guidelines
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a. Initial request will be approved for 12 months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
D. Trikafta® (elexacaftor/tezacaftor/ivacaftor and ivacaftor)
1. Approval will be given if the following criteria are met and documented:
a. The recipient is 12 years of age and older; and
b. The recipient has a documented diagnosis of CF; and
c. The recipient has at least one F508del mutation in the CFTR gene
as detected by an FDA cleared CF mutation test, or a test performed
at a CLIA approved facility; and
d. The medication is prescribed by or in consultation with either a
Pulmanologist or a specialist affiliated with a CF care center.
2. Recertification Request
a. The recipient must have documentation of a positive clinical
response to Trikafta® therapy (e.g. improvement in lung function
[percent predicted forced expiratory volume in one second
{PPFEV1}] or decreased number of pulmonary exacerbations)
3. Prior Authorization Guidelines
a. Initial request will be approved for 12 months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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MM. RESERVED FOR FUTURE USE
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NN. Platelet Inhibitors
Therapeutic Class: Platelet Inhibitors
Last Reviewed by the DUR Board: January 23, 2014
Brilinta® (ticagrelor) and Effient® (prasugrel) are subject to prior authorization and quantity
limitations based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Coverage and Limitations
Authorization will be given if the following criteria are met and documented:
a. Brilinta® (ticagrelor)
1. The recipient has a diagnosis of Acute Coronary Syndrome (ACS) (unstable
angina, non-ST elevation myocardial infarction or ST elevation myocardial
infarction); and
2. The recipient does not have an active pathological bleed or history of
intracranial hemorrhage; and
3. The recipient will be receiving concomitant treatment with aspirin in a dose
of <100 mg/daily; and
4. The recipient has been started and stabilized on the requested medication;
or
5. The recipient has experienced an adverse event with or has an allergy or
contraindication to clopidogrel; or
6. Another clinically appropriate rationale is provided for why clopidogrel
cannot be used.
b. Effient® (prasugrel)
1. The recipient has a diagnosis of ACS (unstable angina, non-ST elevation
myocardial infarction or ST elevation myocardial infarction); and
2. The recipient does not have an active pathological bleed or history of
transient ischemic attack or cerebral vascular accident (CVA); and
3. The recipient will be receiving concominant treatment with aspirin in a dose
of <100 mg/daily; and
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4. The recipient has a history of percutaneous coronary intervention; and
5. The recipient has been started and stabilized on the requested medication;
or
6. The recipient has experienced an adverse event with or has an allergy or
contraindication to clopidogrel; or
7. Another clinically appropriate rationale is provided for why clopidogrel
cannot be used.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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OO. Osteoporosis Agents
Therapeutic Class: Bone Resorption Inhibitors (Osteoporosis Agents)
Last Reviewed by DUR Board: October 22, 2020
Osteoporosis agents are subject to prior authorization based on the Application of Standards in
Section 1927 of the SSA and/or approved by the DUR Board.
1. Coverage and Limitations
a. Evenity® (romosozumab-aqqg)
1. Approval will be given if all criteria are met and documented:
a. The recipient has a diagnosis of postmenopausal osteoporosis or
osteopenia; and
b. One of the following:
1. Both the following:
a. The recipient’s Bone Mineral Density (BMD) T-
score is -2.5 or lower in the lumbar spine, femoral
neck, total hip, or radius (one-third radius site); and
b. One of the following:
1. The recipient has documented history of low-
trauma fracture of the hip, spine, proximal
humerus, pelvis, or distal forearm; or
2. The recipient has documented trial and
failure, contraindication, or intolerance to
one anti-resorptive treatment (e.g.,
alendronate, risedronate, zoledronic acid,
Prolia [denosumab]); or
c. Both the following:
1. The recipient has a BMD T-score between -
1.0 and -2.5 in the lumbar spine, femoral
neck, total hip, or radius (one-third radius
site); and
2. One of the following:
a. The recipient has a documented
history of low-trauma fracture of the
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hip, spine, proximal humerus, pelvis,
or distal forearm; or
b. Both the following:
1. The recipient has a
documented trial and failure,
contraindication, or
intolerance to one anti-
resorptive treatment (e.g.,
alendronate, risedronate,
zoledronic acid, Prolia
[denosumab]); and
2. One of the following FRAX
(Fracture Risk Assessment
Tool) 10-year probabilities:
a. The recipient has a
major osteoporotic
fracture at 20% or
more in the U.S., or
the country-specific
threshold in other
countries or regions.
b. The recipient has a hip
fracture at 3% or more
in the U.S., or the
country-specific
threshold in other
countries or regions;
and
c. The recipient has a documented trial and failure, contraindication,
or intolerance to one of the following:
a. Forteo® (teriparatide)
b. Tymlos® (abaoparatide); and
d. Treatment duration of Evenity® (romosozumab-aqqg) has not
exceeded a total of 12 months during the recipient’s lifetime.
2. Prior Authorization Guidelines:
a. Prior authorization approval will be given for 12 months.
b. Prior Authorization forms are available at:
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http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
b. Prolia® (denosumab)
1. For bone loss in men receiving androgen deprivation therapy for
nonmetastatic prostate cancer.
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of nonmetastatic prostate
cancer; and
2. The recipient is undergoing androgen deprivation therapy
with one of the following:
a. Luteinizing hormone-releasing hormone
(LHRH)/gonadotropin releasing hormone (GnRH)
agonist [e.g., Eligard/Lupron (leuprolide), Trelstar
(triptorelin), Vantas (histrelin), and Zoladex
(goserelin)]; or
b. Bilateral orchiectomy (i.e., surgical castration); and
3. One of the following:
a. The recipient is 70 years of age or older; or
b. Both the following:
1. The recipient is less than 70 years of age; and
a. One of the following:
1. BMD scan T-score is less than
-1.0 (1.0 standard deviation or
greater below the mean for
young adults); or
2. Documented history of one of
the following resulting from
minimal trauma:
a. Vertebral
compression fracture
b. Fracture of the hip
c. Fracture of the distal
radius
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d. Fracture of the pelvis
e. Fracture of the
proximal numerous;
and
b. Recertification Request (the recipient must meet all criteria):
1. The recipient is undergoing androgen depravation therapy
with one of the following:
a. Luteinizing hormone-releasing hormone
(LHRH)/gonadotropin releasing hormone (GnRH)
agonist [e.g., Eligard/Lupron (leuprolide), Trelstar
(triptorelin), Vantas (histrelin), and Zoladex
(goserelin)]; or
b. Bilateral orchiectomy (i.e., surgical castration); and
2. The recipient has no evidence of metastases; and
3. Documentation that the recipient is benefiting from therapy
(e.g., improved or stabilized BMD, no new fractures,
improved biochemical markers, etc.)
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. Bone loss in women receiving adjuvant aromatase inhibitor therapy for
breast cancer.
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of breast cancer; and
2. The recipient is receiving adjuvant aromatase inhibitor
therapy (e.g., Arimidex [anastrozole], Aromasin
[exemestane], Femara [letrozole]); and
3. One of the following:
a. The recipient’s BMD scan T-score is less than -1.0
(1.0 standard deviation or greater below the mean for
young adults); or
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b. Documented history of one of the following resulting
from minimal trauma:
1. Vertebral compression fracture
2. Fracture of the hip
3. Fracture of the distal radius
4. Fracture of the pelvis
5. Fracture of the proximal humerous; and
4. The recipient has a documented trial and failure, intolerance,
or contraindication to one bisphosphonate (e.g. alendronate)
b. Recertification Request (recipient must meet all criteria):
1. The recipient is receiving adjuvant aromatase inhibitor
therapy (e.g., Arimidex [anastrozole], Aromasin
[exemestane], Femara [letrozole]); and
2. Documentation that the recipient is benefiting from therapy
(e.g., improved or stabilized BMD, no new fractures,
improved biochemical markers, etc.)
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. For Postmenopausal Osteoporosis or Osteopenia
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of postmenopausal
osteoporosis or osteopenia; and
2. One of the following:
a. The recipient has a BMD scan indicative of
osteoporosis: T-score less than or equal to -2.5 in the
lumbar spine, femoral neck, total hip, or radius (one-
third radius site); or
b. Both the following:
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1. The recipient has a BMD scan indicative of
osteopenia: T-score between -1.0 and -2.5
(BMD T-score greater than -2.5 and less than
or equal to -1.0) in the lumbar spine, femoral
neck, total hip, or radius (one-third radius
site); and
2. One of the following FRAX 10-year
probabilities:
a. Major osteoporotic fracture at 20% or
more in the U.S., or the country-
specific threshold in other countries
or regions; or
b. Hip fracture at 3% or more in the
U.S., or the country-specific
threshold in other countries or
regions; or
c. The recipient has a documented history of one of the
following resulting from minimal trauma:
1. Vertebral compression fracture
2. Fracture of the hip
3. Fracture of the distal radius
4. Fracture of the pelvis
5. Fracture of the proximal humerous; and
3. The recipient has a documented trial and failure, intolerance,
or contraindication to one bisphosphonate (e.g.,
alendronate).
b. Recertification Request:
1. Documentation that indicates the recipient is benefiting from
therapy (e.g., improved or stabilized BMD, no new fractures,
improved biochemical markers, etc.) without significant
adverse effects.
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for 24 months.
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2. Recertification approval will be for 24 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Glucocorticoid-Induced Osteoporosis
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of glucocorticoid-induced
osteoporosis; and
2. The recipient is initiating or continuing greater than or equal
to 7.5 mg/day of prednisone (or its equivalent) and is
expected to remain on glucocorticoid therapy for at least 6
months; and
3. One of the following:
a. The recipient has a BMD T-score less than or equal
to -2.5 based on BMD measurements from lumbar
spine, femoral neck, total hip, or radius (one-third
radius site); or
b. One of the following FRAX 10-year probabilities:
1. Major osteoporotic fracture at 20% or more
in the U.S., or the country-specific threshold
in other countries or regions; or
2. Hip fracture at 3% or more in the U.S., or the
country-specific threshold in other countries
or regions; or
c. The recipient has a documented history of one of the
following fractures resulting from minimal trauma:
1. Vertebral compression fracture
2. Fracture of the hip
3. Fracture of the distal radius
4. Fracture of the pelvis
5. Fracture of the proximal humerous; and
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4. The recipient has a documented trial and failure, intolerance,
or contraindication to one bisphosphonate (e.g.,
alendronate).
b. Recertification Request:
1. Documentation that the recipient is benefiting from therapy
(e.g., improved or stabilized BMD, no new fractures,
improved biochemical markers, etc.) without significant
adverse effects.
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for 24 months.
2. Recertification request will be approved for 24 months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Forteo® (teriparatide)
1. For Postmenopausal Osteoporosis or Osteopenia, or Men with Primary or
Hypogonadal Osteoporosis or Osteopenia at High Risk for Fracture
a. Approval will be given if all criteria are met and documented:
1. The recipient has a diagnosis of postmenopausal osteoporosis or
osteopenia, or primary or hypogonadal osteoporosis or osteopenia;
and
2. One of the following:
a. Both the following:
1. The recipient has a BMD T-score of -2.5 or lower in
the lumbar spine, femoral neck, total hip, or radius
(one-third radius site); and
2. One of the following
a. The recipient has documented history of low-
trauma fracture of the hip, spine, proximal
humerus, pelvis, or distal forearm; or
b. Documented trial and failure,
contraindication intolerance to one
osteoporosis treatment (e.g., alendronate,
risedronate, zoledronic acid, Prolia
[denosumab]); or
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b. Both the following:
1. The recipient has a BMD T-score between -1.0 and -
2.5 in the lumbar spine, femoral neck, total hip, or
radius (one-third radius site); and
2. One of the following:
a. Recipient has documented history of low-
trauma fracture of the hip, spine, proximal
humerus, pelvis, or distal forearm; or
b. Both the following:
1. Recipient has a documented trial and
failure, contraindication, or
intolerance to one osteoporosis
treatment (e.g., alendronate,
risedronate, zoledronic acid, Prolia
[denosumab]); and
2. One of the following FRAX 10-year
probabilities:
a. Major osteoporotic fracture at
20% or more in the U.S., or
the country-specific threshold
in other countries or regions;
or
b. Hip fracture at 3% or more in
the U.S., or the country-
specific threshold in other
countries or regions; and
3. Recipient’s treatment duration of parathyroid hormones (e.g.,
teriparatide, Tymlos [abaloparatide]) has not exceeded a total of 24
months during the patient's lifetime.
2. For Glucocorticoid-Induced Osteoporosis at High Risk for Fracture
a. Approval will be given if all criteria are met and documented:
1. The recipient has a diagnosis of glucocorticoid-induced
osteoporosis; and
2. The recipient has documented history of prednisone or its equivalent
at a dose greater than or equal to 5 mg/day for greater than or equal
to three months; and
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3. One of the following:
a. BMD T-score less than or equal to -2.5 based on BMD
measurements from lumbar spine, femoral neck, total hip, or
radius (one-third radius site); or
b. The recipient has one of the following FRAX 10-year
probabilities:
1. Major osteoporotic fracture at 20% or more in the
U.S., or the country-specific threshold in other
countries or regions; or
2. Hip fracture at 3% or more in the U.S., or the
country-specific threshold in other countries or
regions; or
c. The recipient has documented history of one of the following
fractures resulting from minimal trauma:
1. Vertebral compression fracture
2. Fracture of the hip
3. Fracture of the distal radius
4. Fracture of the pelvis
5. Fracture of the proximal humerous; and
4. Documented trial and failure, contraindication, or intolerance to one
bisphosphonate (e.g., alendronate); and
5. The recipient’s treatment duration of parathyroid hormones (e.g.,
teriparatide, Tymlos [abaloparatide]) has not exceed a total of 24
months during the patient's lifetime.
3. Prior Authorization Guidelines:
a. Prior authorization approval will be for 24 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
d. Tymlos® (abaloparatide)
1. Approval will be given if all criteria are met and documented:
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a. The recipient has a diagnosis of postmenopausal osteoporosis or osteopenia;
and
b. One of the following:
1. Both the following:
a. BMD T-score of -2.5 or lower in the lumbar spine, femoral
neck, total hip, or radius (one-third radius site); and
b. One of the following:
1. Documented history of low-trauma fracture of the
hip, spine, proximal humerus, pelvis, or distal
forearm; or
2. Documented trial and failure, contraindication, or
intolerance to one osteoporosis treatment (e.g.,
alendronate, risedronate, zoledronic acid, Prolia
[denosumab]); or
2. Both the following:
a. Recipient has a BMD T-score between -1.0 and -2.5 in the
lumbar spine, femoral neck, total hip, or radius (one-third
radius site); and
b. One of the following:
1. Recipient has a documented history of low-trauma
fracture of the hip, spine, proximal humerus, pelvis,
or distal forearm; or
2. Both the following:
a. Documented trial and failure,
contraindication, or intolerance to one
osteoporosis treatment (e.g., alendronate,
risedronate, zoledronic acid, Prolia
[denosumab]); and
b. The recipient has one of the following FRAX
10-year probabilities:
1. Major osteoporotic fracture at 20% or
more in the U.S., or the country-
specific threshold in other countries
or regions; or
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2. Hip fracture at 3% or more in the
U.S., or the country-specific
threshold in other countries or
regions; and
c. Recipient’s treatment duration of parathyroid hormones (e.g., teriparatide,
Tymlos [abaloparatide]) has not exceeded a total of 24 months during their
lifetime.
2. Prior Authorization Guidelines:
a. Prior authorization approval will be for 24 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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PP. Gonadotropin Releasing Hormone Receptor (GnRH) Antagonist and Combinations
Therapeutic Class: GnRH Antagonist and Combinations
Last Reviewed by DUR Board: October 22, 2020
GnRH Antagonist and Combinations are subject to prior authorization based on the Application
of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
1. Orilissa® (elagolix)
a. Approval will be given if all criteria are met and documented:
1. The recipient has a diagnosis of moderate to severe pain associated with
endometriosis; and
2. One of the following:
a. The recipient has documented history of inadequate pain control
response following a trial of at least three months or the recipient
has documented history of intolerance or contraindication:
1. Danazol; or
2. Combination (estrogen/progesterone) oral contraceptive; or
3. Progestins; or
b. The recipient has had surgical ablation to prevent occurrence.
3. For Orilissa 200 mg request only, the treatment will not exceed six months.
b. Recertification Request (All criteria must be met and documented):
1. The recipient has documented improvement in pain associated with
endometriosis improvement in dysmenorrhea and non-menstrual pelvic
pain); and
2. Treatment duration has not exceeded a total of 24 months; and
3. The request is for Orilissa 150 mg.
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for six months.
2. Recertification approval will be for six months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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2. Oriahnn® (elagolix, estradiol, and norethindrone)
a. Approval will be given if all criteria is met and documented:
1. The recipient has a diagnosis of heavy menstrual bleeding associated with
uterine leiomyomas (fibroids); and
2. One of the following:
a. The recipient has documented history of inadequate pain control
response following a trial of at least three months or the recipient
has documented history of intolerance or contraindication:
1. Danazol; or
2. Combination (estrogen/progesterone) oral contraceptive; or
3. Progestins; or
b. The recipient has had surgical ablation to prevent occurrence.
b. Recertification Request:
1. The recipient has documented improvement in menstrual bleeding; and
2. Treatment duration will not exceed a total of 24 months.
c. Prior Authorization Guidelines:
1. Prior authorization approval will be for six months.
2. Recertification approval will be for six months.
3. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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QQ. Spravato™ (esketamine)
Therapeutic Class: Miscellaneous Anti-Depressant
Last Reviewed by the DUR Board: July 25, 2019
Spravato™ (esketamine) is subject to prior authorization and quantity limits based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Initial approval will be given if the following criteria are met and documented:
1. The recipient is 18 years of age or older; and
2. Recipient must have a diagnosis of treatment resistant depression as
evidence of failure of two antidepressants; and
3. Medication must be administered under the direct supervision of a
healthcare provider with post-administration observation; and
4. Treatment must be in conjunction with an oral antidepressant; and
5. The medication must be prescribed by or in consultation with a psychiatrist;
and
6. The recipient must not have an aneurism or AV (arteriovenous)
malformation.
b. Approval will not be given for recipients who are currently pregnant or lactating
and breastfeeding.
2. Recertification Request:
a. In addition to the prior authorization criteria listed above (initial approval), the
recipient must also have a positive clinical response to the medication treatment.
3. Prior Authorization Guidelines
a. Initial prior authorization approval will be given for four weeks.
b. Recertification authorization approval will be given for six months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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RR. Omontys® (Peginesatide)
Therapeutic Class: Erythropoiesis Stimulating Agent (ESA)
Last Reviewed by DUR Board: October 25, 2012
Omontys® (Peginesatide) is subject to prior authorization based on the Application of Standards
in Section 1927 of the SSA and/or approved by the DUR Board.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of anemia secondary to chronic kidney disease;
b. The recipient must be over 18 years of age;
c. The recipient is receiving dialysis;
d. Other causes for anemia have been evaluated and ruled out (e.g., iron, vitamin B12
or folate deficiencies);
e. The recipient’s hemoglobin level is <10 g/dL, (laboratory values from the previous
14 days must accompany the request); and
f. The target hemoglobin level will not exceed 11 g/dL.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one month.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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SS. Colony Stimulating Factors (POS Claims Only)
Therapeutic Class: Colony Stimulating Factors
Last Reviewed by the DUR Board: April 28, 2016
Colony Stimulating Factors are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The requested agent is being used for an FDA-approved indication.
b. The requests for a diagnosis of nonmyeloid malignancy must meet one of the
following criteria:
1. The recipient is receiving myelosuppressive anticancer drugs that are
associated with a febrile neuropenia risk of ≥ 20%; or
2. The recipient is at high risk for complications from neutropenia (e.g., sepsis
syndrome, current infection, age > 65 years, absolute neutrophil count
(ANC) < 100 cells/μL or the expected duration of neutropenia is > 10 days);
or
3. The recipient has experienced a prior episode of febrile neutropenia and the
requested drug will be used as secondary prophylaxis.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one month.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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TT. Auvi-Q® (epinephrine injection device)
Therapeutic Class: Anaphylaxis-Self Injectable Epinephrine
Last Reviewed by the DUR Board: January 23, 2014
Auvi-Q® (Epinephrine Injection Device) is subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient or recipient’s caregiver is unable to read or comprehend written
directions.
2. Prior Authorization Guidelines
a. Initial prior authorization approval will be for one year.
b. Recertification approval will be for one year.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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UU. RESERVED
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VV. Medications for the Treatment of Acne
Therapeutic Class: Acne Agents
Last Reviewed by the DUR Board: July 24, 2014
Acne agents are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
No prior authorization necessary for recipients up to 21 years of age.
Approval will be given if the following criteria are met and documented:
a. The recipient is age 21 years of age or older; and
b. The recipient has a diagnosis of moderate to severe acne (Grade III or higher).
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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WW. Functional Gastrointestinal Disorder Agents
Therapeutic Class: Chronic Idiopathic Constipation (CIC) Agents, Irritable-Bowel Syndrome
Agents, Opioid-Induced Constipation Agents
Last Reviewed by the DUR Board: January 23, 2020
Functional Gastrointestinal Disorder Agents are subject to prior authorization and quantity limits
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Chronic Idiopathic Constipation (CIC) Agents
a. Approval will be given if all the following criteria are met and documented:
1. The requested drug must be FDA approved for the recipient’s age; and
2. Must have a diagnosis of CIC; and
3. Recipient has trial and failure, contraindication or intolerance to either
lactulose or polyethylene glycol (Miralax); and
4. Recipient has trial and failure, contraindication or intolerance to at least one
stimulant laxative, such as sessosides (Ex-lax, Senokot), bisacodyl
(Dulcolax) or cascara sagrada; and
5. The maximum allowable dose for CIC indication are as follows:
a. Linzess® (linaclotide): 145 mcg, once daily
b. Amitiza® (lubiprostone): 24 mcg, twice daily
c. Motegrity® (prucalopride): 2mg, once daily
d. Trulance® (plecanatide): 2mg, once daily
b. Prior Authorization Guidelines
1. Prior authorization approval will be for one year.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Irritable-Bowel Syndrome Agents
a. Coverage and Limitations
1. Approval will be given if the following criteria are met and documented:
a. The recipient is 18 years of age or older; and
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b. The requested agent is being prescribed based on FDA approved
guidelines; and
1. For requests for a diagnosis of Irritable-Bowel Syndrome
with Constipation (IBS-C):
a. For requests for Amitiza® (lubiprostone), the
recipient must be female.
b. The requested dose is appropriate based on
indication and age.
1. Linzess® (linaclotide): 290 μg daily.
2. Amitiza® (lubiprostone): 16 μg daily.
3. Trulance® (plecanatide): 3 μg daily.
2. For requests for a diagnosis of Irritable-Bowel Syndrome
with Diarrhea (IBS-D):
a. The medication is being prescribed by or in
consultation with a gastroenterologist; and
b. The requested dose is appropriate based on
indication and age.
1. Lotronex® (alosetron): 0.5 mg twice daily or
1 mg twice daily.
2. Viberzi® (eluxadoline): 75 mg twice daily or
100 mg twice daily.
3. Xifaxan® (rifaximin): 550 mg three times a
day for 14 days.
b. Prior Authorization Guidelines
1. Prior authorization approval will be given for an appropriate length
of therapy based on the requested agent and diagnosis, not to exceed
one year.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
c. Zelnorm® (tegaserod)
1. Approval will be given if all the following criteria are met and documented:
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a. The recipient has a diagnosis of IBS-C; and
b. The recipient is female; and
c. The recipient is less than 65 years of age; and
d. The recipient has had trial and failure, contraindication, or
intolerance to one of the following:
1. Lactulose; or
2. Polyethylene glycol.
2. Reauthorization Request (the recipient must meet all criteria):
a. Documentation of positive clinical response to Zelnorm® therapy.
3. Prior Authorization Guidelines
a. Initial prior authorization approval will be for six weeks.
b. Recertification approval will be 12 months.
c. Prior authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Opioid-Induced Constipation Agents
a. Approval will be given if all the following criteria are met and documented:
1. The recipient is 18 years of age or older; and
2. The requested medication is being used for an FDA approved indication;
and
3. The recipient must meet the following criteria:
a. There is documentation in the recipient’s medical record of an
inadequate response, adverse reaction or contraindication to one
agent from three of the four traditional laxative drug classes:
1. Bulk forming laxatives;
2. Osmotic laxatives;
3. Saline laxatives;
4. Stimulant laxatives.
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4. And, requests for methylnaltrexone bromide that exceed the quantity limit
must meet all the following criteria:
a. The recipient has opioid-induced constipation in advanced illness,
is receiving palliative care, and is not enrolled in the DHCFP’s
hospice program; and
b. The requested dose is 0.15 mg/kg; and
c. The recipient’s current weight is >114 kg.
b. Prior Authorization Guidelines
1. Prior authorization approval will be for one year.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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XX. Xartemis® XR (oxycodone and acetaminophen)
Therapeutic Class: Opioid Analgesic
Last Reviewed by the DUR Board: January 22, 2015
Xartemis® XR (oxycodone and acetaminophen) is subject to prior authorization and quantity
limitations based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient is 18 years or older; and
b. A diagnosis code of Acute Pain is documented on the prescription and transmitted
on the claim; or
c. An approved prior authorization documenting the recipient meeting the following
criteria:
1. The recipient is 18 years or older; and
2. A diagnosis code of Acute Pain is documented on the Prior Authorization
form.
2. Prior Authorization Guidelines
a. More than two fills of a quantity of 60 each, within six months requires an approved
Prior authorization documenting the reason to exceed the prescribing limit.
b. Prior authorization approval will be for six months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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YY. GnRH Analogs
Therapeutic Class: GnRH Analogs
Last Reviewed by the DUR Board: April 26, 2018
GnRH Analogs are subject to prior authorization and quantity limits based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. This prior authorization criteria only applies to recipients who are under 18 years
of age. Approval of Lupron® (leuprolide) will be given if all the following criteria,
per individual diagnosis, are met and documented:
1. The recipient has a diagnosis of idiopathic or neurogenic central precocious
puberty (CPP), and
a. The requested dose and frequency is based on FDA-approved
guidelines; and
b. The medication is being prescribed by or in consultation with a
pediatric endocrinologist; and
c. There is an onset of secondary sex characteristics before age eight
years (females) or nine years (males); and
d. The recipient is currently less than 11 years of age (females) or 12
years of age (males).
2. The recipient has a diagnosis of gender dysphoria, formerly known as
gender identity disorder; and
a. The medication is being prescribed for suppression of puberty; and
b. The provider indicates a demonstrable knowledge what
gonadotropins medically can and cannot do and their social benefits
and risks; and
c. One of the following:
1. A documented real-life experience (living as the other
gender) for at least three months prior to the administration
of gonadotropin; or
2. A period of psychotherapy for a duration specified by the
mental health professional after the initial evaluation
(usually a minimum of three months).
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d. The member must meet the definition of gender dysphoria (see
definition below):
1. Gender Disphoria:
a. A strong and persistent cross-gender identification
(not merely a desire for any perceived cultural
advantages of being the other sex).
b. Persistent discomfort with his or her sex or sense of
inappropriateness in the gender role of that sex.
c. The disturbance is not concurrent with a physical
intersex condition.
d. The disturbance causes clinically significant distress
or impairment in social, occupational or other
important areas of functioning.
e. The transsexual identity has been present persistently
for at least two years.
f. The disorder is not a symptom of another mental
disorder or a chromosomal abnormality.
3. The recipient has a diagnosis of endometriosis, and
a. The requested dose and frequency is based on FDA-approved
guidelines; and
b. The recipient has had an inadequate response, adverse reaction or
contraindication to an NSAID; and
c. The recipient has had an inadequate response, adverse reaction or
contraindication to a hormonal contraceptive.
4. The recipient has a diagnosis of uterine leiomyomata (fibroids), and
a. The requested dose and frequency is based on FDA-approved
guidelines; and
b. The recipient is symptomatic; and
c. Documentation has been submitted of the anticipated surgery date
(or notation that surgery is planned once the fibroids shrink) or
clinical rational why surgical intervention is not required.
5. The recipient has a diagnosis of prostate cancer, and
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a. The requested dose and frequency is based on FDA-approved
guidelines.
2. Prior Authorization Guidelines
a. Prior authorization approval will be given for an appropriate length of therapy
based on the diagnosis, unless the prescriber indicates a shorter duration of
approval.
1. CPP: One year, or until the member reaches the age of 11 years (female) or
12 years (male).
2. Endometriosis: One year.
3. Uterine Leiomyomata (fibroids): One month or until the time of the
documented surgery (maximum of three months).
4. Prostate Cancer: One year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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ZZ. RESERVED
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AAA. Narcolepsy Agents
Therapeutic Class: Narcolepsy Agents (non-stimulants)
Last Reviewed by the DUR Board: April 30, 2020
Narcolepsy Agents are subject to prior authorizations and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Approval will be given if the following criteria are met and documented:
1. Provigil® (modafinil), and Nuvigil® (armodafinil):
a. The recipient has a diagnosis of narcolepsy.
2. Xyrem® (sodium oxybate):
a. The recipient has tried and failed on Provigil® (modafinil) or
Nuvigil® (armodafinil); and/or
b. The recipient has a diagnosis of narcolepsy with cataplexy; and
c. The drug was prescribed by or in consultation with a neurologist or
sleep specialist.
3. Prior Authorization Guidelines
a. Prior authorization approvals will be for 12 months.
b. Prior authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
b. Sunosi® (solriamfetol)
1. For treatment of Narcolepsy
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a diagnosis of narcolepsy confirmed by sleep study
(unless the prescriber provides justification confirming that a sleep
study would not be feasible); and
2. The recipient has had trial and failure, contraindication or
intolerance to both of the following:
a. modafinil; and
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b. armodafinil.
b. Recertification Request
1. Documentation of positive clinical response to Sunosi® therapy.
c. Prior Authorization Guidelines
1. Initial request will be approved for 12 months.
2. Recertification request will be approved for 12 months.
3. Prior authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
2. For treatment of Obstructive Sleep Apnea (OSA)
a. Approval will be given if all the following criteria are met and
documented:
1. The recipient must have a diagnosis of OSA defined by one of the
following:
a. The recipient has had 15 or more obstructive respiratory
events per hour of sleep confirmed by a sleep study (unless
the prescriber provides justification confirming that a sleep
study would not be feasible); or
b. Both the following:
1. Five or more obstructive respiratory events per hour
of sleep confirmed by a sleep study (unless the
prescriber provides justification confirming that a
sleep study would not be feasible); and
2. One of the following signs/symptoms are present:
a. Daytime sleepiness; or
b. Nonrestorative sleep; or
c. Fatigue; or
d. Insomnia; or
e. Waking up with breath holding, gasping, or
choking; or
f. Habitual snoring noted by a bed partner or
other observer; or
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g. Observed apnea; and
3. Both the following:
a. The recipient has used a standard
treatment(s) for the underlying obstruction
for one month or longer (e.g. CPAP, BiPAP);
and
b. The recipient is fully compliant with ongoing
treatment(s) for the underlying airway
obstruction; and
4. The recipient has had a trial and failure,
contraindication or intolerance to both of the
following:
a. Modafinil; and
b. Armodafinil.
b. Recertification Request (recipient must meet all the criteria)
a. Documentation of positive clinical response to Sunosi® therapy;
and
b. The recipient continues to be fully compliant with ongoing
treatment(s) for the underlying airway obstruction. (e.g. CPAP,
BiPAP)
c. Prior Authorization Guidelines
1. Initial request will be approved for six months.
2. Recertification request will be approved for for six months.
3. Prior authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Wakix® (pitolisant)
1. Approval will be given if all the following criteria are met and documented:
a. The recipient has a documented diagnosis of narcolepsy as confirmed by
sleep study (unless the prescriber provides justification confirming that a
sleep study would not be feasible); and
b. The recipient is 18 years of age and older.
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2. Recertification Requests
a. The recipient must have documentation of positive clinical response to
Wakix® therapy.
3. Prior Authorization Guidelines
a. Initial request will be approved for six months.
b. Recertification request will be approved for 12 months.
c. Prior Authorization form are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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BBB. Vimovo® (naproxen/esomeprazole magnesium), Duexis® (ibuprofen/famotidine)
Therapeutic Class: Nonsteroidal Anti-inflammatory Drug/Anti-ulcer Agent Combinations
Last Reviewed by the DUR Board: April 23, 2015
Vimovo® (naproxen/esomeprazole magnesium), Duexis® (ibuprofen/famotidine) are subject to
prior authorizations and quantity limitations based on the Application of Standards in Section 1927
of the SSA and/or approved by the DUR Board. Refer to the Nevada Medicaid and Check Up
Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The drug is being used for an FDA approved indication; and
b. The recipient’s medical records documents one of the following risk factors for
developing a NSAID-related ulcer:
1. Previous history of a major gastrointestinal bleed, perforation or
obstruction; or
2. Previous history of a peptic ulcer, hemorrhagic gastritis, hemorrhagic
gastropathy or erosive esophagitis; or
3. Concomitant therapy for an anticoagulant or antiplatelet agent (including
aspirin) or chronic oral corticosteroids; or
4. The recipient has had gastric bypass surgery (Roux-en-Y gastric bypass);
and
c. The recipient is intolerant to a COX-2 inhibitor or has had a gastric or duodenal
ulcer while taking a COX-2 inhibitor; and
d. The recipient has experienced an NSAID-associated ulcer in the past while taking
a single-entity proton pump inhibitor (PPI) or prostaglandin agent concomitantly
with an NSAID or the recipient is intolerant to both PPIs and prostaglandin agents;
and
e. The recipient’s medical records document an inadequate response or adverse
reaction with concurrent therapy of an equivalent dose of the individual
components.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for one year.
b. Prior Authorization forms available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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CCC. Rayos® (prednisone delayed-release)
Therapeutic Class: Corticosteroid, Systemic
Last Reviewed by the DUR Board: April 23, 2015
Rayos® (prednisone delayed-release) is subject to prior authorizations based on the Application
of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
1. Coverage and Limitations
Approval will be given if all of the following criteria are met and documented:
a. The requested drug is being used for a FDA approved indication; and
b. The recipient’s medical records document an inadequate response or adverse
reaction to generic prednisone immediate–release tablets.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be:
1. Initial therapy: three months.
2. Recertification: one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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DDD. Corlanor® (ivabradine)
Therapeutic Class: Cardiovascular Agent
Last Reviewed by the DUR Board: September 3, 2015
Corlanor® (ivabradine) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. A diagnosis of chronic heart failure; and
b. A left ventricular ejection fraction (LVEF) < 35%; and
c. A resting heart rate > 70 bpm; and
d. The recipient is > 18 years of age; and
e. The prescriber is a cardiologist or there is documentation in the recipient’s medical
record that a cardiologist has been consulted regarding the diagnosis and treatment
recommendations; and
f. The recipient is in a normal sinus rhythm; and
g. The recipient is on a maximally tolerated dose of a beta-blocker or the recipient has
a contraindication to beta-blocker use.
2. Prior Authorization Guidelines
a. The extent of prior authorization approvals will be based on the appropriate use for
the individual agents.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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EEE. Anti-lipidemic Agents – PCSK9 Inhibitors
Therapeutic Class: AntilipemicAgent, PCSK9 Inhibitors
Last Reviewed by the DUR Board: July 23, 2020
Anti-lipidemic Agents – PCSK9 Inhibitors are subject to prior authorization and quantity
limitation based on the Application of Standards in Section 1927 of the SSA and/or approved by
the DUR Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific
quantity limits.
1. Approval will be given if all the following criteria are met and document:
a. Initial Request:
1. The recipient has an FDA-approved diagnosis; and
2. The requested medication was prescribed by or in consultation with a
cardiologist or lipid specialist; and
3. The requested medication will be used as an adjunct to a low-fat diet and
exercise; and
4. For the treatment of homozygous familial hypercholesterolemia:
a. With alirocumab (Praluent®)
1. The recipient is 18 years of age or older; or
b. With evolocumab (Repatha®)
1. The recipient is 13 years of age or older.
5. And the recipient must meet one of the following (a, b, c, or d):
a. The recipient has had an inadequate response to high intensity
statintherapy defined as all of the following:
1. The recipient has received therapy with atorvastatin > 40 mg
or rosuvastatin > 20 mg for at least the past three months;
and
2. The recipient has received add-on therapy with ezetimibe to
the maximum tolerable dose of statin for at least the past two
weeks or the recipient has a contraindication to ezetimibe
therapy; and
3. The LDL-C after therapy for at least the past three months
was > 100 mg/dL (HeFH) for > 70 mg/dL (clinical
atherosclerotic cardiovascular disease); and
4. The statin therapy will be continued with PCSK-9 therapy.
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b. Or, the recipient has had an inadequate response to moderate
intensity statin therapy defined as all of the following:
1. The recipient has an intolerance or contraindication to high
intensity statin therapy; and
2. The recipient has received therapy with:
a. atorvastatin 10 to 20 mg; or
b. rosuvastatin 5 to 10 mg; or
c. simvastatin > 20 mg; or
d. pravastatin >40 mg; or
e. lovastatin 40 mg; or
f. fluvastatin XL 80 mg; or
g. fluvastatin 40 mg twice daily; or
h. pitavastatin > 2 mg
for at least the past three months; and
3. The recipient has received add-on therapy with ezetimibe to
the maximum tolerable dose of statin for at least the past two
weeks or the recipient has a contraindication to ezetimibe
therapy; and
4. The LDL-C after therapy for at least the past three months
was > 100 mg/dL (HeFH) or > 70 mg/dL (clinical
atherosclerotic cardiovascular disease); and
5. Statin therapy will be continued with PCSK-9 therapy.
c. Or the recipient experienced an adverse reaction to at least two
statins, the statins and adverse reactions must be documented in the
recipient’s medical record.
d. Or the recipient has a labeled contraindication to all statins, the
contraindication is documented in the recipient’s medical record.
2. Recertification Request (The recipient must meet all criteria (a-d))
a. The recipient has been adherent with PCSK-9 inhibitor therapy; and
b. The recipient has been adherent with statin therapy or the recipient has a labeled
contraindication to statin therapy; and
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c. The recipient is continuing a low-fat diet and exercise regimen; and
d. The recipient has achieved a reduction in LDL-C level.
3. Prior Authorization Guidelines
a. Initial authorization will be approved for six months.
b. Recertification approval will be approved for 12 months.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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FFF. Invega Trinza® (paliperidone palmitate)
Therapeutic Class: Second Generation (Atypical) Antipsychotic
Last Reviewed by the DUR Board: November 5, 2015
Invega Trinza® (paliperidone palmitate) is subject to prior authorization and quantity limitations
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented.
a. The recipient has a diagnosis of schizophrenia; and
b. The recipient has been stabilized on once-monthly paliperidone palmitrate injection
(Invega Sustenna®) for at least four months with the two most recent doses of the
once-monthly injection being the same strength; and
c. The recipient is 18 years of age or older; and
d. The requested dose is one injection every three months.
2. Prior Authorization Guidelines
a. Prior authorization approvals will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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GGG. Medications for Recipients on Hospice
Last Reviewed by the DUR Board: January 27, 2017
Previously reviewed: January 28, 2016
Medications for recipients on hospice are subject to prior authorization and quantity limits based
on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. For recipients 21 years of age or older:
1. The prescriber has verified the recipient is enrolled in the hospice program;
and
2. The requested medication is not being used to treat or manage symptoms of
the terminal hospice diagnosis; and
3. The requested medication is not being used for palliative care; and
4. The requested medication is unrelated to the terminal hospice diagnosis and
is medically necessary to treat the recipient; and
5. The requested medication is not providing a curative or long-term
prophylactic therapy.
b. For recipients 20 years of age or younger:
1. The prescriber has verified the recipient is enrolled in a hospice program;
and
2. The requested medication is not being used to treat or manage symptoms
of the terminal hospice diagnosis; and
3. The requested medication is not being used for palliative care.
4. Medically necessary curative medications for this age group are covered
by the DHCFP pursuant to Sections 1905(o)(1) and 2110(a)(23) of the
SSA.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for three months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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HHH. (RESERVED FOR FUTURE USE)
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III. Hetlioz® (tasimelteon)
Therapeutic Class: Sedative Hypnotic
Last Reviewed by the DUR Board: January 28, 2016
Hetlioz® (tasimelteon) is subject to prior authorization and quantity limits based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all following criteria are met and documented:
a. The recipient has a diagnosis of non-24-hour sleep-wake disorder; and
b. The recipient is totally blind; and
c. The medication is being prescribed by or in consultation with a sleep specialist; and
b. The recipient had an adverse reaction, contraindication or an inadequate response
(after at least four weeks of therapy) to a therapeutic dose of melatonin.
2. Prior Authorization Guidelines
a. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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JJJ. Entresto® (sacubitril/valsartan)
Therapeutic Class: Angiotension II Receptor Blocker
Last Reviewed by the DUR Board: January 24, 2019
Entresto® (sacubitril/valsartan) is subject to prior authorization based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of chronic heart failure NYHA Class II to IV; and
b. The recipient has reduced left ventricular ejection fraction (LVEF); and
c. The recipient is 18 years of age or older; and
d. The prescriber is a cardiologist or there is documentation in the recipient’s medical
record that a cardiologist has been consulted; and
e. The recipient has had a trial of an angiotensin converting enzyme (ACE) or an
angiotensin receptor blocker (ARB) for at least four weeks prior to the initiation of
therapy; and
f. The recipient will not concurrently receive an ACE inhibitor; and
g. The recipient is on an individualized dose of a beta blocker or the recipient has a
contraindication to beta blocker use; and
h. Entresto® will be given twice daily with a maximum dose of 97/103 mg.
2. Prior Authorization Guidelines
a. Prior authorization approval will be for one year.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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KKK. Neurokinin-1 Antagonists and Combinations
Therapeutic Class: Neurokinin-1 Antagonists and Combinations
Last Reviewed by the DUR Board: April 28, 2016
Neurokinin-1 antagonists and combinations are subject to prior authorization and quantity limits
based on the Application of Standards in Section 1927 of the SSA and/or approved by the DUR
Board. Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
For requests to exceed the quantity limits approval will be given if all the following criteria
are met and documented:
a. The requested medication is being used for an FDA-approved indication; and
b. The requested medication is being prescribed by an oncologist or in consultation
with an oncologist; and
c. The recipient must meet one of the following criteria:
1. The recipient is 18 years of age or older; or
2. The recipient is 12 years of age or older, the requested medication is
aprepitant (Emend®) and the recipient is diagnosed with nausea and
vomiting caused by chemotherapy.
d. And, it is medical necessity for the recipient to exceed the quantity limit (e.g.,
duration of chemotherapy cycle).
2. Prior Authorization Guidelines
a. Prior authorization approval will be for six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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LLL. RESERVED
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MMM. Duchenne Muscular Dystrophy (DMD) Agents
Therapeutic Class:Duchenne Muscular Dystrophy (DMD) Agents
Last Reviewed by the DUR Board: January 28, 2021
DMD agents are subject to prior authorization and quantity limitations based on the Application
of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Exondys 51® (eteplirsen)
a. Approval will be given if all the following criteria are met and documented:
1. Initial request:
a. The recipient has a diagnosis of Duchenne muscular dystrophy
(DMD); and
b. There is documentation of a confirmed mutation of the dystrophin
gene amenable to exon 51 skipping; and
c. The medication is prescribed by or in consultation with a neurologist
who has experience treating children; and
d. The prescribed dose does not exceed 30 milligrams per kilogram of
body weight once weekly.
2. Recertification Request (the recipient must meet all the following criteria).
a. The recipient has been on therapy for less than 12 months; and
b. The recipient has experienced clinically significant benefit; and
c. The recipient is tolerating therapy; and
d. The prescribed dose will not exceed 30 milligrams per kilogram of
body weight once weekly; and
e. The medication is prescribed by or in consultation with a neurologist
who has experience treating children, or all the following:
1. The recipient has been on therapy for 12 months or more;
and
2. The recipient has experienced a benefit from therapy (e.g.,
disease amelioration compared to untreated patients); and
3. The recipient has experienced clinically significant benefit;
and
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4. The recipient is tolerating therapy; and
5. The prescribed dose will not exceed 30 milligrams per
kilogram of body weight once weekly; and
6. The medication is prescribed by or in consultation with a
neurologist who has experience treating children.
b. Prior Authorization Guidelines
1. Initial authorization will be approved for six months.
2. Recertification request will be approved for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Emflaza® (deflazacort)
a. Approval will be given if all the following criteria are met and documented:
1. Initial request:
a. The recipient must have a diagnosis of (DMD); and
b. The recipient must be five years of age or older; and
c. The recipient must have received genetic testing for a mutation of
the dystrophin gene, and one of the following:
1. Documentation of a confirmed mutation of the dystrophin
gene; or
2. Muscle biopsy confirming an absence of dystrophin protein;
and
d. The medication must be prescribed by or in consultation with a
neurologist who has experience treating children; and
e. The recipient has had at least a three-month trial and failure of
prednisone (prednisolone or equivalent dose) or a documented
intolerance to prednisone (prednisolone or equivalent dose) given at
a dose of 0.75 mg/kg/day or 10 mg/kg/week; and
The dose will not exceed 0.9 milligrams per kilogram of body
weight once daily.
b. Recertification request (the recipient must meet all the following criteria):
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1. Documentation of positive clinical response to Emflaza® therapy (e.g.,
improvement or preservation of muscle strength); and
2. The dose will not exceed 0.9 milligrams per kilogram of body weight once
daily.
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be approved for 12 months.
2. Recertification request will be approved for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
3. Vyondys 53® (golodirsen)
a. Approval will be given if all the following criteria are met and documented:
1. Submission of medical records (e.g. chart notes, laboratory values)
documenting the following:
a. The recipient has a diagnosis of DMD; and
b. Documentation of a confirmed mutation of the dystrophin gene
amenable to exon 53 skipping; and
2. The medication is prescribed by or in consultation with a neurologist who
has experience treating children; and
3. The dose will not exceed 30 milligrams per kilogram of body weight infused
once weekly.
b. Recertification request (recipient must meet all criteria):
1. One of the following:
a. All the following:
1. The recipient has been on therapy for less than 12 months;
and
2. The recipient is tolerating therapy; and
3. Dose will not exceed 30 milligrams per kilogram of body
weight infused once weekly; and
4. The medication is prescribed by or in consultation with a
neurologist who has experience treating children; or
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b. All the following:
1. The recipient has been on therapy for 12 months or more;
and
2. Recipient experienced a benefit from therapy (e.g. disease
amelioration compared to untreated patients); and
3. Recipient is tolerating therapy; and
4. Dose will not exceed 30 milligrams per kilogram of body
weight infused once weekly; and
5. The medication is prescribed by or in consultation with a
neurologist who has experience in treating children.
c. Prior Authorization Guidelines:
1. Initial authorization will be approved for six months.
2. Recertification request will be approved for 12 months.
3. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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NNN. Qutenza® (capsaicin)
Therapeutic Class: Topical Neuropathic Pain Agents
Last Reviewed by the DUR Board: January 28, 2021
Qutenza® (capsaicin) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Approval will be given if all the following criteria is met and documented:
a. The recipient has a diagnosis of neuropathic pain associated with postherpetic
neuralgia; and
b. The recipient has history of failure or intolerance to over-the-counter capsaicin.
2. Recertification Request (recipient must meet all criteria):
a. At least three months have transpired since the last Qutenza®
application/administration; and
b. The recipient experienced pain relief with a prior course of Qutenza®; and
c. The recipient is experiencing a return of neuropathic pain.
3. Prior Authorization Guidelines:
a. Initial authorization will be approved for three months.
b. Recertification request will be approved for three months.
c. The Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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OOO. Austedo® (deutetrabenazine)
Therapeutic Class: Austedo® (deutetrabenazine)
Last Reviewed by the DUR Board: January 25, 2018
Austedo® (deutetrabenazine) is subject to prior authorization and quantity limitations based on
the Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
Austedo® is indicated for the diagnosis of chorea associated with Huntington’s disease or Tardive
Dyskinesia.
1. Coverage and Limitations for Diagnosis of Chorea Associated with Huntington’s Disease
Approval will be given if all the following criteria are met and documented:
a. Initial request:
1. The recipient must have a diagnosis of chorea associated with Huntington’s
disease; and
2. The recipient must be 18 years of age or older; and
3. The medication is prescribed by or in consultation with a neurologist; and
4. Prior authorization will not be approved for recipients who are suicidal or
have untreated/inadequately treated depression, or hepatic impairment, or
are currently utilizing monoamine oxidase inhibitors (MAOIs), reserpine
or tetrabenazine.
b. Recertification request (the recipient must meet all of the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
a. Documentation of positive clinical response to Austedo® therapy.
2. Recertification will not be approved for recipients who are suicidal or have
untreated/inadequately treated depression, or hepatic impairment, or are
currently utilizing monoamine oxidase inhibitors (MAOIs), reserpine or
tetrabenazine.
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for 12 months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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2. Coverage and Limitations for Diagnosis of Tardive Dyskinesia (TD)
Approval will be given if all of the following criteria are met and documented:
a. Initial Request:
1. The recipient must have a confirmed diagnosis of TD; and
2. The recipient must be 18 years of age or older; and
3. At least 60 days of stable (drug, dose) neuroleptic medication exposure
(either typical or first-generation antipsychotic agents, atypical or second-
generation antipsychotic agents or certain dopamine receptor-blocking
drugs used in treatment of nausea and gastroparesis); and
4. Presence of involuntary athetoid or choreiform movements lasting at least
30 days; and
5. Must be prescribed by, or in consultation with, a neurologist or psychiatrist;
and
6. The recipient must have one of the following:
a. Persistent symptoms of TD despite a trial dose reduction, tapering
or discontinuation of the offending medication; or
b. The recipient is not a candidate for trial dose reduction, tapering or
discontinuation of the offending medication.
b. Recertification request (the recipient must meet all the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
a. Documentation of positive clinical response to Austedo® therapy.
2. Prior Authorization Guidelines
a. Initial prior authorization approval will be for three months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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PPP. Brineura® (cerliponase alfa)
Therapeutic Class: Brineura® (cerliponase alfa)
Last Reviewed by the DUR Board: October 19, 2017
Brineura® (cerliponase alfa) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Initial request:
6. The recipient must have a diagnosis of symptomatic late infantile neuronal
ceroid lipofuscinosis Type 2 (CLN2) also known as tripeptidyl peptidase 1
(TPP1) deficiency; and
2. The diagnosis must be confirmed by TPP1 enzyme detected by a dried
blood spot test and CLN2 genotype analysis; and
3. The recipient must be three years of age or older; and
4. The drug must be prescribed by or in consultation with a neurologist with
expertise in the diagnosis of CLN2; and
5. The drug must be administered by, or under the direction of, a physician
knowledgeable in intraventricular administration; and
6. The recipient must not have acute intraventricular access-related
complications (e.g., leakage, device failure or device-related infections);
and
7. The recipient must not have a ventriculoperitoneal shunt.
b. Recertification request (the recipient must meet all of the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
a. The recipient must not have acute intraventricular access-related
complications (e.g., leakage, device failure or device-related
infections); and
b. The recipient must not have a ventriculoperitoneal shunt; and
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c. Documentation of positive clinical response to Brineura®, (e.g.,
improvement in walking or crawling, or no evidence of disease
progression).
c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for four months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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QQQ. Ingrezza® (valbenazine)
Therapeutic Class: Ingrezza® (valbenazine)
Last Reviewed by the DUR Board: October 19, 2017
Ingrezza® (valbenazine) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Initial request:
1. The recipient must have a diagnosis of tardive dyskinesia (TD) confirmed
by the most current edition of Diagnostic and Statistical Manual of Mental
Disorders (DSM), and the following:
a. At least 60 days of stable (drug, dose) neuroleptic medication
exposure (either typical or first generation antipsychotic agents
(such as, chlorpromazine, haloperidol or fluphenazine), atypical or
second-generation antipsychotic agents (such as, clozapine,
risperidone, olanzapine, quetiapine or aripiprazole, or certain
dopamine receptor-blocking drugs used in treatment of nausea and
gastroparesis (such as, prochlorperazine, promethazine or
metoclopramide)); and
b. The presence of involuntary athetoid or choreiform movements
lasting at least 30 days.
1. The recipient must be 18 years of age or older; and
2. The drug must be prescribed by or in consultation with a neurologist or
psychiatrist; and
3. The recipient must have persistent symptoms of TD despite a trial of dose
reduction, tapering or discontinuation of the offending medication; or
4. The recipient must not be a candidate for a trial of dose reduction, tapering
or discontinuation of the offending medication.
b. Recertification request (the recipient must meet all of the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
2. Documentation of positive clinical response to Ingrezza® therapy.
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c. Prior Authorization Guidelines
1. Initial prior authorization approval will be for three months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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RRR. RESERVED FOR FUTURE USE
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SSS. Xadago® (safinamide)
Therapeutic Class: Xadago® (safinamide)
Last Reviewed by the DUR Board: October 19, 2017
Xadago® (safinamide) is subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if all the following criteria are met and documented:
a. Initial request:
1. The recipient must have a diagnosis of Parkinson’s disease; and
2. The recipient must be five years of age or older; and
3. Documented continued Levodopa and/or other dopaminergic treatments;
and
4. Recipient reports greater than 1.5 hours per day of “off” episodes (“off”
episodes refer to “end-of-dose wearing off” and unpredictable “on/off”
episodes); and
5. Recipient must not also be taking any of the following drugs: other MAOIs,
or other drugs that are potent inhibitors of MAOI (e.g., linezolid), opioid
drugs (e.g., tramadol, meperidine and related derivatives), selective
norepinephrine reuptake inhibitors (SNRIs), tri- or tetra-cyclic or
triazolopyridine antidepressants (TCAs), cyclobenzaprine,
methylphenidate, amphetamine and their derivatives, St. John’s wort or
dextromethorphan; and
6. The recipient must not have severe hepatic impairment (e.g., Child-Pugh
C).
b. Recertification request (the recipient must meet all of the following criteria):
1. Authorization for continued use shall be reviewed at least every 12 months
when the following criteria are met:
a. Documentation of positive clinical response to Xadago® therapy;
and
b. Documented continued Levodopa and/or other dopaminergic
treatments.
c. Prior Authorization Guidelines
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1. Initial prior authorization approval will be for three months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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TTT. Codeine and Tramadol for Children
Therapeutic Class: Opioid Analgesic
Last Reviewed by the DUR Board: October 19, 2017
Codeine, codeine with acetaminophen and tramadol, tramadol with acetaminophen are subject to
prior authorization and quantity limitations based on the Application of Standards in Section 1927
of the SSA and/or approved by the DUR Board. Refer to the Nevada Medicaid and Check Up
Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
a. Codeine, codeine with acetaminophen
1. All of the following criteria must be met:
a. The recipient must be 12 years of age or older; and
b. The lowest effective dose for the shortest period of time is being
requested; and
c. The recipient must not be obese (BMI > 30 kg/m²), have obstructive
sleep apnea, or severe lung disease; and
d. The recipient is not being prescribed the drug for post-surgical pain
following a tonsillectomy and/or adenoidectomy.
b. Tramadol, tramadol with acetaminophen
1. All of the following criteria must be met:
a. The recipient must be 12 years of age or older; and
b. The lowest effective dose for the shortest period of time is being
requested; and
c. The recipient must not be obese (BMI > 30 kg/m²), have obstructive
sleep apnea, or severe lung disease; and
d. The recipient is not being prescribed the drug for post-surgical pain
following a tonsillectomy and/or adenoidectomy; and
e. The prescribed dose does not exceed 200mg/day and does not
exceed a five day supply.
2. Tramadol Extended Release (ER) will not be approved for children under
18 years of age and will reject at point of sale.
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c. Prior Authorization Guidelines
1. Codeine, codeine with acetaminophen
a. Prior authorization approval will be given for the lowest effective
dose for the shortest period of time requested.
1. Prior authorization will be given for a one month time
period.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
2. Tramadol, tramadol with acetaminophen
a. Prior authorization approval will be given for the lowest effective
dose for the shortest period of time requested.
b. Prior authorization will be given for a one month time period.
c. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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UUU. High Dollar Claim
Last Reviewed by the DUR Board: April 26, 2018
A High Dollar Claim is defined as a single point-of-sale claim that exceeds $10,000. A High Dollar
Claim is subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits. If other prior authorization
criteria exists, it will supersede this criteria.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. One of the following:
1. The medication is being prescribed for a Food and Drug Administration
(FDA) approved indication; or
2. One of the following:
a. Diagnosis is supported as a use of American Society of Health-
System Pharmacists Drug Information (AHFS DI); or
b. Diagnosis is supported in the FDA Uses/Non-FDA Uses section in
DRUGDEX Evaluation and carries a Strength of Recommendation
rating of IIb or better (see DRUGDEX Strength of Recommendation
table); or
3. Both of the following:
a. Diagnosis is listed in the FDA Uses/Non-FDA Uses section in
DRUGDEX Evaluation and carries a Strength of Recommendation
rating of III or Class Indeterminant (see DRUGDEX Strength of
Recommendation table); and
b. Efficacy is rated as “Effective” or “Evidence Favors Efficacy” (see
DRUGDEX Efficacy Rating and Prior Authorization Approval
Status table); or
4. Diagnosis is supported in any other section in DRUGDEX; or
5. The use is supported by clinical research in two articles from major peer-
reviewed medical journals that present data supporting the proposed off-
label use or uses as generally safe and effective unless there is clear and
convincing contradictory evidence presented in a major peer-reviewed
medical journal.
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b. And one of the following:
1. The dosage/quantity/duration of the medication is reasonably safe and
effective based on information contained in the FDA approved labeling,
peer-reviewed medical literature or accepted standards of medical practice;
or
2. The dosage/quantity/duration of the medication is reasonably safe and
effective based on one of the following compendia:
a. American Hospital Formulary Service (AHFS) Compendium.
b. Thomson Reuters (Healthcare) Micromedex/DRUGDEX (not Drug
Points) Compendium.
c. Elsevier Gold Standard Clinical Pharmacology Compendium.
d. National Comprehensive Cancer Network Drugs and Biologics
Compendium.
c. Excluded:
1. Hemostatic coagulation factors used for the treatment of hemophilia are
excluded from this criteria.
d. Prior Authorization Guidelines
1. Prior authorization approval will be for 12 months.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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VVV. (RESERVED FOR FUTURE USE)
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WWW. Botulinum Toxin
Therapeutic Class: Neurotoxic Protein
Last reviewed by the DUR Board: July 26, 2018
Botulinum toxins are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Policy
Botulinum toxin injections are a Nevada Medicaid covered benefit for certain spastic
conditions including, but not limited to cerebral palsy, stroke, head trauma, spinal cord
injuries and multiple sclerosis. The injections may reduce spasticity or excessive muscular
contractions to relieve pain, to assist in posturing and ambulation, to allow improved range
of motion, to permit better physical therapy and provide adequate perineal hygiene.
2. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. It is expected that physicians be familiar with and experienced in the use of
botulinum toxin products and utilize FDA-approved product labeling, compendia
and peer-reviewed scientific literature to select the appropriate drug and dose
regimen for each recipient condition. A complete list of covered indications can be
found within the “Provider Type 20, 24 and 77 Billing Guide” applicable to
botulinum toxins.
b. Documentation must be provided that the recipient has been unresponsive to
conventional methods of treatment (e.g., medication, physical therapy and other
appropriate methods used to control and/or treat spastic conditions); and
c. If maximum dose is reached and positive clinical response is not established,
treatment must be discontinued; and
d. Documentation of medical necessity is required for treatment more frequent than
every 90 days; and
e. Coverage will be approved for one injection per site. A site is defined as including
muscles of a single contiguous body part, such as a single limb, eyelid, face or neck.
f. Coverage will not be provided for injections given for cosmetic or for
investigational purposes.
3. Recertification Request (the recipient must meet all the following criteria):
a. Authorization for continued use shall be reviewed at least every 12 months when
the following criteria are met:
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1. Documentation of a positive clinical response to Botulinum Toxin therapy.
4. Prior Authorization Guidelines
a. Prior authorization approval will be for six months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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XXX. Compounded Medications
Last Reviewed by the DUR Board: January 24, 2019
Compounded medications are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. Each active ingredient in the compounded medication is FDA-approved or national
compendia supported for the condition being treated; and
b. The therapeutic amounts and combinations are supported by national compendia or
peer-reviewed literature for the condition being treated in the requested route of
delivery; and
c. If any prescription ingredients require prior authorization and/or step therapy, all
drug specific criteria must also be met; and
d. The compounded medication must not be used for cosmetic purpose; and
e. The compounded medication must not include any ingredient that has been
withdrawn or removed from the market due to safety reasons (drugs withdrawn
from the market due to safety or effectiveness); and
f. The recipient has tried and failed therapy or had an intolerance to at least two FDA-
approved, commercially available prescription therapeutic alternatives, one of
which is the same route of administration as the requested compound, unless one
of the following criteria are met:
1. The recipient has a contraindication to commercially available products; or
2. One or no other therapeutic alternatives are commercially available; or
3. Compound medication is prepared in a different dosage form for a recipient
who is unable to take the commercially available formulation (mixing or
reconstituting commercially available products based on the manufacturer’s
instructions or the product’s approved labeling does not meet this criteria);
or
4. The recipient has an allergy or sensitivity to inactive ingredients (e.g., dyes,
preservatives, sugars, etc.) that are found in commercially available
products.
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2. Prior Authorization Guidelines
a. Prior authorization approval will be for six months unless the provider requests for
a shorter length of therapy.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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YYY. Antibiotics
Last Reviewed by the DUR Board: July 26, 2018
Antibiotic medications are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
The outpatient antibiotic class criteria apply to the following:
Third Generation Fluoroquinolones Oxazolidinones
Cephalosporins
cefixime ciprofloxacin tedizolid
cefdinir levofloxacin linezolid
cefpodoxime delafloxacin
ceftibuten moxifloxacin
cefdotoren ofloxacin
If applicable, reference current Infectious Disease Society of America (IDSA) (or equivalent
organization) guidelines to support the use of the following:
1. Coverage and Limitations for Third Generation Cephalosporins and Fluoroquinolones
Approval will be given if the following criteria are met and documented:
a. Culture and sensitivity-proven susceptibilities and resistance to other agents
suggest the requested drug is necessary.
2. Coverage and Limitations for Oxazolidinones
a. Sivextro® (tedizolid)
Approval will be given if the following criteria are met and documented:
1. Recipient has diagnosis of Acute Bacterial Skin and Skin Structure
Infection; and
2. Infection is caused by methicillin-resistant Staphylococcus aureus
(MRSA); and
3. Recipient has had a trial of or has a contraindication to an alternative
antibiotic that the organism is susceptible to (depending on manifestation,
severity of infection and culture or local sensitivity patterns, examples of
alternative antibiotics may include, but are not limited to:
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trimethoprim/sulfamethoxazole (TMP/SMX), doxycycline, vancomycin,
daptomycin, telavancin, clindamycin); or
4. Recipient started treatment with intravenous antibiotic(s) in the hospital and
requires continued outpatient therapy.
b. Zyvox® (linezolid)
Approval will be given if the following criteria are met and documented:
1. Recipient has a diagnosis of vancomycin-resistant enterococcus (VRE)
faecium infection or diagnosis of MRSA infection; and
2. Recipient has had a trial of or has a contraindication to an alternative
antibiotic that the organism is susceptible to (depending on manifestation,
severity of infection and culture or local sensitivity patterns, examples of
alternative antibiotics may include, but are not limited to: TMP/SMX,
doxycycline, vancomycin, tetracycline, clindamycin); or
3. Recipient started treatment with intravenous antibiotic(s) in the hospital and
requires continued outpatient therapy.
3. Exception Criteria (applies to antibiotic medications)
a. Prescribed by an infectious disease specialist or by an emergency department
provider; or
b. Ceftriaxone prescribed as first line treatment for gonorrhea, pelvic inflammatory
disease, epididymo-orchitis and as an alternative to benzylpenicillin to treat
meningitis for those with a severe penicillin allergy; or
c. If cefixime is prescribed for gonococcal infection where ceftriaxone is unavailable;
or
d. The recipient resides in one of the following:
1. Acute Care
2. Long-term Acute Care (LTAC)
3. Skilled Nursing Facility (SNF)
4. Prior Authorization Guidelines
a. Prior authorization approval will be for a single course.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
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5. References
a. CDC Antibiotic Prescribing and Use in Doctor’s Offices:
https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/index.html
b. CDC Improving Prescribing:
https://www.cdc.gov/antibiotic-use/community/improving-prescribing/index.html
c. IDSA Guidelines:
https://www.idsociety.org/practice-guidelines/#/score/DESC/0/+/
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ZZZ. Oral Oncology Agents
Therapeutic Class: Oral Oncology Agents
Last Reviewed by the DUR Board: January 24, 2019
Oral oncology agents are subject to prior authorization based on the Application of Standards in
Section 1927 of the SSA and/or approved by the DUR Board. Refer to the Nevada Medicaid and
Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations (this criteria only applies if other product-specific criteria is not
available in MSM Chapter 1200 – Prescribed Drugs)
Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis that is indicated in the FDA approved package insert
or listed in nationally recognized compendia, for the determination of medically
accepted indications; and
b. If the oral oncology medication is not indicated as a first line agent, either in the
FDA approved package insert or nationally recognized compendia, then
documentation of previous therapies tried and failed is required; and
c. The medication is prescribed by or in consultation with an oncologist or
hematologist; and
d. The recipient does not have any contraindications to the requested oral oncology
medication; and
e. The requested quantity and dosing regimen falls within the manufacturer’s
published dosing guidelines or nationally recognized compendia and is appropriate
for the recipient’s age; and
f. The medication must be used in combination with other chemotherapeutic or
adjuvant agents according to the FDA approved prescribing information; and
g. One of the following:
1. If an FDA-approved companion diagnostic test for the requested agent
exists, then documentation that the test was performed to confirm the
diagnosis is required; or
2. If a test with adequate ability to confirm a disease mutation exists, then
documentation that the test was performed to confirm the diagnosis is
required.
2. Recertification Request
a. Documentation of a positive clinical response to the oral oncology treatment.
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3. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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AAAA. Pulmonary Arterial Hypertension Agents
Therapeutic Class: Pulmonary Arterial Hypertension Agents
Reviewed by the DUR Board: January 24, 2019
Pulmonary arterial hypertension (PAH) agents are subject to prior authorization based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Coverage and Limitations
Approval will be given if the following criteria are met and documented:
a. The recipient has a documented diagnosis of pulmonary arterial hypertension; or
b. The recipient has one of the following ICD-10 diagnosis codes submitted on the
pharmacy claim:
ICD-10 Description
127.20 Pulmonary Hypertension, Unspecified
127.21 Secondary Pulmonary Arterial Hypertension
127.22 Pulmonary Hypertension Due to Left Heart Disease
127.23 Pulmonary Hypertension Due to Lung Diseases and Hypoxia
127.9 Pulmonary Heart Disease, Unspecified
2. Prior Authorization Guidelines
a. Prior authorization approval will be for 12 months.
b. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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BBBB. Anticonvulsants
Therapeutic Class: Anticonvulsants
Last Reviewed by the DUR Board: January 28, 2021
Anticonvulsants are subject to prior authorization and quantity limitations based on the
Application of Standards in Section 1927 of the SSA and/or approved by the DUR Board. Refer
to the Nevada Medicaid and Check Up Pharmacy Manual for specific quantity limits.
1. Cannabinoid
a. Epidiolex® (cannabidiol)
1. Approval will be given if the following criteria are met and documented:
a. The recipient has a diagnosis of Lennox-Gastaut syndrome, Dravet
Syndrome or Tuberous Sclerosis Complex (TSC); and
b. The recipient is one years of age or older; and
c. A recent serum transaminase (ALT and AST) and total bilirubin
level has been obtained and is within normal limits; and
d. The drug is prescribed by or in consultation with a neurologist; and
e. The total dose does not exceed 20 mg/kg/day (10mg/kg twice daily);
and
f. The medication will be used as adjunctive therapy (the recipient has
been taking one or more antiepileptic drugs and has chart notes
confirming the presence of at least four convulsive seizures per
month).
2. Recertification Request
a. Documentation of a positive clinical response to Epidiolex® therapy; and
b. Serum transaminase (ALT and AST) and total bilirubin level has been re-
checked per package insert.
3. Prior Authorization Guidelines
a. Initial prior authorization will be for three months.
b. Recertification approval will be for 12 months.
c. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx
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4. For anticonvulsant criteria for children and adolescents, refer to Section N, titled
Psychotropic Medications for Children and Adolescents.
2. Nayzilam® (midazolam)
a. Approval will be given if the following criteria are met and documented:
1. The recipient has a diagnosis of acute intermittent seizures; and
2. The recipient is at least 12 years of age; and
3. The medication is prescribed by or in consultation with a Neurologist; and
4. The dose must not exceed two sprays per seizure cluster, no more than one
episode every three days and treat no more than five episodes per month.
b. Recertification Request
1. Documentation of positive clinical response to Nayzilam® therapy.
c. Prior Authorization Guidelines
1. Initial prior authorization will be for six months.
2. Recertification approval will be for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
3. Valtoco® (diazepam)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a diagnosis of epilepsy; and
2. The recipient is six years and older; and
3. The medication is prescribed for the acute treatment of intermittent,
stereotypic episodes of frequent seizure activity that are distinct from a
patient’s usual seizure pattern; and
4. The prescriber documents a reason or special circumstance that precludes
the use of diazepam rectal gel; and
5. The medication is prescribed by or in consultation with a neurologist; and
6. The quantity must not exceed five episodes per month.
b. Prior Authorization Guidelines:
July 5, 2021 PRESCRIBED DRUGS Appendix A Page 197
APPENDIX A - Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
1. Documentation of positive clinical response to Valtoco® therapy.
c. Prior Authorization Guidelines:
1. Initial authorization will be approved for six months.
2. Recertification approval will be approved for 12 months.
3. Prior Authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
4. Fintepla® (fenfluramine)
a. Approval will be given if all the following criteria are met and documented:
1. The recipient has a documented diagnosis of seizures associated with
Dravet Syndrome; and
2. The recipient is two years of age or older; and
3. The medication is prescribed by or in consultation with a neurologist.
b. Recertification Request:
1. The recipient has documentation of positive clinical response to Fintepla®
therapy.
c. Prior Authorization Guidelines:
1. Initial authorization will be for 12 months.
2. Recertification approval will be for 12 months.
3. Prior authorization forms are available at:
https://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
July 5, 2021 PRESCRIBED DRUGS Appendix A Page 198
APPENDIX B - Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
2. MEDICATIONS WITH GENDER/AGE EDITS
A. Prenatal Vitamins
1. Payable only for female recipients.
October 1, 2015 PRESCRIBED DRUGS Appendix B Page 1
APPENDIX B - Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
B. Oral/Topical Contraceptives
1. Payable only for female recipients.
October 1, 2015 PRESCRIBED DRUGS Appendix B Page 2
APPENDIX B - Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
C. Gender Edits
1. Hormones
a. Estrogen – payable only for female recipients.
b. Progestins – payable only for female recipients.
c. Estrogen and Androgen Combinations – payable only for female recipients.
d. Estrogen and Progestin Combinations – payable only for female recipients.
e. Contraceptive Hormones – payable only for female recipients.
f. Transdermal Testosterone – payable only for male recipients.
g. Androgen Hormone Inhibitor – payable only for male recipients.
2. Exception to the above gender edits:
A diagnosis of Gender Dysphoria (formerly known as Gender Identity Disorder) will
bypass the gender edit if the appropriate ICD code is documented on the prescription and
transmitted on the claim.
November 4, 2019 PRESCRIBED DRUGS Appendix B Page 3
APPENDIX B - Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
D. Vitamins with Fluoride
1. Payable only for recipients up to age 21 years.
October 1, 2015 PRESCRIBED DRUGS Appendix B Page 4
APPENDIX B - Coverage and Limitations
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
3. ANTIRETROVIRALS
Antiretrovirals for the treatment of HIV/AIDS are a covered benefit for Nevada Medicaid recipients. FDA
approved antiretrovirals whose manufacturers participate in the federal Drug Rebate Program and are not
DESI drugs, are covered.
October 1, 2015 PRESCRIBED DRUGS Appendix B Page 5
APPENDIX B– Standard Therapeutic Drug Classes
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
4. DIABETIC SUPPLY PROGRAM
Diabetic Supplies are subject to prior authorization and quantity limitations based on the Application of
Standards in Section 1927 of the SSA Act and/or approved by the DUR Board. Refer to the Nevada
Medicaid and Check Up Pharmacy Manual for specific quantity limits.
Prior authorization is required for preferred and non-preferred diabetic products (including insulin
delivery system and Continuous Glucose Monitor [CGM] receivers and readers).
Preferred diabetic product information is found at:
https://www.medicaid.nv.gov/providers/rx/diabeticsupplies.aspx
Preferred (including sensors and transmitters) and nonpreferred (including tubing, reservoirs for pumps
and transmitters and sensors for CGM’s) diabetic supplies do not require a prior authorization. These items
require a documented diagnosis of diabetes mellitus type I (DM1) or gestational diabetes and recipients
must meet all age restrictions stated on the manufacturer’s label.
Pharmacy benefit allows a 100-day supply for insulin system and CGM supplies.
1. Preferred Insulin Delivery System
a. Approval will be given if the following criteria are met and documented:
1. Recipient must have a documented diagnosis of Diabetes Mellitus Type I or
Gestational Diabetes; and
2. The product must be prescribed by or in consultation with an endocrinologist; and
3. The recipient must meet all age restrictions stated in the manufacturer’s label; and
4. The recipient must have been compliant on their current antidiabetic regimen for at
least the last six months and this regimen must include multiple day injections of
insulin (requiring at least three injections per day); and
5. One of the following:
a. Documented history of recurring hypoglycemia; or
b. Wide fluctuations in pre-meal blood glucose, history of severe glycemic
excursions or experiencing “Dawn” phenomenon with fasting blood
glucose exceeding 200 mg/dL, or
c. Prior use of an insulin pump with documented frequency of glucose self-
testing of at least four times per day in the month immediately prior to the
request.
August 3, 2020 PRESCRIBED DRUGS Appendix B Page 6
APPENDIX B– Standard Therapeutic Drug Classes
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
b. Prior Authorization Guidelines
1. Initial prior authorization approval will be for one year.
2. Prior Authorization forms are available at:
http://www.medicaid.nv.gov/providers/rx/rxforms.aspx.
c. Recertification Request
1. Recertification of prior authorization approval will be given if the recipient has
documented positive clinical response to the product (including current HbA1C).
2. Recertification prior authorization approval will be for one year.
2. Non-Preferred Insulin Delivery System
a. Approval will be given if the following criteria are met and documented:
1. In addition to meeting the “Preferred Insulin Delivery System” criteria, the
recipient must also meet the following:
a. The recipient must have been trained to use the non-preferred product; and
b. The recipient must have benefited from use of the non-preferred product;
and
c. The recipient must have one of the following reasons/special
circumstances:
d. Recipient has had an allergic reaction to a preferred product or related
supply; or
e. Recipient has a visual impairment which requires the use of a non-
preferred product; or
f. Recipient has medical necessity justification (e.g. mental or physical
limitation) which requires them to stay on their current product.
3. Preferred Continuous Glucose Monitors (CGMs)
a. Approval will be given if the following criteria are met and documented:
1. Recipient must have a documented diagnosis of Diabetes Mellitus Type I or
Gestational Diabetes; and
2. Recipient must meet all age restrictions stated in the manufacturer’s label; and
3. Recipient must have been compliant on their current antidiabetic regimen for
PRESCRIBED DRUGS Appendix B Page 7
APPENDIX B – Standard Therapeutic Drug Classes
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MEDICAID SERVICES MANUAL
at least the last six months and this regimen must include multiple daily
injections of insulin (requiring at least three injections per day); and
4. One of the following:
a. Documented history of recurring hypoglycemia; or
b. Wide fluctuations in pre-meal blood glucose, history of severe
glycemic excursions or experiencing “Dawn” phenomenon with
fasting blood glucose exceeding 200 mg/dL; or
c. Recipient is currently using insulin pump therapy while continuing to
need frequent dosage adjustments or experiencing recurring episodes
of severe hypoglycemia (50 mg/dL).
b. Prior Authorization Guidelines
1. Initial prior authorization approval will be for one year.
2. Prior Authorization forms are available at:
http/www.medicaid.nv.gov/providers/rx/rxfor
ms.aspx.
4. Non-Preferred Continuous Glucose Monitor (CGM)
a. Approval will be given if the following criteria are met and documented:
1. In addition to meeting the Preferred CGM criteria, the recipient must also meet
the following:
a. Recipient has had an allergic reaction to a preferred product or related
supply; or
b. Recipient has a visual impairment which requires the use of a non-
preferred product; or
c. Recipient has medical necessity justification (e.g. mental or physical
limitation) which requires them to stay on their current product; or
d. The recipient must have been trained to use the non-preferred product;
and
e. The recipient must have benefited from use of the non-preferred
product.
5. Test Strips and Lancets
August 3, 2020 PRESCRIBED DRUGS Appendix B Page 8
APPENDIX B – Standard Therapeutic Drug Classes
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
a. Pharmacy Services billing information including Billing Manual and Quantity
Limits is available at: https://www.medicaid.nv.gov/providers/rx/billinginfo.aspx
*Blood Glucose monitors with special features (e.g. voice synthesizers) require a prior authorization.
For special blood glucose monitors, a diagnosis and a statement from the physician documenting the
impairment is required with a prior authorization.
August 3, 2020 PRESCRIBED DRUGS Appendix B Page 9
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
February 25, 2020
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: CODY L. PHINNEY, DEPUTY ADMINISTRATOR /Cody L. Phinney/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1300 – DME DISPOSABLE SUPPLIES AND
SUPPLEMENTS
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1300 – DME Disposable Supplies and
Supplements are being proposed to update the invoice verbiage for consistency throughout,
referenced provider type (PT 33) billing guideline, removed the Insulin Pump policy and made
reference along with Continuous Glucose Monitors that they will now be under the pharmacy
benefit, removed the rental option verbiage for Osteogenesis Stimulators to allow straight purchase
and removed facility based polysomnogram verbiage which opens up to allow home based sleep
studies.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: DME (PT 33) and Pharmacy (PT 28).
Financial Impact on Local Government: Unknown at this time.
These changes are effective February 26, 2020.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 09/20 MTL 07/18
MSM Chapter 1300 – DME Disposable MSM Chapter 1300 – DME Disposable
Supplies and Supplements Supplies and Supplements
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
1303.2(A)(2) Detailed Product Removed “of cost” for the type of invoice.
Description
Page 1 of 2
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
1303.4(C) Provider Responsibility Added verbiage to direct providers to the (PT
33) DMEPOS specific billing guide.
Appendix B, Diabetic Services Added verbiage referring External Ambulatory
pages 16 and 17 Infusion Pump, Insulin systems and
Continuous Glucose Monitors are now under
the pharmacy program.
Appendix B, Osteogenesis Changed six months to three or more months
page 48 Stimulator Devices, for non-spinal. Removed the rental
Qualifications and requirement verbiage for both to match
Misc. policy Statements Medicare and allow access to care.
Appendix B, Respiratory Services, Removed facility based, attended verbiage and
pages 56, 57, 61 BiPAP and CPAP, added complete.
Qualifications
Page 2 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS
1300 INTRODUCTION ...............................................................................................................................1
1301 AUTHORITY ......................................................................................................................................1
1302 DEFINITIONS .....................................................................................................................................1
1303 POLICY ...............................................................................................................................................1
1303.1 DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, ORTHOTIC DEVICES,
DISPOSABLE MEDICAL SUPPLIES (DMEPOS) PROGRAM ......................................................1
1303.2 DOCUMENTATION REQUIREMENTS ...........................................................................................4
1303.3 RENTAL AND PURCHASE OPTIONS ............................................................................................8
1303.4 PRIOR AUTHORIZATION .............................................................................................................11
1303.5 DISPENSING AND DELIVERY OF DMEPOS ..............................................................................16
1303.6 REPAIR, REPLACEMENT AND WARRANTY OF EQUIPMENT ..............................................17
1303.7 SECTION RESERVED FOR FUTURE USE ...................................................................................19
1303.8 SECTION RESERVED FOR FUTURE USE ...................................................................................19
1303.9 DME AT INSTITUTIONAL FACILITY (IF) ..................................................................................19
1303.10 SECTION RESERVED FOR FUTURE USE ...................................................................................20
1303.11 SECTION RESERVED FOR FUTURE USE ...................................................................................20
1303.12 SECTION RESERVED FOR FUTURE USE ...................................................................................20
1303.13 SECTION RESERVED FOR FUTURE USE ...................................................................................20
1303.14 SECTION RESERVED FOR FUTURE USE ...................................................................................20
1303.15 UTILIZATION CONTROL .............................................................................................................20
1304 HEARINGS .........................................................................................................................................1
APPENDIX A - NON COVERED SERVICES………………………………………………… ..........................1
APPENDIX B - COVERAGE AND LIMITATIONS POLICIES
INTRODUCTION AND GENERAL INFORMATION .....................................................................1
BATHING AND TOILETING AIDS..................................................................................................2
BEDS (HOSPITAL) AND ACCESSORIES .......................................................................................3
COMMUNICATION DEVICES .......................................................................................................11
DIABETIC SERVICES .....................................................................................................................16
DISPOSABLE SUPPLIES ................................................................................................................18
MOBILITY ASSISTIVE EQUIPMENT (MAE) ..............................................................................20
NUTRITIONAL SERVICES.............................................................................................................39
ORTHOTIC AND PROSTHETIC DEVICES ...................................................................................43
OSTEOGENESIS STIMULATOR DEVICES ..................................................................................48
PHOTOTHERAPY UNITS ...............................................................................................................49
1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
PNEUMATIC COMPRESSION DEVICES .....................................................................................50
PREGNANCY-RELATED EQUIPMENT .......................................................................................51
RESPIRATORY SERVICES ............................................................................................................53
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1300 INTRODUCTION
Durable Medical Equipment, Prosthetics, Orthotics and Disposable Medical Supplies (DMEPOS)
are a covered benefit for Nevada Medicaid recipients. All items are subject to program criteria and
reimbursement restrictions as outlined throughout this chapter. Nevada Medicaid covers standard
medical equipment that meets the basic medical need of the recipient. Items classified as
educational or rehabilitative by nature are not covered by Provider Type 33. Administrative
authorization for additional services may be made by the Division of Health Care Financing and
Policy (DHCFP) in collaboration with the Quality Improvement Organization (QIO)-like vendor
for exceptional cases where medical need is adequately documented.
Products must have received approval from the federal Food and Drug Administration (FDA) and
be consistent with the approved use. Products or usage considered experimental or investigational
are not covered services. Consideration may be made on a case-by-case basis for items approved
by the FDA as a Humanitarian Device Exemption (HDE) under the Safe Medical Device Act of
1990 and as defined by the FDA. That is, a device that is intended to benefit patients by treating
or diagnosing a disease or condition that affects fewer than 4,000 individuals in the United States
per year.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), except as indicated in the NCU Manual Chapter 1000. Reference Medicaid
Services Manual (MSM) Chapter 100 – Medicaid Program, Addendums Chapter and MSM
Definitions for further information.
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1301 AUTHORITY
The Division of Health Care Financing and Policy (DHCFP) covers Durable Medical Equipment,
Prosthetics, Orthotics and Supplies (DMEPOS) as a mandatory program under Title XIX of the
Social Security Act (SSA).
The citations denoting the amount, duration and scope of services can be found in 42 Code of
Federal Regulations (CFR), Part 440, Sections 70 and 230, Section 1902 (a)(10)(d) of Title XIX
of the Social Security Act, 42 United States Code (USC) Chapter 7, Section 1396a and 1397jj.
Reference Title XIX State Plan Attachment 3.1-A Page 2h and 3c, Attachment 4.19-B page 1b and
page 2.
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MEDICAID SERVICES MANUAL DEFINITIONS
1302 DEFINITIONS
ANKLE-FOOT ORTHOSES
Ankle-foot orthoses extend well above the ankle (usually to near the top of the calf) and are
fastened around the lower leg above the ankle. These features distinguish them from foot orthotics,
which are shoe inserts that do not extend above the ankle.
CUSTOM FABRICATED ORTHOSIS
A custom fabricated orthosis is one which is individually made for a specific patient starting with
basic materials including, but not limited to, plastic, metal, leather or cloth in the form of sheets,
parts, etc. It involves substantial work such as cutting, bending, molding, sewing, etc. It may
involve the incorporation of some prefabricated components. It involves more than trimming,
bending or making other modifications to a substantially prefabricated item.
DISPOSABLE MEDICAL SUPPLIES
Disposable medical supplies are those health care items which are not reusable, and are primarily
and customarily used to serve a medical purpose, and generally are not useful to a person in the
absence of an individual disability, illness or injury.
DURABLE MEDICAL EQUIPMENT (DME)
DME is defined as equipment which can withstand repeated use, and is primarily and customarily
used to serve a medical purpose, and generally is not useful to a person in the absence of disability,
illness or injury and is appropriate for use in the home.
DURABLE MEDICAL EQUIPMENT MEDICARE ADMINISTRATIVE CONTRACTOR
(DME MAC)
The Centers for Medicare and Medicaid Services (CMS) utilize four insurance companies to
process durable medical equipment, prosthetic, orthotic and disposable medical supply claims for
Medicare in four distinct jurisdictions. Nevada is in Jurisdiction D. This was formerly referred to
as Durable Medical Equipment Regional Carrier (DMERC).
DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES
(DMEPOS)
Aggregate term used under the Medicare program and by some Medicaid programs, which
incorporates all durable medical equipment, prosthetics, orthotics and disposable medical supplies.
The acronym is pronounced “demipose.”
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MEDICAL DOCUMENTATION
For the purposes of obtaining DMEPOS through Nevada Medicaid and Nevada Check Up (NCU),
medical documentation used to support medical necessity is part of a medical record which is
completed, signed and dated by a licensed medical professional. Clinical reports or assessments
required to support medical necessity must be from a licensed/certified professional performing
within their scope of practice. Information used as medical documentation cannot be compiled or
composed by the recipient, their relatives or representatives.
MISUSE
To use in a manner in which an item is not intended, excessive use or to use incorrectly.
MOLDED TO PATIENT MODEL ORTHOSIS
A molded-to-patient-model orthosis is a particular type of custom fabricated orthosis in which an
impression of the specific body part is made (by means of a plaster cast, CAD-CAM technology,
etc.) and this impression is then used to make a positive model (of plaster or other material) of the
body part. The orthosis is then molded on this positive model.
ORTHOSIS
An orthosis (brace) is a rigid or semi-rigid device which is used for the purpose of supporting a
weak or deformed body member or restricting or eliminating motion in a diseased or injured part
of the body. An orthosis can be either prefabricated or custom-fabricated.
PREFABRICATED ORTHOSIS
A pre-fabricated orthosis is one which is manufactured in quantity without a specific patient in
mind. A prefabricated orthosis may be trimmed, bent, molded (with or without heat) or otherwise
modified for use by a specific patient (i.e., custom fitted). An orthosis that is assembled from
prefabricated components is considered prefabricated. Any orthosis that does not meet the
definition of a custom-fabricated orthosis is considered prefabricated.
PROSTHETIC DEVICES
Prosthetic devices are replacement, corrective or supportive devices prescribed by a physician (or
other licensed practitioner of the healing arts within the scope of his practice as defined by state
law) to:
a. Artificially replace a missing portion of the body;
b. Prevent or correct physical deformity or malfunction; or
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c. Support a weak or deformed portion of the body (as defined by 42 CFR § 440.120(c)).
For Nevada Medicaid’s DMEPOS program purposes, dentures and eyeglasses are not included as
a prosthetic device.
SPEECH GENERATING DEVICE (SGD)
SGDs, also commonly known as “Augmentative and Alternative Communication” (AAC) devices
are electronic aids, devices or systems that correct expressive communication disabilities that
preclude an individual from meaningfully participating in activities of daily living. SGDs are
covered as DME. Requests for SGDs must provide the information required in Appendix B to this
Chapter of the Medicaid Services Manual (MSM).
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1303 POLICY
1303.1 DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, ORTHOTIC DEVICES,
DISPOSABLE MEDICAL SUPPLIES (DMEPOS) PROGRAM
A. GENERAL INFORMATION
1. DMEPOS Program coverage areas include parenteral and enteral nutrition (PEN),
medical foods, and oxygen and oxygen equipment, all of which must meet the
definition of durable medical equipment, a prosthetic device, an orthotic device or
disposable medical supply.
2. Durable Medical Equipment (DME) of a medical nature, needed as a result of a
medical condition and which lasts a considerable time without significant
deterioration and appropriate for use where normal life activities take place, is
covered by the DHCFP and NCU for eligible recipients. New equipment, repairs or
replacement requires medical documentation and are subject to limitations of
model, cost and frequency, which are deemed reasonable by the program.
3. Disposable medical supplies are covered by the DHCFP and NCU for eligible
recipients only if they are necessary for the treatment of a medical condition and
would not generally be useful to a person in the absence of an illness, disability or
injury.
4. All DMEPOS products and services must be medically necessary, safe and
appropriate for the course and severity of the condition, using the least costly and
equally effective alternative to meet the recipient’s medical needs.
5. Deluxe equipment will not be authorized when it is determined that a standard
model will meet the basic medical needs of the recipient. The recipient must have
a medical need for each component of the item(s) requested. This includes
accessory items and features not included in the standard models of the product.
6. Equipment which the program determines is principally for education or
rehabilitation will not be approved.
7. Refer to Appendix A of this Chapter for non-covered services, and for special
coverage considerations that are based on medical necessity outside of the
DMEPOS Program or that is considered under the Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) Healthy Kids Program.
8. Refer to Appendix B of this Chapter, for Coverage and Limitation Policies
regarding specific coverage information, qualifications, documentation
requirements and miscellaneous information.
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9. Refer to the Provider Type 33 DMEPOS Fee Schedule for specific item coverage
under the DMEPOS program.
Access http://dhcfp.nv.gov/Resources/Rates/RatesCostContainmentMain.
10. The DHCFP does not reimburse for items that are the same or similar to items that
the recipient has already acquired or has access to such as, but not limited to, back-
up equipment, unless allowed in the specific policy for that item. Duplicate items
intended to be used within the same span of time are not considered medically
necessary.
11. Individuals deemed eligible for Nevada Medicaid or NCU and who have ownership
of existing equipment from any prior resource must continue using that equipment.
Existing equipment, regardless of who purchased it, must be identified, including
the estimated date of purchase or age of equipment and medical documentation
showing evidence of need for replacement. All documentation must be submitted
with a prior authorization request.
12. Some items not covered under the DMEPOS Program may be covered under other
Medicaid programs such as Pharmacy, Audiology or Ocular programs. Additional
resources may be available through other agencies or through waiver programs for
items not covered under the DMEPOS Program or by the Medicaid State Plan.
B. PROVIDER RESPONSIBILITY
1. All DMEPOS providers must be licensed through the Nevada State Board of
Pharmacy (BOP) as a Medical Device, Equipment and Gases (MDEG) supplier,
with the exception of a pharmacy that has a Nevada State Board of Pharmacy
license and provides DMEPOS. Once licensed, providers must maintain
compliance with all Nevada BOP licensing requirements. Reference Medicaid
Services Manual (MSM) Chapter 100 – Medicaid Program for further information
on enrollment and provider responsibilities. Also refer to the Enrollment Checklist
posted on the following website at: https://www.medicaid.nv.gov.
2. Suppliers of products covered under the Medicare Part B program are required to
be enrolled in the Medicare Part B program in order to provide those services to
Medicare and Medicaid dually eligible recipients. This includes obtaining and
maintaining the Centers of Medicare and Medicaid Services (CMS) required
accreditation and surety bond.
3. Potential providers who are not enrolled with the Medicare Part B program and who
will not be supplying products covered under the Medicare Part B program to
individuals eligible for Medicare are required to provide a statement on/with their
application that requests a waiver of the requirements for Medicare Part B
enrollment. This statement must indicate that they do not service Medicare-eligible
individuals and include a listing of the products they plan to supply.
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4. A DMEPOS provider must adhere to all Federal Rules and Regulations applicable
to their provider type including, but not limited to, 42 CFR Part 440 for enrollment.
i.e. not limited to: storefront, background checks, etc.
5. A Medicaid-contracted DMEPOS provider may be reimbursed for services
rendered to Medicaid eligible recipients when provided in accordance with
established policies, guidelines and timeframes.
6. The provider is responsible for ensuring the equipment is appropriate for the
recipient and the recipient’s location of normal life activities prior to billing the
DHCFP.
7. The provider is responsible for providing a manufacturer’s suggested retail pricing
(MSRP) invoice for certain items, where no rate has been established.
8. The DMEPOS provider must comply with additional requirements as specified
throughout this Chapter and its Appendices, Medicaid Services Manual (MSM)
Chapter 100, the Provider Type (PT) 33 DMEPOS Fee Schedule, the Provider
Billing Manual and DMEPOS Billing Guidelines.
9. The provider is responsible to teach the recipient, caregivers or authorized
representative(s) about the operation, proper use, maintenance requirements and
any unacceptable use of the medical equipment.
C. RECIPIENT RESPONSIBILITY
The eligible Nevada Medicaid or NCU recipient and/or their authorized representative will:
1. Make and keep appointments necessary for securing medical services/equipment;
2. Present current verification of Nevada Medicaid or NCU eligibility;
3. Present any forms or identification necessary to utilize other health insurance
coverage;
4. Contact and return to the provider of services/equipment for any necessary
adjustment within the time allotted for such adjustments;
5. Maintain the equipment provided by routinely cleaning and caring for the devices
according to user information and supplier’s guidance. Provide safe, secure storage
for item(s) when not in use to protect item(s) from loss or theft;
6. Not misuse, abuse or neglect purchased or rented item(s) in a way that renders the
item(s) unsafe, non-usable or shortens the lifetime of the item;
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7. Return all rented equipment to the DMEPOS provider when no longer being used,
or upon the DME provider’s request. Failure to return rented equipment could result
in a recipient’s financial responsibility for the retail price of the rented equipment,
even if the equipment is lost/stolen, the recipient has moved or they are no longer
eligible for Nevada Medicaid/NCU.
8. Comply with additional requirements as specified throughout this Chapter and its
Appendices and MSM Chapter 100.
1303.2 DOCUMENTATION REQUIREMENTS
A. Supplier/provider records must substantiate the medical necessity for all DMEPOS items
dispensed to recipients. The following describes the requirements for specific types of
documentation associated with DMEPOS.
1. ORDERS/PRESCRIPTIONS
a. All DME items, Prosthetics, Orthotics or Disposable Supplies (POS)
dispensed must have an order/prescription from the treating physician or
practitioner, (To determine included practitioners, refer to MSM Chapter
600 – Physician’s Services), such as a Physician’s Assistant (PA) or
Advanced Practitioner of Nursing (APN), when within their scope of
practice and in accordance with federal and state laws governing that entity,
prior to dispensing the item.
In accordance with the Patient Protection and Affordable Care Act
(PPACA) (The Affordable Care Act) of 2010 (Public Law 111-148), all
orders for DMEPOS items, whether verbal or written, must be
incidental/relevant to the treating physician-documented face-to-face
encounter between the recipient and the prescribing physician/practitioner
(as allowed by The Act) within 30 - 60 days prior to the start date of the
order/script. The encounter must be clearly documented and relevant to the
need for the prescribed DMEPOS.
Refer to Appendix B of this Chapter for additional order requirements on
specific products.
General standards of care/practice mandate that if an order is not clear, a
clarification of the order must be obtained from the ordering practitioner
prior to acting on it.
b. Verbal Orders:
1. Verbal orders from the prescribing physician/practitioner may be
accepted for DMEPOS items that do not require prior authorization
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by the DHCFP (except when Medicare is primary and Medicaid co-
payment will be requested, and Medicare requires a written order
for that item prior to delivery). Refer online to the DME MAC
Jurisdiction D Supplier Manual, Chapter 3 – Documentation
Requirements, for a current listing of those items at:
https://med/noridianmedicare.com/web/jddme/education/supplier-
manual
2. The verbal dispensing order must include:
a. A description of the item;
b. The recipient’s name;
c. The physician’s name;
d. The start date and length of need of the order; and
e. Additional information sufficient to allow appropriate
dispensing of the item.
3. Suppliers must maintain written documentation of the verbal order
and, if the verbal order is used for dispensing the item, the supplier
must obtain a detailed written order prior to billing the DHCFP.
c. Written Orders:
1. Written orders are acceptable for all transactions involving
DMEPOS and must be obtained prior to submitting a prior
authorization for any DMEPOS items. Written orders may take the
form of a photocopy, facsimile image, electronically maintained or
original “pen-and-ink” document.
2. All written orders must, at a minimum:
a. Clearly specify the start date of the order;
b. Include the length of need;
c. Be sufficiently detailed, including all options or additional
features that are needed to meet the recipient’s needs. The
description must be either a narrative description (e.g.,
lightweight wheelchair base) or a brand name/model
number; and
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d. Be signed and dated by the treating physician/practitioner.
Signature includes computer signature and pen and ink, no
signature stamps allowed.
3. Certain items require additional elements in the written orders, as
follows:
a. If the written order is for supplies that will be provided on a
periodic basis, the written order must include appropriate
information on the quantity used, frequency of change and
duration of need. (For example, an order for surgical
dressings might specify one 4x4-hydrocolloid dressing that
is changed one to two times per week for one month or until
the ulcer heals).
b. If the written order is for an item such as, but not limited to,
enteral formula, oxygen, etc., the order must specify the
name of the product, concentration (if applicable), dosage,
frequency and route of administration and duration of
infusion (if applicable).
c. Custom-fabricated items must be clearly indicated on the
written order that has been signed and dated by the
prescribing physician/practitioner.
4. There are additional specifications for orders for certain items, such
as, but not limited to, Power Mobility Devices (PMDs). Refer to
Appendix B for details.
5. The detailed description of the item(s) may be completed by an
employee of the ordering physician/practitioner; however, the
prescriber must review the detailed description and personally
indicate agreement by signing and dating the order.
6. Medical necessity information (such as the most current appropriate
diagnosis code(s) (ICD), narrative description of the recipient’s
condition, abilities and limitations) is not in itself considered to be
part of the order although it may be put on the same document as the
order.
d. New Orders Are Required When:
1. There is a change in the order of a specific DMEPOS item;
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2. There is a change in the resident’s condition that warrants a change
in the order, a change in the treating physician/practitioner or
DMEPOS supplier;
3. An item is replaced for any reason; or
4. An ongoing unchanged order continues to be medically necessary
one year after the original order (orders are only valid for up to one
year, unless documented with a shorter length of time).
2. DETAILED PRODUCT DESCRIPTION
The detailed product description must contain the Healthcare Common Procedure
Coding System (HCPCS) code, manufacturer, make and model and the
provider’s/supplier’s invoice for each item supplied. The warranty information
must also be included. This may be completed by the provider/supplier but can also
be documented by the physician.
3. PROOF OF DELIVERY (POD)
A POD is a supplier’s delivery receipt, which is dated and timed.
NOTE: Item(s) ordered must be delivered within 120 days of the date of the order.
4. ADDITIONAL MISCELLANEOUS MEDICAL RECORDS
The recipient’s medical records must contain sufficient documentation of the
recipient’s medical condition to substantiate the necessity for the type and quantity
of items ordered and the frequency of the use or replacement. The information must
include the recipient’s diagnosis and other pertinent information, including but not
limited to: duration of recipient’s condition, clinical course (deteriorating or
improving), prognosis, nature and extent of functional limitations, other therapeutic
interventions and results, past experience with related items, etc. The records must
include physician’s office records, hospital, nursing home or home health records,
records from other professionals including but not limited to: nursing, physical and
occupational therapists, prosthetists and orthotists, although medical necessity for
item(s) requested must be stated by the prescribing physician/practitioner.
5. ADVANCED DETERMINATION OF MEDICARE COVERAGE (ADMC)
When Medicare is the primary payer, for all items requiring an ADMC (refer online
to the DME MAC Jurisdiction D, Supplier Manual, Chapter 9). The ADMC
determination must be submitted to the Quality Improvement Organization (QIO)-
like vendor at the same time the prior authorization is submitted.
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B. PROVIDER RESPONSIBILITY
1. The provider must obtain the required documentation in a timely manner as
described under each section listed previously.
2. The provider must maintain records at the physical location of their business for
each item billed to, and paid by, the DHCFP for at least six years from the
Remittance Advice (RA) date. At a minimum, this includes the original signed
order/prescription, all supporting medical documentation, and proof of delivery.
3. The provider must maintain records in a readily accessible location and, for audit
and investigation purposes, to make available upon request by Medicaid staff or its
contractors, all supporting information related to prior authorizations, dispensed
items and/or paid clams for DMEPOS items.
1303.3 RENTAL AND PURCHASE OPTIONS
Items identified in the DMEPOS Fee Schedule with an RR modifier for rental and an NU modifier
for purchase option may require prior authorization to determine if the recipient’s needs justify
rental or purchase based on the item prescribed, the individual’s anticipated length of need and
prognosis (as determined by the prescriber) and cost effectiveness to the DHCFP and NCU. If a
Nevada Medicaid rate has not been assigned, an MSRP invoice is required to be submitted with
the prior authorization (PA) request or claim, if a PA is not already required for that item.
A. RENTAL
1. In addition to all other requirements and qualifications for specific products, if the
DMEPOS Fee Schedule allows a rental option, a device may be rented when:
a. the anticipated length of need (per physician’s/practitioner’s order) is short
term (six months or less) and rental would be more cost effective than
purchase;
b. a temporary trial period is required for the item according to Medicaid’s
policy;
c. the item is only available as a rental per the DMEPOS Fee Schedule; or
d. a temporary rental is needed while a recipient-owned like item is being
repaired.
2. During a rental period, rental rates include all supplies and accessories necessary to
render the equipment useable and safe, delivery and set up services, education and
training for recipient and family, routine maintenance and servicing (such as
testing, cleaning, regulating and checking equipment), repairs, non-routine
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maintenance and servicing (such as breaking down sealed components and
performing tests which require specialized equipment and skills of a technician)
and replacement of items. These services are the responsibility of the owner, the
DMEPOS supplier.
3. Throughout any rental period, there must be an active physician’s/practitioner’s
order for ongoing use, the prior authorization effective dates are still applicable and
there is a continued medical need for the item. The DMEPOS supplier must contact
the recipient or their representative within five business days prior to each billing
cycle to verify the rented item is still medically necessary, in working condition
and being used by the recipient (contact does not include system generated
correspondence). Verification must be documented and maintained in the
DMEPOS supplier’s records and be accessible for audits.
4. Rent-to-Purchase Option:
a. The DHCFP allows rental of certain DMEPOS items up to the maximum
Medicaid allowable purchase price of the item.
b. Only certain equipment, as specifically defined by Medicaid, will be rental
only. Once the total cumulative payments have reached the maximum
Medicaid allowable purchase rate, then the item is considered purchased in
full and recipient-owned.
c. The provider shall automatically transfer the title for the equipment to the
recipient. Providers are not to submit prior authorizations to transfer titles.
Providers are also not to submit prior authorizations coded as a purchase
after the Medicaid allowable purchase rate is reached. No rental or purchase
payments will be made for the remaining reasonable useful lifetime of the
device (usually not less than five years (60 months)). The provider’s records
must include the date the title was transferred to the recipient.
d. When an item was new at the time of issuance, and it is later determined the
recipient will need the item long term, rental payments will be applied
toward the total purchase rate (the Medicaid allowable or if no Medicaid
rate exists, the MSRP invoice). Refer to “Purchase Used Equipment
Option” in Section 1303.
e. Equipment that was not new at the time of issuance, such as items from the
provider/supplier rental fleet, supplied as a temporary short term rental item
must be replaced with new equipment as soon as it is identified the recipient
will need the device long term (no later than in the sixth month of rental).
Payments made on rental fleet-type items will not be applied to the purchase
price of a new item. Purchase or transfer of titles to recipients when the used
equipment is from a rental fleet is not allowed.
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f. For this option, non-routine maintenance and servicing or repairs may be
covered for service dates after the item is owned by the recipient; no sooner
than the month following the last rental month.
5. Rental Only Option:
a. Only specific equipment will be identified by Nevada Medicaid as a rental
only. For these items, a monthly rental will be allowed as long as the
recipient continues to meet all qualifications and requirements, and the
recipient continues to use the device.
b. For this option, the DMEPOS supplier retains ownership of the equipment,
regardless of the length of rental. As the owner, the DMEPOS supplier is
responsible to ensure the equipment remains in safe working condition for
the reasonable useful lifetime of the device. The rental rates include all
supplies and accessories, repairs including routine and non-routine
maintenance and servicing, and replacement of items when needed.
B. PURCHASE
1. Purchase New Equipment Option:
a. Certain products are identified by Nevada Medicaid in the DMEPOS Fee
Schedule with a purchase option for new equipment, or can only be
purchased, such as disposable supplies and custom-made items which can
only be used by that recipient. These will be considered for purchase when,
in addition to all other requirements and qualifications for a specific
item/device:
1. the anticipated length of need (per physician’s order) is long term
(more than six months); and
2. the provider will be supplying a new device/item to the recipient; or
3. the item is only available for purchase.
2. Purchase Rental Equipment Option:
a. Nevada Medicaid identifies specific products for purchase when an item
was new at the time it was dispensed to a recipient for rental purposes, and
prior to billing the third month of rental, if it is determined the item will be
needed indefinitely, the DHCFP may purchase the item for the recipient for
ongoing use. The DHCFP does not purchase used equipment from the
provider’s inventory of rental items used for re-issuance to same or multiple
persons over time (rental fleets, etc.).
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b. The DHCFP will only purchase equipment when, in addition to all other
requirements and qualifications for the item:
1. the recipient meets the criteria for purchase of new equipment;
2. the item was new when placed in the recipient’s use and has been
used for less than three months; and
3. the item is currently being used by the same recipient during a trial
period and it has been determined the length of need will now be
indefinite.
c. A prior authorization must be submitted to request purchase of a rented
piece of equipment with all supportive medical documentation to show the
date the item was initially issued to the recipient and that the recipient
continues to have an ongoing need for the item.
1303.4 PRIOR AUTHORIZATION
A. Prior authorization is a review conducted by the Quality Improvement Organization (QIO)-
like vendor’s medical professionals who review the prior authorization form and any
additional information submitted to evaluate medical necessity, appropriateness, location
of service and compliance with the DHCFP’s policy, prior to delivery of service. Reference
MSM Chapter 100 and the general Billing Manual for detailed information on prior
authorizations and Medicaid eligibility for all providers at:
http://www.medicaid.nv.gov/providers/BillingInfo.aspx.
1. Submission:
a. Prior authorizations must be completed and submitted by a current
Medicaid provider (requestor), and the approval must be received prior to
delivery of services. The exception to this is if the recipient is determined
eligible for Medicaid retroactively or if number four of this section applies.
b. A prior authorization is required for most durable medical equipment,
prosthetics, orthotics and oxygen.
c. A Medicaid provider may submit the prior authorization electronically
using the QIO-like vendor’s on-line prior authorization system or may fax
or mail the prior authorization to the QIO-like vendor. For more
information, refer to the prior authorization section posted at:
https://www.medicaid.nv.gov.
d. Requestors must submit a prior authorization with the most appropriate
HCPCS code available and may not unbundle items included in the HCPCS
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code description. If an item has a designated code available, the
miscellaneous code cannot be used. Providers may contact the Medicare
Pricing, Data Analysis and Coding (PDAC) contractor or the DME MAC
for guidance on correct coding.
e. Documentation requirements are the same regardless of which mode of
submission is used (e.g. the on-line prior authorization system, faxed or
mailed). Documentation submitted for consideration of the request must
include the physician’s order and must clearly support coverage
qualifications and recipient’s medical need for the equipment. Failure to
provide all of the supporting medical documentation in its entirety, and
within the required timeframes, will result in a denial of the prior
authorization request, regardless of mode of submission.
f. Unless otherwise stated in policy, a prior authorization may be submitted to
request authorization to exceed established quantity limitations when the
medical documentation supports medical necessity for the increased
quantity or frequency.
2. Review Consideration:
a. In addition to the specifications mentioned previously for reviewing the
prior authorization, products and services must be medically necessary, safe
and appropriate for the course and severity of the condition using the least
costly equally effective alternative to meet the recipient’s needs.
b. The recipient must have a medical need for and the requested item must be
suitable for use for locations in which normal life activities take place.
Consideration will also be based on the recipient’s additional use of the item
for the conditions in each of the environments the recipient is likely to
encounter in their daily routines, such as, but not limited to: attending
school, work and shopping. This information must be included in the
supportive documentation submitted with the prior authorization.
c. For durable medical equipment, prosthetics, orthotics and disposable
medical supplies and appliances where coverage and limitation policies
have not been established within this Chapter or its Appendices, the DHCFP
may defer to DME MAC Jurisdiction D, Local Coverage Determination
(LCD) and policy articles for coverage and limitation criteria. These can be
accessed at: https://med.noridianmedicare.com/web/jddme. The item must
meet the definition of durable medical equipment, prosthetic, orthotic or
disposable medical supply and must be necessary to meet the medical needs
of the recipient and must be part of the prescribing
physician’s/practitioner’s Plan of Care (POC).
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d. The DHCFP has the option of requesting an Independent Medical
Evaluation (IME) to determine the recipient’s limitations and abilities to
support medical necessity.
3. Prior Authorization Requirements for Third Party Liability (TPL) and Medicare
Crossovers:
a. Refer to MSM Chapter 100, for more information on TPL, and Medicare
Crossovers and the requirements for securing prior authorizations.
4. Prior Authorization Emergency Situations:
a. In an emergency situation, when an order is received by the supplier after
the QIO-like vendor working hours or over weekends or State holidays,
dispensing of a 72-hour supply of those DMEPOS items that require prior
authorization will be allowed only when:
1. A delay of 24 hours of treatment could result in very severe pain,
loss of life or limb, loss of eyesight or hearing, injury to self or
bodily harm to others; and
2. The treating physician/practitioner indicates the most current
appropriate diagnosis code(s)/ICD code on the prescription that
supports the use of the emergency policy.
b. The provider/supplier must submit the prior authorization the next business
day with all required supportive documentation. The documentation must
include proof of the date and time the order was received by the supplier
and documentation to support both 1303.4(a)(1) and (2).
5. DMEPOS Specific Prior Authorization Forms:
All forms must be completed and submitted by a current Medicaid provider. Forms
used must be the most current version.
a. Specific DME prior authorization forms are found on the QIO-like vendor’s
website: https://www.medicaid.nv.gov/providers/forms/forms.aspx. All
DMEPOS items that require prior authorization must be requested on these
forms and submitted electronically, by fax or by mail to the QIO-like vendor
for approval.
b. Usage Evaluation – For Continuing Use of Bi-Level and Continuous
Positive Airway Pressure (BIPAP and CPAP) Devices use the form, FA-1A
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found on the QIO-like vendor’s website. This form may be completed and
submitted for continuing usage of BIPAP or CPAP devices.
c. Mobility Assessment for Mobility Devices, Wheelchair Accessories and
Seating Systems, form FA-1B found on the QIO-like vendor’s website. This
form must be submitted for all mobility devices, wheelchair accessories and
seating systems. The Clinical Assessment must be completed and signed by
the treating physician.
6. Denied Prior Authorization Requests:
a. There are various processing levels associated with prior authorization
requests which do not support medical necessity. These may include but are
not limited to: a contact to the provider by the QIO-like vendor, a system
generated technical denial, a system generated denial or reduction of
services, a provider-requested reconsideration, a provider-requested peer-
to-peer review with the physician. For additional information on the below
time limits and an explanation of each, refer to the general Billing Manual
for all providers at:
https://www.medicaid.nv.gov/providers/billinginfo.aspx.
1. If a prior authorization request is denied or reduced, the provider and
recipient will be sent a Notice of Decision (NOD) with a
citation/reason to provide a general explanation of the denial.
a. The provider may request a peer-to-peer review within 10
days of the date of decision via phone contact to the QIO-
like vendor.
b. The provider may request consideration of the denial by
submitting additional medical documentation and requesting
a reconsideration in writing via fax within 30 days of denial.
c. If a reconsideration is not appropriate or is also denied, the
recipient may be entitled to request a hearing within 90 days
from the date of decision. Refer to MSM Chapter 3100 –
Hearings.
B. COVERAGE AND LIMITATIONS
1. Coverage and limitations are explained throughout this Chapter, including its
appendices. Appendix B details coverage qualifications, prior authorization
documentation requirements, and limitations for specific items.
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2. Refer to the Nevada Medicaid Provider Type 33 – DME Fee Schedule posted at:
http://dhcfp.nv.gov/Resources/Rates/FeeSchedules/ for covered services. The Fee
Schedule identifies covered services/items (listed in alpha-numeric order according
to HCPCS code), and rates. Codes are updated yearly. Codes not included in the
fee schedule after the yearly update are considered non-covered.
C. PROVIDER RESPONSIBILITY
1. The requesting DME provider (supplier) and the prescribing physician/practitioner
must work collaboratively to accurately and timely complete and submit prior
authorization requests, including all supportive documentation in order to ensure
the item(s) being requested is/are the most appropriate to meet the recipient’s
medical needs. This must be done prior to dispensing any DMEPOS item requiring
a prior authorization. Refer to the prior authorization section of the general Billing
Manual for all providers and PT 33 Billing Guidelines
at: https://www.medicaid.nv.gov/providers/BillingInfo.aspx for detailed
information on form completion and submission/transmission of prior authorization
requests.
2. In the event additional information is requested by the QIO-like vendor, the
provider should submit the requested information within established time limits,
and/or review the notice of decision to determine the reason for denial, make any
necessary corrections, continue to work collaboratively with the prescribing
physician/practitioner to obtain medical justification, and/or when appropriate,
request a reconsideration by providing additional supportive information to justify
the medical need for the equipment. Refer to the general Billing Manual for all
providers for details on denied requests.
D. RECIPIENT RESPONSIBILITY
1. The recipient and/or their representative must accurately represent their needs in
relationship to obtaining medical equipment.
2. The recipient must attend appointments with Physical Therapy (PT), Occupational
Therapy (OT) and/or physician/ practitioners for the purpose of evaluation for
DMEPOS, and with DME providers for adjustments and servicing of equipment.
3. The recipient and/or representative must provide the written order/prescription
from the physician/practitioner. If assistance is needed to obtain DMEPOS, the
recipient or their authorized representative should contact the local Nevada
Medicaid District Office Care Coordination unit for assistance. The exception to
this is if the ordering physician/practitioner submits the information directly to the
DME provider/supplier on behalf of the recipient.
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4. The recipient and/or their authorized representative must present proof of identity
and provide documentation of Medicaid coverage and any form of identification
necessary to utilize other health insurance coverage.
1303.5 DISPENSING AND DELIVERY OF DMEPOS
A. Dispensing/Duration of Orders
Medical supply orders must be dispensed at a monthly interval. DMEPOS is dispensed
according to the physician’s orders, subject to coverage limitations. The physician’s order
for medical supplies is valid up to one year. Suppliers may not ship items on a regular,
monthly basis without documentation from the recipient, family member or authorized
representative that the supply is needed. Documentation of this need must be kept on file.
It is acceptable for the supplier to contact the recipient to verify a re-order.
B. Delivery of DMEPOS
1. Delivery Method 1. Supplier delivering items directly to the recipient or authorized
representative:
a. The delivery receipt must include the signature and the signature date which
must match the date the DMEPOS item was received by the recipient or
their authorized representative to verify the DMEPOS item was received.
b. The delivery receipt must include the recipient’s name, quantity, a detailed
description of the item(s) delivered, brand name, make and model, serial
number (if applicable) and date and time of delivery.
c. The date of service on the claim must be the date the DMEPOS item was
received by the recipient or their authorized representative. An exception to
this would be when an item must be billed using a date span and the quantity
dispensed crosses over into the next month.
2. Delivery Method 2. Suppliers utilizing a delivery/shipping service to deliver items:
a. An acceptable delivery/shipping service receipt POD includes the supplier’s
shipping invoice (Bill of Lading (BOL or BL)).
b. The supplier’s BOL must include the recipient’s name, quantity, detailed
description of the item(s) delivered, brand name, make and model, serial
number (if applicable), date and time of delivery/shipment and delivery
service package identification number associated with recipient’s
package(s).
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c. The POD must reference the recipient’s package(s), delivery address and
the corresponding package identification number given by the delivery
service.
d. Without the POD that identifies each individual package with a unique
identification number and delivery address, the item will be denied and any
overpayment will be recouped.
e. Nevada Medicaid only reimburses out-of-state providers for mail order
supplies for a recipient who is on Medicare and the supply is Medicare
covered. Nevada Medicaid does not reimburse for shipping or delivery
service costs.
1303.6 REPAIR, REPLACEMENT AND WARRANTY OF EQUIPMENT
A. REPAIR
1. Repair means to fix or mend a non-functioning part of equipment and to return
damaged or worn equipment back to a safe operating condition. Repair of a base
piece of equipment is appropriate when the lifetime limit of five years has not been
exceeded and repair of the item is more cost effective than replacement.
2. Reimbursement to the provider may be made for repairs of recipient-owned
medically necessary equipment. Medical documentation by the prescribing
practitioner must be submitted to support the recipient’s ongoing medical necessity
for the item needing repair. Additionally, the prior authorization must substantiate
use within normal life activities and the absence of inappropriate use, culpable
neglect, malicious involvement or wrongful disposition on the part of the recipient,
their legal representative or their caregivers. It must indicate the equipment was
being used appropriately in a manner prescribed or recommended. The prior
authorization and claim must include HCPCS modifier RB for all DMEPOS parts
furnished as part of the repair.
3. If a recipient-owned piece of medically necessary equipment requires repairs that
will take more than a day and the recipient needs the device while the repairs are
being performed, the provider must submit a prior authorization to request
temporary (up to one month) rental of an equivalent item which can meet the
recipient’s basic medical needs while the recipient-owned item is being repaired.
4. Repairs to equipment owned or rented by a DMEPOS provider or an institutional
facility in which the recipient is receiving services will not be covered by Nevada
Medicaid or NCU.
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5. Repair HCPCS codes are not to be used for: routine serving, cleaning, installation,
delivery, set-up, travel necessary to make a repair or for services covered by
warranty as these costs are included in the cost of the item.
6. A re-manufactured part with a warranty used to make a repair is considered used
equipment and must be billed as such, using the HCPCS modifier UE.
B. REPLACEMENT
1. Replacement of recipient-owned equipment refers to the provision of an identical
or nearly identical item. Replacement may be considered on a case–by–case basis
when prior authorization request substantiates the need for the replacement and is
a result of either:
a. Irreparable Wear: due to significant deterioration sustained from day-to-day
use over time and a specific event (as indicated below) cannot be identified.
Replacement of equipment due to irreparable wear takes into consideration
the useful lifetime limit of five years and distances or locations in which a
person that is not disabled, ill or injured would not exceed for mobility
purposes. The prior authorization must substantiate use within normal life
activities and the absence of culpable neglect, inappropriate use, malicious
involvement or wrongful disposition on the part of the recipient, their legal
representative or their caregiver. Intentional utilization of DME in a manner
not prescribed or recommended, such as an excessive form of transportation
may be reason for denial of equipment replacement.
b. Irreparable Damage: due to a specific accident or natural disaster (e.g., fire,
flood) which resulted in irreparable damage or loss. These requests may be
considered only when the prior authorization request includes a copy of a
police or fire report, documentation from Federal Emergency Management
Agency (FEMA), the American Red Cross or a newspaper article that
indicates the recipient’s residence was affected by the disaster. Police or fire
reports will only be considered if filed/dated within ten business days of the
loss. The prior authorization must substantiate the absence of inappropriate
use, culpable neglect, malicious involvement or wrongful disposition on the
part of the recipient, their legal representative or their caregiver. The prior
authorization and claim must include HCPCS modifier code RA for all
DMEPOS provided as a replacement. Nevada Medicaid and NCU are
payers of last resource and would be secondary to any insurance
claim/reimbursement. Reference MSM Chapter 100 – Medicaid Program.
2. Replacement of any recipient-owned item, regardless of how it was originally
acquired, requires a new physician’s/practitioner’s order and the recipient must
meet current qualifications for the item. Any assessment(s) necessary to support
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
medical necessity must have been completed within six months of the date of
request.
3. Lost or stolen DMEPOS resulting from failure to maintain possession or properly
secure the item is not covered by Nevada Medicaid or NCU.
C. WARRANTY
1. The purchase of many items includes a product warranty by the manufacturer
and/or the DMEPOS provider. Any service (item or labor) covered by warranty
cannot be billed to Nevada Medicaid or NCU, the recipient or their representative.
2. The requesting provider must obtain verification that any repairs or replacement
items being requested are not covered under the existing warranty. This
documentation must be submitted with the prior authorization.
1303.7 SECTION RESERVED FOR FUTURE USE
1303.8 SECTION RESERVED FOR FUTURE USE
1303.9 DME AT INSTITUTIONAL FACILITY (IF)
A. The DHCFP’s hospital and nursing facility rates for an inpatient stay are all inclusive and
cover all items needed by the patient during the length of stay. Refer to MSM Chapter 500
Nursing Facilities for information on nursing facility policy. This includes all:
1. Disposable supplies;
2. Wound care supplies;
3. Urological supplies;
4. Respiratory supplies;
5. Metabolic, Nutritional and Temperature supplies;
6. Endocrine supplies;
7. Fluid and Electrolyte supplies;
8. Dental supplies;
9. Emollient supplies; and
10. Supplements.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
B. Prosthetics and Orthotics
Prosthetics and Orthotics: Are included in the all-inclusive per-diem if provided to a patient
during an inpatient hospital prior to discharge and the patient uses item for medically
necessary inpatient treatment or rehabilitation. (e.g. after spinal surgery).
C. DME that cannot be utilized by another recipient due to its unique custom features (e.g.
seating system), are not part of the institution’s inclusive rate.
1. All DME must be prior authorized for exception to inclusive facility rates.
2. Hospital and nursing facility patients may be approved for wheelchairs in
preparation for discharge. The DHCFP may approve power chairs one month in
advance of discharge. Physician documentation to substantiate discharge date may
be required.
3. Specialized or custom-made items which will be needed by the patient upon
discharge may be requested during the inpatient stay. However, approval of the
items may be restricted to delivery to the patient at the time of discharge to his
home or other place of residence. Providers of requested items will be paid directly
only if the required prior authorization has been approved. Facilities will not be
paid for items supplied by another provider.
1303.10 SECTION RESERVED FOR FUTURE USE
1303.11 SECTION RESERVED FOR FUTURE USE
1303.12 SECTION RESERVED FOR FUTURE USE
1303.13 SECTION RESERVED FOR FUTURE USE
1303.14 SECTION RESERVED FOR FUTURE USE
1303.15 UTILIZATION CONTROL
A. Pre-Service
The coverage, limitations and exclusions outlined in this chapter constitute pre-service
controls on over-utilization.
B. Pre-Payment
The QIO-like vendor will screen each claim for existence and/or application of prior
resources, correct coding of services and appropriate authorization form. In addition, each
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1303
Subject:
MEDICAID SERVICES MANUAL POLICY
claim will be screened for accuracy in computation and compliance with published
procedures.
C. Post-Payment
All providers offering services to Medicaid recipients are subject to post-payment review.
The Medicaid Program Integrity Section is responsible for review of any improper, abusive
or fraudulent practices. Definition of abuse and the sanctions to be imposed are delineated
in the Nevada MSM Chapter 100.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1304
Subject:
MEDICAID SERVICES MANUAL NON-COVERED SERVICES
1304 HEARINGS
Please reference the Division of Health Care Financing and Policy (DHCFP) Medicaid Services
Manual (MSM) Chapter 3100 for the Medicaid Hearings process
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY HEARINGS
Subject:
MEDICAID SERVICES MANUAL NON-COVERED SERVICES
APPENDIX A
NON-COVERED SERVICES
1. The DHCFP’s DMEPOS program does not cover items if they either do not meet the definition of durable
medical equipment, prosthetic, orthotic or disposable medical supplies; or are not considered primarily
medical in nature; or are not FDA approved or the approved use by the FDA is not applicable.
2. The DHCFP has the authority to establish reasonable standards, consistent with the objectives of the
Medicaid statute, for determining the extent of such coverage (42 U.S.C. § 1396(a)) based on such criteria
as medical necessity or utilization control (42 CFR 440.230 (d)). The DHCFP has an approved list of
covered DMEPOS items. The Provider Type 33 – DMEPOS Fee Schedule is available on the DHCFP
website at: http://dhcfp.nv.gov/Resources/Rates/FeeSchedules/.
a. The DHCFP is required to have a process and criteria for seeking modifications or exceptions to
established coverage policies. This process is available to recipients on a case-by-case basis for
DMEPOS items excluded from the DMEPOS Fee Schedule. Because a provider prescribes, orders
and/or recommends a service or supply does not, of itself, make it an eligible benefit.
b. Consideration will be made on a case-by-case basis using the following criteria:
1. The item must meet the definition of durable medical equipment, prosthetic, orthotic or
disposable medical supply as defined in Section 1302 – the Addendum Medicaid Services
Manual (MSM) Definitions;
2. The prescribing physician/practitioner must submit supporting documentation identifying
the individual’s specific medical needs that meet the standard definition of medical
necessity as defined in MSM Chapter 100 (e.g. physical assessment indicating the
limitations to be ameliorated by the use of the item(s), peer review documentation
indicating this is an accepted standard of care within Nevada’s medical community); and
3. The prescribing physician/practitioner must document that other items have been used and
were found ineffective. The requested item(s) must be the most cost-effective alternative,
medically necessary service, provided at the most appropriate level to meet the medical
needs of the recipient, that it is reasonable and accessible to the recipient.
c. Review chapter and fee schedule for coverage. If not located under this provider type but possibly
might be covered under other programs i.e.: EPSDT, nursing home, etc. please review the coverage
criteria and fee schedule for that specific provider type.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: INTRODUCTION AND GENERAL INFORMATION
Introduction
1. Appendix B is a supplement to the main body of Chapter 1300 and provides: specific coverage qualifications, forms and documentation requirements, and miscellaneous policies
related to specific items of durable medical equipment, prosthetic devices, orthotic devices or disposable medical supplies (DMEPOS).
2. For DMEPOS where coverage and limitations have not been addressed in this Chapter, its Appendices or the DMEPOS Fee Schedule, the Division of Health Care Financing
and Policy (DHCFP) may defer to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction D, Local Coverage Determinations (LCD)
and Policy Articles for coverage and limitations information. This information is available at https://www.noridianmedicare.com.
QUALIFICATIONS FORMS AND DOCUMENTATION REQUIREMENTS MISCELLANEOUS POLICY STATEMENTS
1. Qualifications identified for each specific item 1. Refer to the Documentation section and/or the Prior Refer to the main body of Chapter 1300 for general
listed within this Appendix must all be met for Authorization section in Chapter 1300 for detailed requirements DMEPOS policies.
coverage by the DHCFP. for each type of form. Additional form completion requirements 1. For all items, documentation must support all
2. All DMEPOS products and services must be are found in the Form Release Memorandums or Instructions on criteria in the Qualifications section, as specified
medically necessary, safe and appropriate for the the QIO-like vendor’s website at: in each category.
course and severity of the condition, using the least http://www.medicaid.nv.gov/providers/forms/forms.aspx 2. Providers must submit an approved prior
costly equally effective alternative to meet the 2. All documentation, reports, evaluations and testing must support authorization and claim using the most
recipient’s medical needs. medical necessity as specified under the Qualifications section. appropriate available HCPCS code and may not
3. If all qualifications are not met, refer to Appendix Requirements must be met for each specific item listed within unbundle items included in the HCPCS code
A for other possible coverage options. this Appendix and as specified for that item. description.
a. Physician’s/Practitioner’s Order/Prescription. 3. Rented devices are to be considered purchased by
b. Prior authorization form (when indicated) - Durable the DHCFP once the purchase price has been
Medical Equipment Prior Authorization Forms are reached. The exception to this is when the item is
available on the QIO-like vendor’s website at the above deemed as a rental only by the DHCFP. Refer to
link. There are specific forms for certain items of main body of Chapter 1300 and the DMEPOS
DMEPOS. Refer to policies to determine if a specific form Fee Schedule.
is required. Prior authorization is required to exceed 4. Inclusion of a HCPCS code in this Appendix is
program limitations. not an indication of coverage. Refer to the
c. All services provided in an institutional facility require a DMEPOS Fee Schedule and Appendix A.
prior authorization. 5. The DHCFP will not reimburse providers who
d. Detailed Product Description. supply DMEPOS prior to PA approval except in
e. Proof of Delivery. certain situations, such as retro eligibility.
f. Additional Miscellaneous Medical Records.
g. Manufacturer’s Suggested Retail Price (MSRP) Invoice (to
determine pricing) for certain items, where the DHCFP rate
has not been established.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BATHING AND TOILETING AIDS
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Commodes-standard 1. Medical evidence/ documentation recipient is 1. Physician’s/Practitioner’s Order/Prescription.
Commode pail physically incapable of utilizing regular toilet
Toilet Safety Frame- facilities; and
(versaframe) 2. Recipient has a supporting diagnosis.
Raised Toilet Seat
Bed Pan-plastic
Urinal
Shower Chairs 1. Recipient shows medical evidence/ 1. Physician’s/Practitioner’s Order/Prescription.
(with back and without documentation of incapability to utilize
back) regular bathing facilities; and
Tub Transfer Bench 2. Recipient has a supporting diagnosis.
(padded and non-
padded)
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BEDS (HOSPITAL) AND ACCESSORIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Fixed Height Hospital Medical evidence/documentation showing: 1. Prescription and/or MD signed Prior NOTE:
Bed 1. Recipient requires positioning of the body in Authorization Form.
ways not feasible with an ordinary bed due to 2. Medical documentation supporting qualifying Total Electric Hospital Beds; the electric
a medical condition lasting at least one factors. height adjustment feature is typically a
month; 3. An MSRP Invoice if there is no rate established convenience feature.
2. Alleviation of pain due to positioning of the by the DHCFP. Safety Beds/Enclosure Beds/Canopy are
body in ways not feasible with an ordinary primarily intended for prevention of injury
bed; and use is not primarily medical in nature. Per
3. Elevation of the head more than 30 degrees policy, medically necessary services and
due to a medical condition, i.e.: Congestive supplies are medically needed to diagnose,
Heart Failure (CHF), Chronic Obstructive treat or prevent illness or disease; regain
Pulmonary Disease (COPD), aspiration functional capacity; or reduce or ameliorate
problems. effects of an illness, injury or disability.
Although these beds may prevent injury, they
Variable Height Recipient meets the criteria for Fixed Height Bed are not considered care or treatment of
Hospital Bed (Manual) and requires a bed height different than a fixed disease or injury.
height bed to permit transfers to chair, wheelchair
or standing position.
Semi-Electric Hospital Recipient meets the criteria for a Fixed Height Bed
Bed and requires frequent changes in body position
and/or has an immediate need for a change in body
position.
Heavy Duty Extra Wide Recipient meets the criteria for a Fixed Height
Hospital Bed Hospital Bed and the recipient's weight is more
than 350 pounds, but does not exceed 600 pounds.
Extra Heavy Duty Recipient meets the criteria for a hospital bed and
Hospital Bed the recipient’s weight exceeds 600 pounds.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BEDS (HOSPITAL) AND ACCESSORIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Trapeze Bars 1. Medical evidence/documentation recipient 1. Prescription and/or MD signed Prior
needs assistance to sit up due to respiratory Authorization Form.
conditions, change body positions or to assist 2. Medical documentation supporting qualifying
in transfers in/out of bed. factors.
Lifts and Lift Slings 1. Medical evidence/documentation showing the 1. Prescription and/or MD signed Prior
recipient requires more than one person in Authorization Form.
assisting in transfers from bed/bath, 2. Medical documentation supporting qualifying
bed/commode or bed/chair. factors.
2. Must have an environment able to 3. An MSRP Invoice if there is no rate established
accommodate equipment. by the DHCFP.
3. Capable caregiver to assist with transfers.
Group 1 Support Recipient must meet the following criteria: 1. Prescription and/or MD signed PA Form. Product needs to be adequate enough to
Surfaces 1. Completely immobile (recipient cannot make 2. Medical documentation supporting qualifying prevent the recipient from bottoming out.
changes in body position without assistance); factors.
2. Limited mobility (recipient cannot
independently make changes in body position
significant enough to alleviate pressure); or
3. Any stage pressure ulcer on the trunk or
pelvis; and
a) At least one of the following:
i) Impaired nutritional status;
ii) Fecal or urinary incontinence;
iii) Altered sensory perception;
iv) Compromised circulatory status.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BEDS (HOSPITAL) AND ACCESSORIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Pressure Pad for (E0185) Gel/gel-like mattress overlay, with gel 1. Prescription and/or MD signed Prior
Mattress: Non- layer 2 inches or greater Authorization Form.
Powered Pressure (E0197) Air mattress overlay interconnected air 2. Medical documentation supporting qualifying
Reducing Mattress cells having a cell height of three inches or greater factors.
Overlays that are inflated with an air pump.
(E0198) Water mattress overlay with a filled
height of three inches or greater.
(E0199) Foam mattress overlay with base
thickness of two inches or greater and a peak
height of three inches or greater if it is a
convoluted overlay (egg-crate) or an overall height
of at least three inches if it is a non-convoluted
overlay. Foam with a density and other qualities
that provide adequate pressure reduction, and
durable waterproof cover.
1. Recipient must meet Group 1 support surfaces
criteria for qualification.
Non-Powered (E0184) Foam height of five inches or greater, and 1. Prescription and/or MD signed Prior
Pressure Reducing foam with a density and other qualities that Authorization Form.
Mattress provide adequate pressure reduction, and can be 2. Medical documentation supporting qualifying
placed directly on a hospital bed frame. factors.
(E0186, E0187, E0196) Air, water or gel mattress, 3. An MSRP Invoice if there is no rate established
height of five inches or greater of the air, water or by the DHCFP.
gel layer (retrospectively), and durable,
waterproof cover and can be placed directly on a
hospital bed frame.
1. Recipient must meet Group 1 support surfaces
criteria for qualification.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BEDS (HOSPITAL) AND ACCESSORIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Powered Pressure (E0181, E0182, A4640) Alternating pressure or 1. Prescription and/or MD signed Prior
Reducing Mattress low air loss systems; Air pump or blower which Authorization Form.
Overlay Systems provides either sequential inflation and deflation 2. Medical documentation supporting qualifying
of air cells or a low interface pressure throughout factors.
the overlay, and inflated cell height of the air cells 3. An MSRP Invoice if there is no rate established
through which air is being circulated is 2.5 inches by the DHCFP.
or greater, and height of the air chambers,
proximity of the air chambers to one another,
frequency of air cycling (for APP overlays) and air
pressure provide adequate patient lift, reduce
pressure and prevent bottoming out.
Recipient must meet Group 1 support surfaces
criteria for qualification.
Group 2 Support Recipient must meet the following criteria: 1. Prescription and/or MD signed Prior
Surfaces 1. Multiple stage II pressure ulcers located on Authorization Form.
the trunk or pelvis; 2. Medical documentation supporting qualifying
2. Recipient has been on a comprehensive ulcer factors.
treatment program for at least the past month 3. An MSRP Invoice if there is no rate established
which has included the use of an appropriate by the DHCFP.
Group 1 support surface.
a. Treatment includes patient/caregiver
education, regular assessment by a
licensed healthcare practitioner,
appropriate turning and positioning,
appropriate wound care, appropriate
management of moisture/incontinence,
nutritional assessment and intervention
consistent with the overall plan of care;
and
3. Ulcers have worsened or remained the same
over the past month; OR
4. Large or multiple stage III or IV pressure
ulcer(s) on the trunk or pelvis; OR
5. Recent myocutaneous flap or skin graft for a
pressure ulcer on the trunk or pelvis (surgery
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BEDS (HOSPITAL) AND ACCESSORIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) within the past 60 days); and
Group 2 Support 6. Recipient has been on a Group 2 or 3 support
Surfaces surface immediately prior to a recent
discharge from a hospital or nursing facility
(discharge within the past 30 days).
Powered Pressure (E0277) An air pump or blower which provides 1. Prescription and/or MD signed Prior
Reducing Mattress either sequential inflation and deflation of the air Authorization Form.
cells or a low interface pressure throughout the 2. Medical documentation supporting qualifying
mattress, inflated cell height of the air cells factors.
through which air is being circulated is five inches 3. An MSRP Invoice if there is no rate established
or greater, and height of the air chambers, by the DHCFP.
proximity of the air chambers to one another,
frequency of air cycling (for alternating pressure
mattresses), and air pressure provide adequate
patient lift, reduce pressure and prevent bottoming
out and surface designed to reduce friction and
shear. Can be placed directly on a hospital bed
frame.
(E0193) Describes a semi-electric or total electric
hospital bed with a fully integrated powered
pressure reducing mattress which has all the
characteristics previously defined.
1. Recipient must meet criteria for Group 2
support surfaces.
Non-Powered Pressure (E0371) Height and design of individual cells 1. Prescription and/or MD signed Prior
Reducing Mattress which provide significantly more pressure Authorization Form.
Overlay reduction than a Group 1 overlay and prevents 2. Medical documentation supporting qualifying
bottoming out, and total height of three inches or factors.
greater, and surface designed to reduce friction and
shear, and documented evidence to substantiate
that the product is effective for the treatment of
conditions described by the coverage criteria for
Group 2 surfaces.
1. Recipient must meet criteria for Group 2
support surfaces.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BEDS (HOSPITAL) AND ACCESSORIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Powered Pressure (E0372) Low air loss, powered flotation without low air loss 1. Prescription and/or MD signed Prior
Reducing Mattress or alternating pressure which is characterized by all of the Authorization Form.
Overlay following: Air pump or blower which provides either 2. Medical documentation supporting qualifying
sequential inflation and deflation of the air cells or a low factors.
interface pressure throughout the overlay, and inflated cell 3. An MSRP Invoice if there is no rate established
height of the air cells through which air is being circulated is by the DHCFP.
3.5 inches or greater, and height of the air chambers,
proximity of the air chambers to one another, frequency of
air cycling (for alternating pressure overlays), and air
pressure to provide adequate patient lift, reduce pressure and
prevent bottoming out, and surface designed to reduce
friction and shear.
1. Recipient must meet criteria for Group 2 support
surfaces.
Advanced Non-Powered (E0373) Height and design of individual cells which provide 1. Prescription and/or MD signed Prior
Pressure Reducing significantly more pressure reduction than a Group 1 Authorization Form.
Mattress mattress and prevents bottoming out, and total height of five 2. Medical documentation supporting qualifying
inches or greater, and surface designed to reduce friction and factors.
shear, and documented evidence to substantiate that the 3. An MSRP Invoice if there is no rate established
product is effective for the treatment of conditions described by the DHCFP.
by the coverage criteria for Group 2 support surfaces, and
can be placed directly on a hospital bed frame.
1. Recipient must meet criteria for Group 2 support
surfaces.
Group 3 Air-fluidized (E0194) Device employing the circulation of filtered air 1. Prescription and/or MD signed Prior
Bed through silicone coated ceramic beads creating the Authorization Form.
characteristics of fluid. 2. Medical documentation supporting qualifying
1. Recipient has a stage III (full thickness tissue loss) or factors.
stage IV (deep tissue destruction) pressure sore; 3. An MSRP Invoice if there is no rate established
2. Is bedridden or chair bound as a result of severely by the DHCFP.
limited mobility;
3. In the absence of an air fluidized bed, the recipient
would require institutionalization;
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BEDS (HOSPITAL) AND ACCESSORIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 4. Ordered in writing by recipient’s attending
Group 3 Air-fluidized physician after comprehensive assessment
Bed and evaluation after completion of
conservative treatment. Evaluation performed
within one month prior to indication of
therapy with air fluidized bed;
5. Conservative treatment must have been at
least one month in duration without
progression toward wound healing. Treatment
should include:
a. Frequent repositioning of recipient
(usually every two hours);
b. Use of Group 2 support surface;
c. Necessary treatment to resolve any
wound infection;
d. Optimization of nutrition status to
promote wound healing;
e. Debridement by any means, including
wet-to-dry gauze dressings to remove
devitalized tissue from the wound bed;
f. Maintenance of a clean, moist bed of
granulation tissue with appropriate moist
dressings protected by an occlusive
covering while the wound heals;
g. Education of the recipient and caregiver
on the prevention and management of
pressure ulcers;
h. Assessment by a physician, nurse or other
licensed healthcare practitioner at least
weekly; and
i. Appropriate management of moisture
/incontinence.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: BEDS (HOSPITAL) AND ACCESSORIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 6. Trained adult caregiver is available to assist
Group 3 Air-fluidized the recipient with ADL’s, fluid balance, dry
Bed skin care, repositioning, recognition and
management of altered mental status, dietary
needs, prescribed treatments and management
and support of the air-fluidized bed system
and its problems such as leakage;
7. A physician directs the home treatment
regimen, and reevaluates and recertifies the
need for the air-fluidized bed on a monthly
basis; and
8. All other equipment has been considered and
ruled out.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 10
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: COMMUNICATION DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Speech Generating 1. A dedicated speech generating device (SGD) 1. Physician’s/Practitioner’s Order/Prescription. 1. For all items, documentation must support
Device (SGD) may be covered when it is medically 2. Prior Authorization. all criteria in the Qualifications section.
(also known as necessary to restore the function of speech to 3. Detailed Product Description. 2. Providers must submit prior authorization
Augmentative an individual with a functional disability 4. Additional Miscellaneous Medical Records and claim using the most appropriate
Communication Device caused by a long term (lasting more than one (if needed); and: available HCPCS code and may not
(ACD) or Augmentative year) and severe speech impairment; and 5. Speech and Language Pathologist (SLP)’s unbundle items included in the HCPCS
and Alternative 2. When all of the following are met: formal written evaluation which includes, at a code description.
Communication (AAC) a. The recipient has had a formal written minimum, all of the following: 3. Codes E2500 – E2510 perform the same
Device evaluation of their cognitive and a. Current communication impairment, essential function - speech generation and
(E2500 – E2510) communication abilities by a speech- including the type, severity, language may not be issued in conjunction with
language pathologist (SLP) which skills, cognitive ability and anticipated E2511.
Digitized Speech contains all of the items specified in the course of the impairment; 4. Code E2511 – SGD software program for
Devices: Forms/Documentation column; b. An assessment of whether the recipient's Personal Computers (PC) or Personal
(E2500, E2502, E2504, b. The recipient's medical condition is one daily communication needs could be met Digital Assistant (PDA) may not be issued
E2506) resulting in a long term (lasting more than using other natural modes of in conjunction with E2500 – E2510.
one year) and severe expressive speech communication or with low-technology 5. Computer-based and PDA-based AAC
Synthesized Speech impairment; devices; devices/speech generating devices are
Devices: c. The recipient's speaking needs cannot be c. A description of the functional covered when they have been modified to
(E2508, E2510) met using natural communication communication goals expected to be run only AAC software and will not be
methods; achieved and treatment options; reimbursed in conjunction with another
d. Other forms of treatment have been d. Rationale for selection of a specific SGD. Laptop computers, desktop
considered and ruled out; device and any accessories; computers, personal digital assistants
e. The recipient's speech impairment will e. Demonstration that the recipient (PDAs), tablets or other devices that are
benefit from the device ordered; and possesses a treatment plan that includes a not dedicated SGDs do not meet the
f. A copy of the SLP's written evaluation training schedule for the selected device; definition of durable medical equipment
and recommendation was forwarded to f. The cognitive and physical abilities to (DME).
the recipient's treating physician/ effectively use the selected device and 6. Expected lifespan of SGD E2500-E2510
practitioner and the prescribing any accessories to communicate; and or E2511 is considered 60 months and are
physician/ practitioner agreed with, and g. An attestation statement from the SLP limited accordingly. Replacement
ordered the specific device and performing the recipient evaluation equipment may be authorized prior to the
accessories as recommended. and/or recommending the product(s) 60 months based on medical necessity.
indicating they are not an employee of,
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 11
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: COMMUNICATION DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) and have no financial relationship with The recipient’s condition and product
Speech Generating the supplier/manufacturer of the SGD. performance will be taken into review.
Device (SGD) h. For a subsequent upgrade to a previously 7. Refer to Section 1303.4 for exceptions to
issued SGD, documentation must support quantity and frequency limitations. Refer
the medical necessity regarding the to Section 1303.6 for policy regarding lost,
functional benefit to the recipient of the stolen, or damaged equipment.
upgrade compared to the initially 8. Reimbursement for Codes E2500, E2502,
provided SGD. E2504, E2506, E2508 and E2510 is
i. SLP evaluations and recommendations intended to include all applicable software
should consider recipient’s needs both at programs (whether they are on the device
present and over the useful lifespan of the when shipped by the manufacturer or
device being recommended. added by the supplier prior to delivery)
6. Prior authorizations for synthesized speech necessary to render the device operational,
output SGDs and digitized speech output batteries, battery chargers and AC adapters
SGDs with dynamic displays must include the and a carrying case. These items may not
software required for operation of the device. be billed separately at the time of initial
Any requests for supplemental software for a issuance.
synthesized speech output SGD must be 9. Non-integrated keyboards provided with
established as specifically medically an SGD are not separately reimbursable.
necessary. 10. One symbol set may be billed separately
7. Prior authorizations for digitized speech using Code E2599.
output SGDs with static displays must Device Descriptions:
identify the symbol set that will be used to 1. Digitized speech devices, sometimes
operate the device. referred to as devices with "whole
8. For all products and accessories, the MSRP message" speech output, utilize words or
Invoice which includes: name of product, phrases that have been recorded by an
make, model, HCPCS code and cost. individual other than the SGD user for
playback upon command of the SGD user.
2. Synthesized speech devices translate a
user's input into device-generated speech.
Users of synthesized speech SGDs are not
limited to pre-recorded messages but
rather can independently create messages
as their communication needs dictate.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 12
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: COMMUNICATION DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 3. Devices that have the capability to
Speech Generating generate both digitized and synthesized
Device (SGD) speech are coded as E2508 or E2510,
depending on the method of synthesized
speech formulation and device access.
4. E2508 devices require that the user make
physical contact with a keyboard, touch
screen or other display containing letters.
5. E2510 devices permit the user multiple
methods of message formulation and
multiple methods of device access.
a. Multiple methods of message
formulation must include the
capability for message selection by
two or more of the following
methods: letters, words, pictures or
symbols.
b. Multiple methods of access must
include the capability to access the
device by two or more of the
following: direct physical contact
with a keyboard or touch screen,
indirect selection techniques with a
specialized access device such as a
joystick, head mouse, optical head
pointer, switch, light pointer, infrared
pointer, scanning device or Morse
Code.
Speech Generating 1. Accessories (E2599) for E2500 – E2510 may 1. As previously described for SGD.
Device (SGD) be covered if the basic coverage qualifications
Accessories previously described for the base device are
(E2599) met and medical necessity for each accessory
is clearly documented in the formal evaluation
by the SLP and ordered by the
physician/practitioner.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 13
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: COMMUNICATION DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Speech Generating 1. All of the previously described qualifications 1. As previously described for SGD. 1. Installation of the software program or
Software Programs for for a Speech Generating Device are met; and 2. An MSRP Invoice if there is no rate established technical support that enables a recipient-
Personal Computer (PC) 2. The recipient currently owns the PC or PDA by the DHCFP. owned laptop computer, desktop
or Personal Digital to which the software will be applied to computer or PDA to function as an SGD
Assistant (PDA) enable the device to function as a Speech is included in the cost of the software
(E2511) Generating Device (SGD). program, therefore is not separately
reimbursable.
2. Medically necessary upgrades to speech
generating devices and/or software
programs may be reimbursed 60 months
after the month of initial issuance of the
device.
3. Repairs to, or replacement of recipient-
owned equipment (PC and PDA) is not
reimbursable.
Access Device 1. All of the previously described qualifications 1. Documentation by a licensed medical 1. An access device enables the selection of
(E2599) for a Speech Generating Device (SGD) are professional, such as a physician, speech- letters, words or symbols via direct or
met; and language pathologist or physical therapist, indirect selection techniques.
(such as, but not limited 2. The access device has been determined to be which supports the medical necessity for the 2. Any components such as software
to: optical head pointers, medically necessary. requested access device. programs, interfaces, cables, adapters,
joysticks, switches and 2. An MSRP Invoice if there is no rate established interconnects or switches necessary for
scanning devices) by the DHCFP. the access device to interface with the
SGD should be included in the charge for
the access device itself and is therefore
not separately reimbursable.
Electronic Components 1. All of the previously described qualifications 1. Documentation must include that the recipient
(E2599) for a Speech Generating Device (SGD) are requires the use of a power wheelchair and must
met; and address the recipient’s ability to operate the
2. The electronic components are necessary to SGD from the power wheelchair.
allow the SGD to be operated by the drive 2. An MSRP Invoice if there is no rate established
control interface of a power wheelchair. by the DHCFP.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 14
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: COMMUNICATION DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
SGD Mounting Systems 1. All of the previously described qualifications 1. Documentation supporting medical necessity
(E2512) for a Speech Generating Device are met; and for the mounting system and that the recipient
2. The accessories are needed to place the SGD, has a medical need for, and owns the device to
switches or other access devices within the which the SGD is to be mounted.
reach of the recipient.
SGD Batteries, Battery 1. All of the previously described qualifications
Chargers, and AC for a Speech Generating Device are met; and
Adapters 2. The accessories are needed to replace an SGD
battery, a battery charger or AC adapter that
was provided with initial issuance of the SGD
and is no longer functioning.
SGD Carrying Case 1. All of the previously described qualifications
for a Speech Generating Device are met; and
2. A carrying case may be paid separately with
the initial issuance of an SGD when it would
be charged separately to the general public or
to the primary insurer; or
3. Replacement is needed to protect a medically
necessary device due to wear and tear; no
more frequently than one unit per calendar
year.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 15
MTL 08/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: DIABETIC SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
External Covered ICD codes: 1. A prescription from a physician who manages 1. External ambulatory infusion pump
Ambulatory Diabetes Mellitus recipients with insulin pumps and who works recipients with Gestational Diabetes
Infusion Gestational Diabetes closely with a team including nurses, diabetes whom do not meet conditions one
Pump, educators and dietitians. through six but do meet qualifications
Insulin (E0784) All of the following conditions must be met: 2. Prior authorization is required for the insulin under Gestational Diabetes approval of
1. Fasting serum C-peptide level that is less than pump with all of the following documentation: the insulin pump will be on a rental basis
or equal to 110% of the lower limit of normal a. Certification of Diabetic Education Class until the end of the pregnancy.
of the laboratory’s measurement method or as with first time request. 2. Insulin Pump-related Supplies through
an alternative must be beta cell autoantibody b. Signed statement from the physician the DMEPOS program:
positive. acknowledging medical necessity and the E0784 - External Ambulatory Infusion
2. Recipient has completed a comprehensive following: pump, Insulin
diabetic education program within the last year. 1. Recipient is motivated to achieve and A4230 - Infusion set for external pump,
3. Recipient is motivated to achieve and maintain maintain improved glycolic control, non-needle cannula type
improved glycemic control. indicated by showing documented A4231 - Infusion set for external pump,
4. Recipient has been on a program of multiple finger sticks (at least four times per needle type
daily injections of insulin (e.g., at least three day) with multiple injections. A4232 - Syringe with needle for external
injections per day), with frequent self- 2. Recipient has been on a program of insulin pump, sterile, 3cc
adjustments of insulin doses for at least six multiple injections of insulin (at least
months prior to request for the insulin pump. three times per day) with frequent Note: Available under DHCFP Pharmacy
5. Documented frequency of glucose self-testing self- adjustment of insulin doses at Program, billed through point of sale (POS).
is an average of at least four times per day least six months prior to initiation of
during the two months prior to starting the the insulin pump.
insulin pump. 3. Cognitive ability to operate pump and
6. Glycosylated hemoglobin level (HbA1C) > calculate insulin dosages.
7.0% 3. Qualifying lab results per qualifications.
In addition, one or more of the following 4. Physician current history and physical
indications must be present: including one or more of the additional
1. History of recurring hypoglycemia; indications listed in the qualification column.
2. Wide fluctuations in blood glucose before 5. Documentation requirements for recipients
mealtime (e.g., preprandial blood glucose level using the insulin pump prior to Medicaid
commonly exceeds 140 mg/dl; eligibility requires a PA with the following
3. Dawn phenomenon with fasting blood sugars documentation:
frequently >200 ml/dl; a. A HbA1C level (within last 60 days).
b. Signed narrative from the physician
documenting the recipient’s compliance.
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 16
MTL 09/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: DIABETIC SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 4. Extreme insulin sensitivity; or and ability to self adjust the insulin pump
External 5. Gestational diabetes or when pregnancy occurs according to glucose levels.
Ambulatory or is anticipated within three months in a 6. An MSRP Invoice if there is no rate established
Infusion previously diagnosed diabetic with ANY of the by the DHCFP.
Pump, following indications:
Insulin (E0784) a. Erratic blood sugars in spite of maximal
recipient compliance and split dosing; or
b. Other evidence that adequate control is not
being achieved.
Qualifications for recipients on the external
ambulatory infusion pump prior to Medicaid
eligibility:
1. A Glycosylated hemoglobin level (HbA1C)
within the last 60 days.
2. Recipient has been compliant with using the
insulin pump and has the ability of self-
adjusting the insulin pump according to
glucose levels.
Diabetic Equipment 1. Physician’s/Practitioner’s Order / Prescription 1. Diabetic shoes, fitting, and modification
and Supplies A5500 – A5507, A5512 – A5513
2. Diabetic equipment and supplies, such as
Glucometers, Test strips, Lancet Device,
Lancets, Insulin syringes for self-
injection, Insulin systems and
Continuous Glucose Monitors are not
covered under the DHCFP’s DME
program. These items are covered under
the DHCFP’s pharmacy program and
must be billed through the Point of Sale
(POS). Refer to MSM Chapter 1200,
Pharmacy Services.
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 17
MTL 08/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: DISPOSABLE SUPPLIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Disposable Incontinent 1. Disposable briefs/diapers, pull-ons/protective 1. A physician’s order. In addition to other 1. Use of diapers and related products for
Supplies underwear, liners/ shields/ guards/ pads/ requirements for written orders, the prescriber individuals under the age of four years
undergarments and underpads may be covered must indicate on the written order all of the are considered age appropriate and are
for individuals age four years and older with a following: non-covered, unless the individual meets
medical diagnosis (1) of a neurological or a. Diagnosis of medical condition causing the qualifications and the order was a
neuromuscular disorder or other diagnosis of a incontinence with a diagnosis of urinary result of an Early and Periodic Screening,
medical condition that causes urinary or bowel and/or bowel incontinence; Diagnosis and Treatment (EPSDT)
incontinence, and (2) a diagnosis of urinary b. The specific item (diaper/brief, pull-on, screening. These would require prior
and/or bowel incontinence. liner/ shield/ guard/ pad, underpads) and authorization.
2. Diagnoses must be supported by medical the order must specify the recipient’s 2. Refer to the DMEPOS Fee Schedule.
documentation which includes other recent measurements for the ordered item; Prior authorization may be submitted to
(within past six months) interventions used to c. Frequency of replacement and/or changes exceed established limits for these
treat or ameliorate the incontinence, such as but needed and monthly quantity of each item products when medical documentation
not limited to a bowel and bladder to be dispensed; clearly indicates a greater quantity is
training/retraining program, other toileting d. The size of the item to be dispensed medically necessary.
programs, exercise and strengthening including the individual’s current weight, 3. Use of multiple types of briefs, diapers,
regimens. waist/girth and belt to belt measurements pull-ons or protective underwear in any
3. The individual’s weight, waist/girth to support the size of product needed. The size combination cannot exceed the
measurements and belt-to-belt measurements size of the product supplied must be maximum limit (either 100 units or 186
must be consistent with manufacture’s consistent with the manufacturer’s units per month depending on the item)
recommendations for the sizing of their recommendation for their product. without PA. Liners, shields, guards, pads
products. 2. Documentation of other interventions tried or and underpads in any combination cannot
4. Recipients with waist size greater than 60 currently in progress to treat or ameliorate the exceed the maximum limit of 100 units
inches may be considered for Bariatric size incontinence. per month without prior authorization
briefs/diapers. 3. Documentation must be included in the and may be in addition to diapers, briefs,
5. Individuals under four years of age must have a medical record and must be part of the pull-ons or protective underwear.
diagnosis of Human Immune Deficiency Virus treatment plan for the individual. The supplier 4. Gloves, sterile or non-sterile and
(HIV) positive or Acquired Immune must retain copies of all supporting disposable wipes/washcloths are not
Deficiency Syndrome (AIDS) with an documentation for audits. considered medically necessary for use
accompanying gastrointestinal abnormality 4. Prior authorization is always required for code with incontinence care and are non-
causing frequent or intractable diarrhea which T4543, Bariatric size brief/diapers or to exceed covered.
is documented by the prescribing practitioner. established quantity limitations, or for ages less 5. Underpads used for tube feedings or other
than four years old. procedures not related to incontinence are
May 1, 2016 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 18
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: DISPOSABLE SUPPLIES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) considered convenience items.
Disposable Incontinent 6. Any products used for menses are non-
Supplies covered items.
Note: Failure of the provider to maintain
required documentation could result in
post-payment recoupment of monies
paid.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 19
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
MAE General The qualifications identified in this “general The forms and specifications as described in this Refer to the main body of MSM Chapter 1300
Information information” section must all be met for any items “general information” section pertain to all MAE for general DMEPOS policies. The
(pertains to all items in included in this policy section. Each specific item items. Refer to the Documentation section and/or the comments/policy statements identified in this
this policy section) may also have additional qualifications listed Prior Authorization section in Chapter 1300 for “general information” section pertain to all
further in this appendix that must be met. Items detailed requirements for each type of form. MAE items.
may be covered if all of the following Additional completion requirements are found in the Note: Special attention to MSM Section
qualifications are met: Form Release Memorandums/Instructions for the 1303.6 Repair, Replacement and Warranty of
1. The recipient has a mobility limitation that Division’s forms on the following website: Equipment section of chapter.
significantly impairs his/her ability to https://www.medicaid.nv.gov/providers/forms/form 1. For all MAE items, documentation must
participate in one or more Mobility-Related s.aspx support all criteria in the Qualifications
Activities of Daily Living (MRADL) Each specific item may also have additional form section, as specified in each category.
performed in the home and in each of the requirements and specifications listed further that a. All rented mobility devices are to be
environments the recipient is likely to must be met. considered purchased by the DHCFP
encounter in their daily routines, such as but 1. Physician’s/Practitioner’s Order/Prescription. once the purchase price is reached.
not limited to: attending school, work and 2. Prior authorization forms found on the QIO- b. Providers must submit prior
shopping. The MRADLs to be considered in like vendor’s website (when indicated) refer to authorization and claim with the
this and all other statements in this policy are: the DMEPOS Fee Schedule to determine need most appropriate HCPCS code and
toileting, grooming, bathing, dressing, eating for a prior authorization for each item. may not unbundle items included in
and transferring. Note: For items that require prior authorization the HCPCS code description.
Note: A mobility limitation is one that: and have a Nevada Medicaid assigned rate of c. Inclusion of a HCPCS code in this
a. Prevents the recipient from less than $500.00, use the DME Prior policy section is not an indication of
accomplishing the MRADL entirely; Authorization, Form FA-1; for items with a coverage. Refer to the DMEPOS Fee
b. Places the recipient at reasonably Nevada Medicaid assigned rate of $500.00 or Schedule.
determined heightened risk of morbidity more, the Mobility Assessment and Prior d. The recipient must have a medical
or mortality secondary to the attempts to Authorization Form, FA-1B is required. need within the locations of normal
perform an MRADL; or 3. An MSPR Invoice if there is no rate established life activities for the requested item.
c. Prevents the recipient from completing by the DHCFP. In addition, consideration will
the mobility-related Activities of Daily 4. Detailed Product Description. include:
Living (ADL) within a reasonable time 5. Proof of Delivery. 1. recipient’s medical needs;
frame. 6. Additional Miscellaneous Medical Records. 2. use of the item; and
2. All required assessments, evaluations and 3. the conditions in each of the
physician/practitioner’s orders as indicated environments the recipient is
likely to encounter in their daily
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 20
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) throughout this section were completed within routines, such as, but not limited
MAE General the required time limits. to:
Information a. attending school;
(pertains to all items in b. work; and
this policy section) c. shopping.
This information must be included in the
supportive documentation submitted
with the prior authorization.
Canes and Crutches 1. The MAE General Qualifications are met and 1. Physician’s/Practitioner’s Order/Prescription. 1. Cane and/or crutch accessory items may
the recipient: be provided as replacement items for
Cane Accessories a. has a medical condition causing impaired recipient-owned MAE. When the cane
ambulation and there is a potential for or crutch HCPCS description includes
Crutch Accessories ambulation; the accessory item, these items cannot
b. is able to safely use the cane or crutches; be billed separately with the initial
and purchase.
c. has functional mobility deficit that can be
sufficiently resolved by use of the item.
Crutch Substitute, 1. The MAE General Qualifications are met and 1. Physician’s/Practitioner’s Order/Prescription.
Lower Leg Platform, the recipient: 2. Prior Authorization.
With or Without a. has a below-the-knee injury and/or surgery 3. The additional medical documentation by the
Wheels (E0118) causing impaired ambulation and there is a prescribing physician/practitioner, submitted
potential for ambulation; with the prior authorization, must indicate why
b. is medically unable to safely use a cane(s), the recipient is not able to use an alternative,
standard crutches, a walker or a more cost-effective mobility device, such as:
wheelchair; cane(s), crutches, walker or a wheelchair.
c. has functional mobility deficit that can be
sufficiently resolved by use of the item;
and
d. (self) or care giver is not requesting the
device for convenience.
Walkers 1. If the MAE General Qualifications are met, a 1. Physician’s/Practitioner’s Order/Prescription. All from General Information
standard walker may be covered if the 2. Prior Authorization, when indicated. Miscellaneous Policy Statement section;
Walker Accessories recipient: 3. A heavy-duty walker requires a prior and
authorization to verify weight.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 21
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) a. is unable to safely use appropriately fitted 1. Walker accessory items may be
Walkers canes or crutches to resolve functional provided as replacement items for
mobility deficits; and recipient-owned MAE. When the
Walker Accessories b. is able to safely use the walker; and walker HCPCS description includes
c. has functional mobility deficit that can be the accessory item, these items
sufficiently resolved with use of a walker. cannot be billed separately with the
1. In addition to #1 and #2 in the MAE General initial purchase.
Information Qualification section and #1 of this
section, a heavy-duty walker may be covered if
the recipient’s weight is greater than 300
pounds.
Gait Trainers 1. EPSDT only. 1. Physician’s/Practitioner’s Order/Prescription. Note: Rehab equipment and physical/
2. Mobility Assistive Device for moderate to 2. Prior authorization documenting recipient’s occupational therapy equipment for home
maximum support for walking. inability to utilize a standard or reverse walker use is not covered under the DME benefit.
3. Functional mobility deficit cannot be resolved and how the gait trainer will meet the Please review policies applicable to therapies
using a walker. recipient’s needs. and rehabilitation.
3. Must demonstrate the capability of
independently walking with the use of a gait
trainer.
4. An MSRP Invoice if there is no rate established
by the DHCFP.
Wheelchairs 1. In addition to the MAE General Qualification All from MAE General Qualification section; and 1. Medicaid allows only one wheelchair
(pertains to all section, a wheelchair may be covered if the 1. Mobility Assessment form found on the QIO- at a time. Backup chairs are denied as
wheelchair types – recipient’s mobility limitation cannot be like vendor’s website (refer to detailed a duplicate benefit.
manual and power) sufficiently resolved by the use of an requirements in Form Instructions at: For all Medicare/Medicaid dual eligible
appropriately fitted cane(s), crutches or a https://www.medicaid.nv.gov/providers/forms/ recipients, Medicaid is payer of last resort.
walker; and forms.aspx and in MSM Chapter 1300. Therefore, any MAE that qualifies as an
2. The recipient meets the specific qualifications 2. An MSRP Invoice if there is no rate established Advanced Determination of Medicare
listed further in this section for the type of by the DHCFP. Coverage (ADMC) item must be submitted
wheelchair being requested. to Medicare prior to requesting approval by
The recipient must have a medical need for, and Medicaid. After the ADMC decision is
the requested item must be suitable for use in received from Medicare, provider/supplier
the home and other locations the recipient is must submit a copy of the ADMC written
likely to encounter in their normal life
activities, in accordance with 42 CFR
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 22
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 440.70(b)(3). Consideration for prior decision by Medicare with the prior
Wheelchairs (pertains authorization is also based on the recipient’s authorization.
to all wheelchair types – additional use of the item for the conditions in 3. Reimbursement for all wheelchair
manual and power) each of the environments the recipient is likely codes includes all labor charges
to encounter in their daily routines. involved in the assembly of the
wheelchair and all covered additions
or modifications. Reimbursement also
includes support, such as emergency
services, delivery, set-up education
and on-going assistance with use of
the wheelchair.
4. For all wheelchairs (manual or power)
recipient weight capacity is:
Standard Duty = 300 lbs or less;
Heavy Duty = 301-450 lbs;
Very Heavy Duty = 451 – 600 lbs;
Extra Heavy Duty = 601 lbs or more.
Manual – Standard 1. The recipient’s home provides adequate access
Adult size between rooms, maneuvering space and
surfaces for use of the manual wheelchair that
is provided;
2. Use of an optimally configured manual
wheelchair will significantly improve the
recipient’s ability to participate in MRADLs.
Note: an optimally-configured manual
wheelchair is one with an appropriate
wheelbase, device weight, seating options and
other appropriate non-powered accessories;
3. The recipient’s weight is within the established
weight limitations of the wheelchair that is
requested/provided;
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 23
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 4. The recipient will use it on a regular basis in the
Manual – Standard home and other location where normal life
Adult size activities take place;
5. The recipient or their caregiver has not
expressed an unwillingness to use the manual
wheelchair that is provided in the home; and
6. The recipient has sufficient upper extremity
strength, function, and other physical and mental
capabilities needed to safely self-propel the
manual wheelchair that is provided in the home
and other location where normal life activities
take place during a typical day, or the recipient
has a caretaker available, willing and able to
assist in the operation of the wheelchair.
Manual – Standard 1. The pediatric recipient must meet the 1. All requirements from the Forms/ 1. Stroller-type devices readily available
Pediatric Size qualifications in relationship to his/her age- Documentation section under “Wheelchairs” without a prescription in commercial or
appropriate developmental stages and mobility plus: retail stores, and which have not been
limitations for all qualifications for a Manual – 2. All pediatric device requests must include the coded by the DME Pricing, Data
Standard Adult Size Wheelchair; growth capabilities of the equipment requested Analysis and Coding (PDAC)
2. Pediatric wheelchairs are covered only for a and address how that equipment can contractor as medical devices, will be
pediatric recipient (or an adult of very small accommodate for the recipient’s growth over denied.
stature). Recipient’s weight cannot exceed 125 the 60-month period that follows approval. 2. Stroller-type devices used for children
pounds; and This information should be included on the absent of illness, injury and/or a missing
3. Recipient has not mastered age appropriate Mobility Assessment form found on the QIO- or malfunction of a body part do not
sensory and motor development requirements like vendor’s website. meet the definition of DME.
(e.g., two years old is unable to ambulate/walk).
4. Stroller-type pediatric wheelchair devices, rigid
or folding, will be considered only when:
a. classified by the DME Pricing, Data
Analysis and Coding (PDAC) contractor
as pediatric wheelchairs, when all of the
previous criteria are met;
b. due to severity of illness, injury and/or
absence of or malfunction of a body part,
there is a medical need for the features of
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 24
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) the device requested to provide for the
Manual – Standard recipient’s proper alignment/positioning,
Pediatric Size transportation of the individual, and any
medical devices attached to the individual;
and
c. a manual wheelchair would not be more
beneficial to the individual’s
developmental needs and there is no
potential for the recipient to participate in
self propelling a manual wheelchair.
Manual Specialty 1. May be covered if, in addition to the general
qualifications for a wheelchair and a manual
wheelchair, the qualifications for the following
specified devices are met and determined to be
medically necessary.
Standard Hemi- 1. May be covered when the recipient requires a
Wheelchair (K0002) lower seat height (17" to 18") because of short
stature or to enable the recipient to place his/her
feet on the ground for propulsion.
Lightweight 1. May be covered when a recipient:
Wheelchair (K0003) a. cannot self-propel in a standard wheelchair;
and
b. the recipient can and does self-propel in a
lightweight wheelchair.
High Strength 1. May be covered when a recipient:
Lightweight a. self-propels the wheelchair while engaging
Wheelchair (K0004) in frequent activities that cannot be
performed in a standard or lightweight
wheelchair; and/or
b. requires a seat width, depth or height that
cannot be accommodated in a standard,
lightweight or hemi-wheelchair and spends
at least two hours per day in the wheelchair.
Note: This type of wheelchair is rarely medically
necessary if the expected duration of need is less
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 25
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
than three months (e.g., post-operative
recovery).
Ultra-light-weight 1. May be determined for coverage on an 1. Additional documentation of the medical
Wheelchair (K0005) individual consideration basis, as follows: necessity must include a description of the
a. Recipient must have a medical condition recipient's routine activities, types of activities
Ultra-light-weight which is progressively deteriorating, or be at the recipient frequently encounters and
Wheelchair (K0005) risk for injury due to use of another whether the recipient is fully independent in
optimally-configured mobility device; and the use of the wheelchair. Describe the
b. Recipient must have a medical need for features of the K0005 base which are needed
anticipated future adaptations of the and not available in the K0001 - K0004 bases.
wheelchair that can only be accommodated This may be included in the Mobility
by the K0005 device. Assessment form.
Heavy Duty 1. May be covered if the recipient weighs more
Wheelchair (K0006) than 250 pounds or has severe spasticity.
Extra Heavy-Duty 1. May be covered if the recipient weighs more
Wheelchair (K0007) than 300 pounds.
Power Mobility Devices 1. May be covered if the recipient meets all 1. Additional Documentation Requirements for a 1. Purchase of any Power Mobility
(PMDs) previously described qualifications for a Power Mobility Device or Power Wheelchair: Device is not considered medically
(pertains to all POVs wheelchair (either adult or pediatric, whichever a. Orders: The physician/ practitioner’s necessary when the underlying
and PWCs below) is appropriate); and the recipient’s mobility order must contain all of the following condition is reversible, and the length
limitation cannot be sufficiently resolved by the components: of need is less than six months. The
use of an appropriately fitted cane(s), crutches, 1. Recipient’s name. item may be approved for rental if all
walker or an optimally-configured manual 2. Description of the item ordered. qualifications are met.
wheelchair; This may be general – e.g., “power 2. The Mobility Assessment and written
2. The recipient does not have sufficient upper wheelchair,” “power operated supportive documentation must be
extremity strength or function needed to safely vehicle,” or “power mobility performed by an individual who is
self-propel an optimally configured manual device” – or may be more specific. fiscally, administratively and
wheelchair to perform MRADLs during a 3. Pertinent diagnosis/conditions that contractually independent from the
typical day. Note: Limitations of strength, relate to the need for the power DME provider/supplier, and who
endurance, range of motion, coordination, device. receives no form of compensation
presence of pain or deformity or absence of one 4. Length of need. from the billing DME provider /
or both upper extremities are to be assessed in 5. Physician/practitioner’s signature. supplier.
the Mobility Assessment; and b. Order must be received by the provider Note: The exception to this is
within 45 days after the completion of information about whether the
the Mobility Assessment.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 26
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 3. The recipient meets the additional qualifications 2. Mobility Assessment form found on the QIO- recipient’s home can accommodate the
Power Mobility Devices for the specific device requested, as indicated like vendor’s website (refer to detailed requested equipment, which may be
(PMDs) further in this section. requirements in Form Instructions at: obtained from or documented by the
(pertains to all POVs https://www.medicaid.nv.gov/providers/form DME provider/supplier.
and PWCs below) s/forms.aspx and in MSM Chapter 1300 Prior 3. Prescribing physician/practitioners
Authorization section. may bill an additional fee using
3. Additional supporting documentation may HCPCS code G0372 on the claim for
include the Medicare-required Face-to-Face the office visit (CPT 99211) during
evaluation/examination. which the Medicare-required Face-to-
Face examination was completed.
Power Operated 1. The recipient is able to:
Vehicle (POV) a. safely transfer to and from the POV;
b. operate the tiller steering system; and
c. maintain postural stability and position
while operating the POV for normal life;
2. The recipient’s mental capabilities (e.g.,
cognition and judgment) and physical
capabilities (e.g., vision and hearing) are
sufficient for safe mobility using a POV in the
home;
3. The recipient’s home provides adequate access
between rooms, maneuvering space and
surfaces for use of the POV that is
requested/provided;
4. Use of a POV will significantly improve the
recipient’s ability to participate in MRADLs;
5. The recipient will use it on a regular basis;
6. The recipient or their caregiver has not
expressed an unwillingness to use the POV that
is provided in the home;
7. If unable to operate the POV independently, the
recipient has a caretaker available, willing and
able to assist in the operation of the POV;
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 27
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 8. The recipient’s weight is within the established
Power Operated weight limitations of the POV that is
Vehicle (POV) requested/provided; and
9. Documented outcome of the Mobility
Assessment for the recipient determines this to
be the most appropriate device for their needs.
Power Wheelchairs 1. May be covered if the recipient’s mobility
(PWC) - Adult limitation cannot be sufficiently resolved by the
use of an appropriately fitted cane(s), crutches,
walker, an optimally-configured manual
wheelchair or a POV;
2. Recipient does not have sufficient strength,
postural stability or other physical or mental
capabilities needed to safely operate a POV;
3. Recipient does have the mental and physical
capabilities, or has a willing and capable
caregiver to safely operate the power
wheelchair that is requested/provided;
4. Recipient’s home does not provide adequate
access between rooms, maneuvering space and
surfaces for the operation of a POV with a small
turning radius;
5. Recipient’s home does provide adequate access
between rooms, maneuvering space and
surfaces for the operation of the power
wheelchair that is requested/ provided;
Use of a power wheelchair will significantly
improve the recipient’s ability to participate in
MRADLs;
6. Recipient will use it on a regular basis;
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 28
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 7. Recipient or their caregiver has not expressed
Power Wheelchairs an unwillingness to use the power wheelchair
(PWC) – Adults that is requested/provided in the home;
8. If the recipient is not able to operate the power
wheelchair independently, the recipient has a
caregiver who is unable to adequately propel an
optimally configured manual wheelchair, but is
available, willing and able to safely operate the
power wheelchair that is provided; and
9. The recipient’s weight is within the established
weight limitations of the power wheelchair
requested/provided.
Power Wheelchair 1. The recipient is expected to grow in height with
(PWC) – Pediatric a maximum weight of 125 pounds; and
2. The outcome of the Mobility Assessment has
determined this item to be the most appropriate
for the individual over the 60-month period
following approval.
Power Wheelchairs 1. Meets above qualifications for a PWC (either
(listed by specific adult or pediatric, whichever is appropriate); and
groups) as indicated for each specific item below.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 29
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Power Wheelchairs (PWCs) are categorized into Groups based on their performance and the following specifications table:
CHARACTERISTICS GROUP 1 GROUP 2 GROUP 3 GROUP 4 GROUP 5
Length <= 40” <= 48” <= 48” <= 48” <= 48”
Width <= 24” <= 34” <= 34” <= 34” <= 28”
Minimum Obstacle Height 20mm 40mm 60mm 75mm 60mm
Minimum Top-end Speed – flat surface 3 MPH 3 MPH 4.5 MPH 6 MPH 4 MPH
Minimum Range 5 miles 7 miles 12 miles 16 miles 12 miles
Dynamic Stability Incline 6 degrees 6 degrees 7.5 degrees 9 degrees 9 degrees
Chair Accommodates Non-powered options Seating and positioning items (seat Same as Group 2 Same as Group Weight capacity up to 125#; and
and seating systems and back cushions, headrests, 2 Same as Group 1 and Group 2; and
(recline-only, manually lateral trunk supports, lateral hip Adjustability for growth (minimum
elevating leg rests – supports, medial thigh supports - of 3” for width, depth and back
except captain’s chair) except captain’s chair) height adjustments)
Group 1, 2, or 3 PWC 1. As previously stated for Power Wheelchairs.
“Standard” No additional qualifications.
Group 2 PWC 1. Recipient requires a drive control interface
“Single Power Option” other than a hand or chin-operated standard
proportional joystick (examples include but are
not limited to head control, sip and puff, switch
control); or
2. Recipient meets qualifications for a power tilt
or recline seating system and the system is
being used on the wheelchair.
Group 2 PWC 1. Same as Group 2 Single Power Option
“Multiple Power qualifications; and
Option” 2. The recipient meets the qualifications for a
power tilt and/or recline seating system with
three or more actuators; or
3. The recipient uses a ventilator, which is
mounted on the wheelchair.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 30
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Group 3 PWC 1. Same as Group 2 Single Power Option
“Single Power Option” qualifications; and
2. The recipient’s mobility limitation is due to a
neurological condition, myopathy or skeletal
deformity in which the mobility limitation
cannot be accommodated by a Group 2 option.
Group 3 PWC 1. Same as Group 2 Multiple Power Option
“Multiple Power qualifications; and
Option” 2. The recipient’s mobility limitation is due to a
neurological condition, myopathy or skeletal
deformity in which the mobility limitation
cannot be accommodated by a Group 2 option.
Group 4 PWC “Any This group of PWC is rarely considered medically As listed previously; additional documentation from
Power Option” necessary due to the added features, such as the prescribing physician/practitioner that
increased speed, climbing ability and travel specifically addresses why the Group 4 PWC and
distance which are not needed to complete accompanying accessories are medically necessary
MRADLs. and why a Group 1, 2, or 3 PWC with accompanying
1. The recipient must meet the qualifications for accessories will not meet the recipient’s medical
a Group 1, Group 2 or Group 3 PWC with the needs.
same power option being requested for the
Group 4 PWC.
2. The recipient must have additional medical
needs and mobility limitations that cannot be
accommodated by an appropriately configured
Group 1, 2 or 3 PWC.
Group 5 Pediatric 1. Same as Group 2 Single Power Option
PWC “Single Power qualifications; and
Option” 2. The recipient is expected to grow in height.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 31
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Wheelchair Options, 1. Options and accessories for wheelchairs may For all items under this heading: all from General See also General Information and Coverage
Accessories, and be covered if: Information section above; and and Limitations that may include items
Seating Systems a. The recipient meets the wheelchair desired for reasons other than medical
qualifications as indicated previously, and 1. Mobility Assessment form found on the QIO- necessity:
has either a manual or power wheelchair; like vendor’s website (refer to detailed 1. An option/accessory that is primarily to
b. The device is an appropriate requirements in Form Instructions at: allow the recipient to perform leisure or
option/accessory for the type of chair the https://www.medicaid.nv.gov/providers/forms/f recreational activities.
individual has; orms.aspx and MSM Chapter 1300 - Prior 2. Electronic interface used to control lights
c. The option/accessory itself is medically Authorization section. or other electrical devices.
necessary, as determined through the 2. An MSRP Invoice if there is no rate established 3. Power seat elevation feature and power
Mobility Assessment, form found on the by the DHCFP. standing feature.
QIO-like vendor’s website; 4. Non-medically necessary power
d. When the option/accessory is not a wheelchair features may include, but not
required component of the mobility device limited to: stair climbing (A9270),
at the time of initial dispensing; electronic balance (A9270), ability to
e. The option/accessory is not covered under balance on two wheels (A9270), remote
an existing warranty; and operation (A9270), an attendant control
f. As indicated for each specific item listed (E2331) provided in addition to a patient-
further in this section. operated drive control system are
2. All wheelchair seating system items in this considered duplicative and contradictory
category may be covered if: as one option indicates recipient’s ability
a. The recipient meets the wheelchair to operate safely and the other indicates
qualifications as indicated above, and has it is not safe for the recipient to operate.
either a manual or power wheelchair;
b. The item is appropriate for the type of
chair the individual has;
c. The item itself is medically necessary, as
determined through the Mobility
Assessment, form found on the QIO-like
vendor’s website;
d. When the item is not a required component
of the mobility device at the time of initial
dispensing;
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 32
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) e. The item is not covered under an existing
Wheelchair Options, warranty; and
Accessories, and f. As indicated for each specific item further.
Seating Systems
Anti-rollback Device 1. May be covered if the recipient propels
(E0974) himself/herself and needs the device because of
ramps which enable the individual to gain
access to and from or within the home.
Arm of Chair 1. May be covered if the recipient requires an arm
Adjustable Arm Height height that is different than that available using
Option (E0973, K0017, nonadjustable arms and the recipient spends at
K0018, K0020) least two hours per day in the wheelchair.
Arm Trough (E2209) 1. May be covered if recipient has quadriplegia,
hemiplegia or uncontrolled arm movements.
Batteries / Chargers 1. Up to two batteries (E2361, E2363, E2365, 1. Replacements only when not covered
E2371, K0731 and K0733) at any one time are under warranty.
allowed if required for a power wheelchair.
Footrest / Leg rest 1. May be covered if:
a. The recipient has a musculoskeletal
Elevating Leg rests condition or the presence of a cast or brace
(E0990, K0046, K0047, which prevents 90-degree flexion at the
K0053, K0195) knee;
b. The recipient has significant edema of the
lower extremities that requires having an
elevating leg res; or
2. The recipient meets he qualifications for and
has reclining back on the wheelchair.
Hardware Swing away, May be covered if recipient needs to move the
Retractable, component out of the way to perform a slide transfer
Removable for to a bed or chair, or to enable performance of
Joystick, Other Control MRADLs, unless the hardware is included in the
Interface, or allowance for the item (such as E2325, a sip and
puff interface).
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 33
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 1. May be covered if recipient needs to move the
Hardware Swing away, component out of the way to perform a slide
Retractable, transfer to a bed or chair, or to enable
Removable for performance of MRADLs, unless the hardware
Joystick, Other Control is included in the allowance for the item (such
Interface, or as E2325, a sip and puff interface).
Positioning Accessory
(E1028)
Headrest (E0955) 1. May be covered when the recipient has a 1. A headrest for a POV or a power
manual tilt-in-space, manual semi or fully wheelchair with a captain’s chair seat is
reclining back on a manual wheelchair, a not covered as the chair does not tilt or
manual fully reclining back on a power recline
wheelchair or power tilt and/or recline power
seating system.
Manual Fully Reclining 1. May be covered if the recipient has one or more
Back option (E1226) of the following conditions:
a. The recipient is at high risk for
development of a pressure ulcer and is
unable to perform a functional weight
shift; or
b. The recipient utilizes intermittent
catheterization for bladder management
and is unable to independently transfer
from the wheelchair to the bed.
Non-Standard Seat 1. May be covered only if the recipient's
Frame Dimensions dimensions justify the need.
Non-Standard Seat
Width and/or Depth
for a Manual
Wheelchair (E2201-
E2204)
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 34
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Power Tilt and/or 1. May be covered if the recipient meets the criteria
Recline Seating for a power wheelchair and the outcome of the
Systems: (E1002- Mobility Assessment, form found on the QIO-
E1010) like vendor’s website has determined the
specific feature to be medically necessary; and
Power Seating System a. The recipient is at high risk for
(tilt only, recline only, development of a pressure ulcer and is
or combination tilt and unable to perform a functional weight shift;
recline – with or b. The recipient utilizes intermittent
without power elevating catheterization for bladder management
leg rests) and is unable to independently transfer
from the wheelchair to bed; or
2. The power seating system is needed to manage
increased tone or spasticity.
Power Wheelchair 1. May be covered in place of a patient-operated
Drive Control Systems drive control system if recipient meets MAE
An Attendant Control qualifications for a wheelchair, is unable to
(E2331) operate a manual or power wheelchair and has a
caregiver who is unable to operate a manual
wheelchair but is able to operate a power
wheelchair.
Power Wheelchair 1. May be covered if the recipient meets the criteria
Electronic Interface for, and has a covered speech generating device.
(E2351)
(to allow a Speech
Generating Device to
be operated by the
PWC control interface)
Push-Rim Activated 1. May be covered if the recipient meets all
Power Assistive qualifications for a power mobility device; and
Device (E0986) for a the recipient has been self-propelling in a manual
Manual Wheelchair wheelchair for at least one year.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 35
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Safety Belt / Pelvic 1. May be covered if the recipient has weak upper
Strap (E0978) body muscles, upper body instability or muscle
spasticity which requires use of this item for proper
positioning.
Seating Systems As listed for Wheelchair Options, Accessories and For all items under this heading: all from MAE All from MAE General Information; and
(wheelchair): Seating Systems. General Information; and 1. All seating and positioning devices/
1. Mobility Assessment, form found on the QIO- material and included components must
like vendor’s website (refer to detailed meet the requirements of CMS and as set
requirements in Form Instructions at: forth in the DME MAC Local Coverage
https://www.medicaid.nv.gov/providers/form Determination (LCD) – L15670 (or more
s/forms.aspx and MSM Chapter 1300 - Prior current) and related Policy Articles at the
Authorization section. time of dispensing.
2. Coverage and Limitations/Non-Covered
are typically not medically necessary but
may be reviewed under special criteria,
see Appendix A:
a. Powered seat cushion (E2610)
(effectiveness has not been
established).
b. A seat or back cushion provided for
a transport chair (these are for short
term sitting).
c. A prefabricated seat cushion, a
prefabricated positioning back
cushion or a brand name custom
fabricated seat or back cushion
which has not received a written
coding verification from the DME
Pricing, Data Analysis and Coding
(PDAC) contractor.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 36
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
General Use Seat 1. May be covered if the recipient has a manual or 1. General use seat cushion or wheelchair
Cushion (E2601, power wheelchair with a sling/solid seat/back. back cushion for a POV or a PWC with
E2602) and Wheelchair a captain’s chair seat are included in
Back these seating systems.
Custom Fabricated 1. May be covered if the recipient meets all
Seat Cushion (E2609) qualifications for a prefabricated skin protection
seat cushion or positioning seat cushion; and
2. The documentation and Mobility Assessment
form clearly explains why a prefabricated
seating system is not sufficient to meet the
recipient’s seating and positioning needs.
Custom Fabricated 1. May be covered if the recipient meets all
Back Cushion (E2617) qualifications for a prefabricated positioning
back cushion; and
2. The documentation and Mobility Assessment
form clearly explains why a prefabricated
seating system is not sufficient to meet the
recipient’s seating and positioning needs.
Skin Protection Seat 1. May be covered for a recipient who has a manual
Cushion (E2603, or power wheelchair with a sling/solid seat/back;
E2604, K0734, K0735) and either of the following:
(Pre-fabricated) a. Current or past history of a pressure ulcer on
the area of contact with the seating surface;
or
b. Absent or impaired sensation in the area of
contact with the seating surface or inability
to carry out a functional weight shift due to
one of the following diagnoses: spinal cord
injury resulting in quadriplegia or
paraplegia, other spinal cord disease,
multiple sclerosis, other demyelinating
disease, cerebral palsy, anterior horn cell
diseases including amyotrophic lateral
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 37
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: MOBILITY ASSISTIVE EQUIPMENT (MAE)
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) sclerosis, post-polio paralysis, traumatic brain
Skin Protection Seat injury resulting in quadriplegia, spina bifida,
Cushion (E2603, childhood cerebral degeneration, Alzheimer’s
E2604, K0734, K0735) disease or Parkinson’s disease.
(Pre-fabricated)
Positioning Seat 1. May be covered for a recipient who:
Cushion (E2605, a. Has a manual or power wheelchair with a
E2606), Positioning sling/solid seat/back; and
Back Cushion (E2613- b. Has any significant postural asymmetries
E2616, E2620, E2621) that are due to one of the diagnoses listed in
and/or Positioning Skin Protection Seat Cushion qualification
Accessory (E0955- 1.b. above, or to one of the following
E0957, E0960) diagnoses: monoplegia of the lower limbor
hemiplegia due to stroke, traumatic brain
injury or other etiology, muscular
dystrophy, torsion dystonia spinocerebellar
disease.
Combination Skin 1. May be covered for a recipient who meets the
Protection and qualifications for both a Skin Protection Seat
Positioning Seat Cushion and a Positioning Seat Cushion as
Cushion (E2607, indicated previously.
E2608, K0736, K0737)
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 38
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: NUTRITIONAL SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Parenteral Nutrition 1. Total Parenteral Nutrition (TPN) is covered for a 1. Physician’s/Practitioner’s Order/Prescription 1. Parenteral nutrition may be covered
recipient with permanent, severe pathology of the 2. All TPN services require prior authorization. in situations involving permanent
alimentary tract which does not allow absorption of Medical coverage will be determined by the impairments.
sufficient nutrients to maintain weight and strength DHCFP QIO-like vendor.
commensurate with the recipient's general condition. 3. A new authorization would be required when:
Permanence does not require a determination that a. Nutrients billed with a different code are
there is no possibility that the recipient's condition ordered;
may improve sometime in the future. If the judgment b. The number of days per week
of the attending physician, substantiated in the administered is increased or decreased; or
medical record, is that the condition is of long and c. Parenteral nutrition services are resumed
indefinite duration (ordinarily at least three months), when they are not required for two
the test of permanence is considered met. consecutive months.
2. The recipient must have: 4. There must be objective evidence supporting
a. A condition involving the small intestine and/or the clinical diagnosis.
its exocrine glands which significantly impairs
the absorption of nutrients; or
b. Disease of the stomach and/or intestine which is
a motility disorder and impairs the ability of
nutrients to be transported through the
gastrointestinal (GI) system.
Infusion Pumps 1. Infusion pumps (B9004 and B9006) are covered for 1. An MSRP Invoice if there is no rate established 1. Only one pump (stationary or
Equipment and recipients in whom parenteral nutrition is covered. by the DHCFP. portable) will be covered at any one
Supplies: time. Additional pumps will be
(B9004 and B9006) denied as duplicative.
Supply Kit, (B4220 or 1. If the coverage requirements for parenteral nutrition
B4222) are met, one supply kit (B4220 or B4222) and one
Administration Kit administration kit will be covered for each day that
parenteral nutrition is administered, if such kits are
medically necessary and used.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 39
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: NUTRITIONAL SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Enteral Nutrition 1. Enteral equipment and supplies are a Medicaid 1. Physician’s/Practitioner’s Order/Prescription. Reminder:
program benefit that requires a prior authorization. 2. Prior authorization when indicated.
The following diagnoses and conditions are 3. A MSRP Invoice if there is no rate 1. Nutritional supplies and products:
acceptable for medical coverage, based on severity established by the DHCFP. a. Enteral nutrition are covered in
and the QIO-like vendor determination: situations involving permanent
a. AIDS wasting syndrome (as indicated by a impairments.
weight loss of 20 pounds or 10% of reference b. Enteral nutrition are covered for
weight); recipients with a non-
b. Carcinoma of gastrointestinal tract; functioning gastrointestinal tract
c. Disease of pancreas; whose need for enteral nutrition
d. Dysphagia; is not due to reasons such as
e. Failure to thrive; anorexia or nausea associated
f. Fistulas of the gastrointestinal tract; with mood disorder, end-stage
g. Gastrostomy tube, artificial opening status; disease, etc.
h. Gastrostomy tube, attention to artificial c. Enteral nutrition products and
opening; related supplies cannot be
i. Inborn errors of metabolism; administered orally.
j. Inflammatory bowel disease; d. Baby food and other regular
k. Intestinal malabsorption; grocery products that can be
l. Malabsorption; blenderized and used with the
m. Malnutrition; enteral system are not
n. Necrotizing enterocolitis; considered an enteral benefit.
o. Noninfectious gastroenteritis and colitis; 2. Nutritional supplements carved out
p. Pancreatitis and pancreatic insufficiency; from institutional per diem if clinical
q. Radiation or chemotherapeutic enteropathy; coverage criteria are met.
r. Short bowel syndrome; and/or
s. Vascular disease of the small bowel.
2. As a non-allergenic source of food in infants when
all (e.g., soy base formulas) other food formulas are
not tolerated; or
3. Other medical conditions with appropriate medical
justification.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 40
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: NUTRITIONAL SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Medical Foods for 1. Authorization of “medical foods” will be 1. A prescription signed by the requesting 1. Medical foods may be approved after
Inborn Errors of considered for recipients under the age of 21 physician specializing in the treatment of review of submitted documentation if
Metabolism years as an EPSDT service with a diagnosis of metabolic conditions for requested “medical found to meet the following conditions:
(S9435) an inherited metabolic disease in which foods”; a. Documentation supports dietary
treatments are restricted and a monitored diet 2. A completed prior authorization form that treatment of the metabolic disease or
consisting of specially formulated low-protein includes: conditions mentioned in this policy
foods are an established standard of care. The a. types of medical food (e.g., LP baking for which nutritional requirements
following inherited metabolic conditions fit the mix); are established by medical
category, but are not limited to: b. product line company names and product evaluation, but does not include a
Phenylketonuria (PKU) code numbers; natural food that is naturally low in
Homocystinuria c. total amount (units or case) of each protein;
Maple Syrup Urine Disease medical food;
b. Submitted supporting documentation
2. Definitions and qualifications: d. number of servings for each product unit
is found to support inherited
a. Medical foods refer to products designed for (number of servings per box, can or case);
metabolic diagnosis; and
the specific nutrition management of a e. cost per unit or case for each medical food
disease or condition for which distinctive product; c. Approved time-frame will be for a
nutrition requirements based on recognized f. total cost of all products submitted; and maximum of six-months and the
scientific principles are established by g. Dates and duration of request servicing provider can only be a
medical evaluation. 3. History and physical examination and current Medicaid Pharmacy or DME
b. “Inherited metabolic disease” means a evaluation (within the last six months) which provider. Grocery stores, health food
disease caused by an inherited abnormality includes all existing diagnoses and medical stores and/or retail vendors may not
of body chemistry for which testing is conditions from the physician specializing in be authorized as providers for
mandated by law. the treatment of metabolic conditions or an medical foods.
c. Medical foods are products specially appropriate specialist. Documentation must
formulated or modified to have less than include test results used in establishing the
one gram of protein per serving. This does diagnosis and any other pertinent medical
not include a food that is naturally low in data/reports to justify products being
protein. requested;
d. Medical food is prescribed by and 4. A copy of the nutritional assessment and
consumed under the direction of a physician treatment plan by a registered dietitian and/or
for the dietary treatment of a qualifying physician specializing in nutritional
metabolic disease. assessment and treatment of metabolic
e. The recipient is currently receiving conditions; and including:
comprehensive nutrition services by a a. Daily number of phenylalanine exchange
physician and dietician for the dietary
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 41
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: NUTRITIONAL SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) treatment of a qualifying metabolic or total protein intake for disorders
Medical Foods for disease. requiring a protein restriction. Snack foods
Inborn Errors of f. Medical foods specifically used to meet do not exceed 10% of total cost of foods
Metabolism the distinctive nutritional requirements of requested; and
(S9435) a qualifying metabolic disorder and not
b. Documentation that the medical food is
generally used by persons in the absence
specially formulated and necessary for
of a qualifying metabolic disorder.
specific dietary management of the
g. Medical foods should be requested as part
metabolic disorder.
of an EPSDT supplement service.
h. Medical foods are not food products
readily available in the grocery stores and
health food stores. For example, a child
with diabetes could find a variety of foods
in the grocery store to meet the child’s
nutritional requirements without specially
formulated medical foods.
i. Approval will be limited to $2,500.00 per
year unless proof of medical necessity
exceeds that amount.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 42
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: ORTHOTIC AND PROSTHETIC DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Orthotics and/or 1. Replacement of a prosthesis, prosthetic 1. Physician’s/Practitioner’s Order/Prescription. 1. Adjustments, routine periodic servicing
Prosthetics component or orthosis is covered if the treating 2. Prior authorization, when indicated. (testing, cleaning and checking) to a
physician orders a replacement device or part prosthesis needed for wear or by a
Adjustments, Repairs because of any of the following: change in the recipient’s condition are
and Component a. A change in the physiological condition of covered under the initial physician’s
Replacements the recipient; order for the prosthesis for the life of the
b. Irreparable wear of the device or a part of the prosthetic.
device, without evidence of recipient 2. Maintenance recommended by the
negligence; or manufacturer that must be performed by
c. The condition of the device or part of the the prosthetist is a covered repair.
device requires repairs and the cost of such 3. Repairs are covered when necessary to
repairs would be more than 60% of the cost make the prosthesis functional. The cost
of a replacement device or of the part being of the repairs must not exceed the cost
replaced. for a replacement.
Orthopedic Shoe- 1. Devices are covered for individuals under age 21 1. Physician’s order. 1. Refer to Diabetic Services section and
Related Services years when determined to be medically necessary 2. Prior authorization is required when “L” code HCPCS “A” codes in Fee Schedule for
(inserts, arch through EPSDT screening and recommendations. product rate is $250.00 or more per unit. diabetic shoe insert coverage
supports, footwear, 2. A surgical boot/shoe or Plastazote sandal may be information.
lifts, wedges, heels, covered for individuals of any age when ordered
and related services) – and determined to be medically necessary.
HCPCS “L” codes
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 43
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: ORTHOTIC AND PROSTHETIC DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Orthotics 1. Appliances necessary for the straightening or 1. Physician order. 1. Orthotics include but may not be limited
Ankle-Foot Orthoses correction of a deformity are covered by the 2. Prior Authorization. to: braces, orthopedic shoes, elastic
(AFO) DHCFP for eligible recipients. 3. Original orthotics, adjustments, repairs, stockings, back supports/ corsets, splints
2. AFOs used in non-ambulatory recipients: replacement of parts or an entire orthosis and garments for treating burn patients.
Knee-Ankle-Foot A static AFO (L4396) is covered if all of the require medical documentation and may be 2. Providers of this type of equipment are to
Orthoses (KAFO) following criteria are met: subject to limitations of costs and frequency identify each component by L-code
a. Plantar flexion contracture of the ankle with which are deemed reasonable by the program. identifiers according to the American
dorsiflexion on passive range of motion Orthotic and Prosthetic Association.
testing of at least 10 degrees (e.g., a non-
fixed contracture);
b. Reasonable expectation of the ability to
correct the contracture;
c. Contracture is interfering or expected to
interfere significantly with the recipient’s
functional abilities; and
d. Used as a component of a therapy program
which includes active stretching of the
involved muscles and/or tendons.
3. AFO/KAFOs used in ambulatory recipients:
A molded-to-patient-model or custom-
fabricated are covered for ambulatory recipients
if the following are met:
a. The recipient could not be fit with a
prefabricated AFO;
b. The condition necessitating the orthotic is
expected to be permanent or of longstanding
duration (more than six months);
c. There is a need to control the knee, ankle or
foot in more than one place;
d. The recipient has a documented
neurological, circulatory or orthopedic
status that requires custom fabricating over
a model to prevent tissue injury; or
e. The recipient has a healing fracture which
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 44
MTL 08/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: ORTHOTIC AND PROSTHETIC DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) lacks normal anatomical integrity or
Orthotics anthropometric proportions.
Ankle-Foot Orthoses
(AFO)
Knee-Ankle-Foot
Orthoses (KAFO)
Thoracic-Lumbar- 1. TLSO or LSO are covered when it is ordered for Note: The use of a LSO or TLSO brace for
Sacral Orthoses one of the following indications: patients with chronic low back pain is not
(TLSO) a. To reduce pain by restricting mobility of the recommended because there is no
trunk; pertinent medical evidence of any long-
Lumbar-Sacral b. To facilitate healing following an injury to term benefit or evidence that brace
Orthoses (LSO) the spine or related soft tissue; therapy is effective in the treatment of
c. To facilitate healing following a surgical patients with chronic (>6 months) low
procedure on the spine or related soft tissue; back pain.
or
d. To otherwise support weak spinal muscles
and/or a deformed spine.
May 1, 2016 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 45
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: ORTHOTIC AND PROSTHETIC DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Prosthetic Devices Appliances necessary to replace a missing part by 1. Initial prosthetics, adjustments for which 1. Myoelectrically controlled prostheses and
an artificial substitute are covered by the DHCFP payment is to be made, repairs, replacement of related equipment are considered deluxe
for eligible recipients. parts or an entire prosthetic device require equipment.
A determination of the medical necessity for medical documentation and may be subject to 2. Providers of this type of equipment are to
certain components/additions to the prosthesis is limitations of cost and frequency which are identify each component by L-code
based on the recipient’s potential functional deemed reasonable by the program. identifiers according to the American
abilities. 2. Sufficient clinical documentation of functional Orthotic and Prosthetic Association.
1. Potential functional ability is based on the need for the technology or design feature of a 3. The following items are included in the
reasonable expectations of the prosthetist and given type of prosthesis is required to be retained reimbursement for a prosthesis and are not
treating physician, considering factors in the physician’s or prosthetist’s files and must separately billable:
including but not limited to: be available for Medicaid review. a. Evaluation of the residual limb and
a. The recipient’s past history (including gait;
prior prosthetic use if applicable); b. Fitting of the prosthesis;
b. The recipient’s current condition including c. Cost of base component parts and
the status of the residual limb and the labor contained in HCPCS base codes;
nature of other medical problems; d. Repairs due to normal wear or tear
c. The recipient’s desire to ambulate; and within 90 days of delivery;
d. Clinical assessments of recipient e. Adjustments of the prosthesis or the
rehabilitation potential must be based on prosthetic component made when
the following classification levels: fitting the prosthesis or component
and for 90 days from the date of
Level 0: Does not have the ability or potential to delivery when the adjustments are not
ambulate or transfer safely with or without necessitated by changes in the residual
assistance and a prosthesis does not enhance their limb or the recipient’s functional
quality of life or mobility. abilities.
Level 1: Has the ability or potential to use a
prosthesis for transfers or ambulation on level
surfaces at fixed cadence. Typical of the limited
and unlimited household ambulatory.
Level 2: Has the ability or potential for ambulation
with the ability to traverse low level environmental
barriers such as curbs, stairs or uneven surfaces.
Typical of the limited community ambulator.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 46
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: ORTHOTIC AND PROSTHETIC DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) Level 3: Has the ability or potential for ambulation
Prosthetic Devices with variable cadence. Typical for the community
ambulatory who has the ability to traverse most
environmental barriers and may have vocational,
therapeutic or exercise activity that demands
prosthetic utilization beyond simple locomotion.
Level 4: Has the ability or potential for prosthetic
ambulation that exceeds basic ambulation skills,
exhibiting high impact, stress or energy levels.
Typical of the prosthetic demands of the child,
active adult or athlete. Services billed for this
functional level are considered deluxe by Medicaid.
Foot and Knee Prosthesis:
Foot and knee prosthesis coverage will be based on
medical necessity by the QIO-like vendor. The
recipient’s functional level will be taken into
consideration.
Sockets:
1. Test (diagnostic) sockets for immediate
prostheses (L5400-L5460) are not medically
necessary.
2. No more than two test (diagnostic) sockets for
an individual prosthesis are medically necessary
without additional documentation.
3. No more than two of the same socket inserts
(L5654-L5665) are allowed per individual
prosthesis at the same time.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 47
MTL 09/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: OSTEOGENESIS STIMULATOR DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Osteogenesis Device may be covered if: 1. Prescription and/or MD signed Prior 1. Electric Implantable Osteogenic
Stimulator 1. Non-union of a long bone fracture after three or Authorization Form. Stimulators are included in the surgical
(Non-spinal more months have elapsed without healing of the 2. Medical documentation supporting qualifying service thus are non-covered under this
Noninvasive Electrical) fracture; factors. chapter.
2. Failed fusion of a joint, other than in the spine,
where a minimum of nine months has elapsed
since the last surgery; or
3. Congenital pseudarthrosis
Osteogenesis Device may be covered if: 1. Prescription and/or MD signed Prior 1. Electric Implantable Osteogenic
Stimulator 1. Failed spinal fusion where a minimum of nine Authorization Form. Stimulators are included in the surgical
(Spinal Noninvasive months has elapsed since the last surgery; 2. Medical documentation supporting qualifying service thus are non-covered under this
Electrical) 2. Following a multilevel spinal fusion surgery factors. chapter.
involving three or more vertebrae; or
3. Following spinal fusion surgery where there is a
history of a previously failed spinal fusion.
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 48
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: PHOTOTHERAPY UNITS
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Phototherapy Unit 1. Bilirubin levels must be at or greater than 12.0 1. Prescription and/or MD signed Prior
with bilirubin therapy on initial day of treatment. Authorization Form.
2. Authorization is for a maximum of three days. 2. Medical documentation supporting qualifying
factors.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 49
MTL 08/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: PNEUMATIC COMPRESSION DEVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Pneumatic 1. One or more limbs involved; and 1. Prescription and/or MD signed Prior Note: Rental only.
Compression Devices 2. Radical surgical procedure with removal of Authorization Form.
(used for lymphedema) regional groups of lymph nodes (after radical 2. Medical documentation supporting qualifying
mastectomy); or factors.
3. Post radiation fibrosis;
4. Spread of malignant tumors to regional lymph
nodes with lymphatic obstruction;
5. Scarring of lymphatic channels,
6. Onset of puberty (Milroy’s disease); or
7. Congenital anomalies; and
8. Must be treatment of last resort with
documented evidence that elevation and custom
fabricated gradient pressure stockings or sleeves
are ineffective; and
9. Continuous oversight by treating physician
(including instruction, treatment plan, fracture
and duration of use ongoing monitoring and
evaluation).
May 1, 2016 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 50
MTL 08/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: PREGNANCY-RELATED EQUIPMENT
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Home-Based Terbutaline infusion pump therapy is a covered 1. Physician’s/Practitioner’s Order/Prescription. Note: Rental only.
(outpatient) benefit when the following conditions are met: 2. Requires a prior authorization.
Terbutaline Infusion 1. The recipient is at high risk for preterm labor 3. Medical records from physician must be
Pump Therapy and delivery based on one or a combination of submitted to substantiate all qualifications.
factors: 4. Prior authorization will not be processed
a. Current diagnosis of preterm labor with without medical records to substantiate request.
uterine contractions of four or more per
hour and progressive cervical change;
b. Cervical dilatation is less than four
centimeters;
c. History of preterm labor/delivery with
previous pregnancies.
2. The recipient is currently or has recently been
under treatment to prevent preterm labor with a
combination of the following methods:
a. Bed rest or restricted activity;
b. Oral tocolytic therapy (document
ineffectiveness);
c. Increased office visits or phone contact for
counseling;
d. Hospitalization.
3. Appropriate alternative treatment has been
tried and was not successful or was
contraindicated.
4. Physician states recipient is capable of
complying with home Terbutaline infusion
pump therapy.
5. Recipient is not less than 20 weeks gestation or
more than 37 weeks gestation.
6. Fetus is alive and well with an estimated weight
of less than 2,500 grams.
7. Costs associated with Terbutaline infusion
pump therapy do not exceed $240/day.
May 1, 2016 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 51
MTL 08/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: PREGNANCY-RELATED EQUIPMENT
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Home Uterine Activity 1. Recipient has a current diagnosis of pre-term 1. Prescription and/or MD signed Prior 1. Reimbursement only for days of
Monitor labor and a history of previous pre-term Authorization Form. documented telephone contact between
labor/delivery with pregnancies. 2. Prior Authorization Note: Prior authorization recipient/physician and monitoring
2. Records from physician showing pre-term submitted more than ten days after onset of device.
labor with uterine contractions of four or more service may be denied.
per hour and progressive cervical changes. 3. Medical documentation supporting qualifying Note: Rental only.
3. Cervical dilation is less than four centimeters. factors
4. Recipient is ordered on bed rest or restricted
activities.
5. Tocolytic therapy initiated (oral, subcutaneous
or intravenous route).
6. Documentation will show there is an increase
in physician/patient contact due to pre-term
labor symptoms.
7. The recipient is, in the opinion of the physician,
capable of complying with the home
monitoring program.
8. Recipient is not less than 24 weeks gestation or
more than 37 weeks gestation.
May 1, 2016 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 52
MTL 09/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Apnea Monitor 1. One-year qualification for at least one of: 1. Prescription and/or MD signed Prior 1. Program limit to one year for diagnoses
a. Prematurity (gestational age must be listed Authorization Form. including prematurity and maternal
on CMS 1500); 2. Medical documentation supporting qualifying substance abuse.
b. Substantially small for gestational age; factors. 2. Other diagnoses limited to six months.
c. HX of maternal alcohol abuse; 3. An Apnea Monitor is a non-
d. HX of maternal narcotics abuse; and/or reimbursable service in conjunction with
e. HX of maternal hallucinogenic agent abuse. a pressure ventilator, with pressure
2. Six-month qualification for at least one of: control pressure support and flow
a. Gastro-esophageal reflux; triggering features.
b. Abnormal pneumogram indicating
desaturating apnea;
c. Periodic respirations;
d. Significant bradycardia or tachycardia of
unknown or specified origin;
e. Congenital heart defect;
f. Bronchopulmonary dysplasia or newborn
respiratory distress;
g. Respiratory distress;
h. Family history of SIDS (siblings only);
i. Respiratory Syncytial Virus (RSV);
j. Apparent Life-Threatening Episode
(ALTE) with subsequent visits to physician
or emergency room;
k. Laryngotracheal malacia;
l. Tracheal stenosis; and/or
m. Swallowing abnormality.
Bi-Level Positive 1. For an E0470 or E0471 Respiratory Assist
Airway Pressure Device (RAD) to be covered, the treating
(BiPAP) Device physician must fully document in the recipient’s
medical record symptoms characteristic of
BiPAP “S” (E0470) sleep-associated hypoventilation, such as
(without back u) daytime hypersomnolence, excessive fatigue,
morning headache, cognitive dysfunction,
BiPiAP “ST” (E0471) dyspnea, etc.
(with back up)
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 53
MTL 09/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 2. For an E0470 or E0471 Respiratory Assist 1. Prescription and/or MD signed Prior 1. The initial rental will be for three
Bi-Level Positive Device (RAD) to be covered, the treating Authorization/CMN Form. months.
Airway Pressure physician must fully document in the recipient’s 2. Sleep Study (Diagnostic and Titrated sleep 2. Further approval requires:
(BiPAP) Device medical record symptoms characteristic of studies). a. A letter of compliance from the
sleep-associated hypoventilation, such as 3. Medical documentation supporting qualifying recipient; or
BiPAP ‘S’ (E0470) daytime hypersomnolence, excessive fatigue, factors. b. A completed form found on the
(without back up) morning headache, cognitive dysfunction, 4. Refer to specific documentation requirements QIO-like vendor’s website; or
dyspnea, etc. specified in the Qualifications section for each c. Follow up notes from physician
BiPAP ‘ST’ (E0471) A RAD (E0470, E0471) used to administer scenario. documenting compliance with the
(with back up rate) Noninvasive Positive Pressure Respiratory 5. MSRPs Invoice is required when no rate is BiPAP; or
Assistance (NPPRA) therapy is covered for established by the DHCFP. d. A readout/printout from the BiPAP
those recipients with clinical disorder groups supplier documenting regular
characterized as (Group I) restrictive thoracic usage of the BiPAP.
disorders (e.g., progressive neuromuscular 3. BiPAP replacement requires proof of
diseases or severe thoracic cage abnormalities), compliance or medical necessity.
(Group II) severe chronic obstructive pulmonary Note: The BiPAP will be rented until the
disease (COPD), (Group III) central sleep apnea purchase price is reached; this includes the
(CSA), or (Group IV) obstructive sleep apnea initial three-month rental period.
(OSA) (E0470 only) and who also meet the
following criteria:
Group I: Restrictive Thoracic Disorders:
a. There is documentation in the recipient’s
medical record of a progressive
neuromuscular disease (e.g., amyotrophic
lateral sclerosis) or a severe thoracic cage
abnormality (e.g., post-thoracoplasty for
TB); and
b. An arterial blood gas PaCO2, done while
awake and breathing the recipient’s usual
FIO2 is > 45 mm Hg; or
c. Sleep oximetry demonstrates oxygen
saturation < 88% for at least five continuous
minutes, done while breathing the
recipient’s usual FIO2; or
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 54
MTL 09/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) d. For a progressive neuromuscular disease
Bi-Level Positive (only), maximal inspiratory pressure is < 60
Airway Pressure cm H20 or forced vital capacity is < 50%
(BiPAP) Device predicted; and
e. Chronic Obstructive Pulmonary Disease
BiPAP ‘S’ (E0470) (COPD) does not contribute significantly to
(without back up) the recipient’s pulmonary limitation.
3. If all previously described criteria are met, either
BiPAP ‘ST’ (E0471) an E0470 or E0471 device (based upon the
(with back up rate) judgment of the treating physician) will be
covered for recipients within this group of
conditions for the first three months of NPPRA
therapy (see continued coverage after the initial
three months). If all of the previously described
criteria are not met, then E0470 or E0471 and
related accessories will be denied as not
medically necessary.
Group II: Severe COPD:
a. An arterial blood gas PaCO2 done while
awake and breathing the recipient’s usual
FIO2 is > 52 mm Hg; and
b. Sleep oximetry demonstrates oxygen
saturation < 88% for at least five continuous
minutes, done while breathing oxygen at 2
LPM or the recipient’s usual FIO2
(whichever is higher);
c. An arterial blood gas PaCO2, done while
awake and breathing the recipient’s usual
FIO2, is > 52 mm Hg; and
d. Prior to initiating therapy, OSA (and
treatment with CPAP) has been considered
and ruled out.
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 55
MTL 09/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 4. If all of the previously described criteria for
Bi-Level Positive recipients with COPD are met, an E0470 device
Airway Pressure will be covered for the first three months of
(BiPAP) Device NPPRA therapy (see Continued Coverage). An
E0471 device will not be covered for a recipient
BiPAP ‘S’ (E0470) with COPD during the first two months, because
(without back up) therapy with a E0470 device with proper
adjustments of the device’s settings and
BiPAP ‘ST’ (E0471) recipient accommodation to its use will usually
(with back up rate) result in sufficient improvement without the
need of a back-up rate. (See further in this
section for coverage of an E0471 device for
COPD after two month’s use of an E0470
device).
5. If all of the previously described criteria are not
met, E0470 and related accessories will be
denied as not medically necessary. If E0471 is
billed, even if the criteria for an E0470 device
are met, since the E0471 is in a different
payment category than E0470 and a least costly
medically appropriate alternative payment
cannot be made, it will be denied as not
medically necessary.
Group III: Central Sleep Apnea (e.g., apnea not due
to airway obstruction):
Prior to initiating therapy, a complete
polysomnogram must be performed
documenting the following:
a. The diagnosis of central sleep apnea (CSA);
b. The exclusion of obstructive sleep apnea
(OSA) as the predominant cause of sleep-
associated hypoventilation;
c. The ruling out of CPAP as effective
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 56
MTL 09/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) therapy if OSA is a component of the sleep-
Bi-Level Positive associated hypoventilation; and
Airway Pressure d. Oxygen saturation < 88% for at least five
(BiPAP) Device continuous minutes, done while breathing
the recipient’s usual FIO2; and
BiPAP ‘S’ (E0470) e. Significant improvement of the sleep-
(without back up) associated hypoventilation with the use of
an E0470 or E0471 device on the settings
BiPAP ‘ST’ (E0471) that will be prescribed for initial use at
(with back up rate) home, while breathing the recipient’s usual
FIO2.
6. If all previously described criteria are met, either
an E0470 or E0471 device (based upon the
judgment of the treating physician) will be
covered for recipients with documented CSA
conditions for the first three months of NPPRA
therapy (see Continued Coverage). If all of the
previously described criteria are not met, then
E0470 or E0471 and related accessories will be
denied as not medically necessary.
Group IV: Obstructive Sleep Apnea (OSA):
Criteria (a) and (b) are both met:
a. A complete polysomnogram has established
the diagnosis of obstructive sleep apnea
according to the following criteria:
1. The apnea-hypopnea index (AHI) is >
15 events per hour; or
2. The AHI is from five to 14 events per
hour with documented symptoms of:
a. Excessive daytime sleepiness,
impaired cognition, mood
disorders, or insomnia; or
b. Hypertension, ischemic heart
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 57
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) disease or history of stroke; and
Bi-Level Positive c. A single level device E0601,
Airway Pressure Continuous Positive Airway
(BiPAP) Device Pressure (CPAP) device has
been tried and proven
BiPAP ‘S’ (E0470) ineffective.
(without back up) 7. If the previously described criteria is met, an
E0470 device will be covered for the first three
BiPAP ‘ST’ (E0471) months of NPPRA therapy (see Continued
(with back up rate) Coverage). If E0470 is billed and these criteria
are not met but the coverage criteria in the
DMEMAC LCD and/or Policy Articles for
Continuous Positive Airway Pressure System
(CPAP) are met, payment will be based on the
allowance for the least costly medically
appropriate alternative, E0601.
8. An E0471 device is not medically necessary if
the primary diagnosis is OSA. If E0471 is
billed, since the E0471 is in a different payment
category than E0470 and E0601 and a least
costly medically appropriate alternative
payment cannot be made, it will be denied as
not medically necessary.
Continued Coverage for E0470 And E0471 Devices
Beyond First Three Months of Therapy:
1. Recipients covered for the first three months
for an E0470 or E0471 device must be re-
evaluated to establish the medical necessity of
continued coverage beyond the first three
months. While the recipient may certainly need
to be evaluated at earlier intervals after this
therapy is initiated, the re-evaluation upon
which will base a decision to continue coverage
beyond this time must occur no sooner than 61
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 58
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) days after initiating therapy by the treating
Bi-Level Positive physician. Medicaid will not continue coverage
Airway Pressure for the fourth and succeeding months of NPPRA
(BiPAP) Device therapy until this re-evaluation has been
completed.
BiPAP ‘S’ (E0470) 2. There must be documentation in the recipient’s
(without back up) medical record about the progress of relevant
symptoms and recipient usage of the device up
BiPAP ‘ST’ (E0471) to that time. Failure of the recipient to be
(with back up rate) consistently using the E0470 or E0471 device
for an average of four hours per 24-hour period
by the time of the re-evaluation (on or after the
31st day, but no later than 91 days after initiation
of therapy) would represent non-compliant
utilization for the intended purposes and
expectations of benefit of this therapy. This
would constitute reason to deny continued
coverage as not medically necessary.
3. The following items of documentation must be
obtained by the supplier of the device for
continuation of coverage beyond three months:
a signed and dated statement completed by the
treating physician no sooner than 61 days after
initiating use of the device, declaring that the
recipient is compliantly using the device (an
average of four hours per 24-hour period) and
that the recipient is benefiting from its use. A
“Usage Evaluation” form FH-1A, found on the
QIO-like vendor’s website is available for use
at: https://www.medicaid.nv.gov/, select
“Provider” then “Forms.” It is not mandatory
that this form be used as long as the above
information is provided by the treating
physician.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 59
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) 4. If the above criteria are not met, continued
Bi-Level Positive coverage of an E0470 or E0471 device and
Airway Pressure related accessories will be denied as not
(BiPAP) Device medically necessary.
5. For Group II (COPD) recipients who qualified
BiPAP ‘S’ (E0470) for an E0470 device, if at a time no sooner than
(without back up) 61 days after initial issue and compliant use of
an E0470 device, the treating physician believes
BiPAP ‘ST’ (E0471) the recipient requires an E0471 device, the
(with back up rate) E0471 device will be covered if the following
criteria are met:
a. an arterial blood gas PaCO2, repeated no
sooner than 61 days after initiation of
compliant use of the E0470, done while
awake and breathing the recipient’s usual
FIO2, still remains > 52 mm Hg;
b. a sleep oximetry, repeated no sooner than 61
days after initiation of compliant use of an
E0470 device, and while breathing with the
E0470 device, demonstrates oxygen
saturation < 88% for at least five continuous
minutes, done while breathing oxygen at 2
LPM or the recipient’s usual FIO2
(whichever is higher); and
c. a signed and dated statement from the
treating physician, completed no sooner
than 61 days after initiation of the E0470
device, declaring that the recipient has been
compliantly using the E0470 device (an
average of four hours per 24-hour period)
but that the recipient is NOT benefiting
from its use.
6. If the above criteria for an E0471 are not met,
since the E0471 is in a different payment
category than E0470 and a least costly
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 60
MTL 09/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) medically appropriate alternative payment
Bi-Level Positive cannot be made, it will be denied as not
Airway Pressure medically necessary.
(BiPAP) Device
BiPAP ‘S’ (E0470)
(without back up)
BiPAP ‘ST’ (E0471)
(with back up rate)
Continuous Positive 1. A single level continuous positive airway 1. Prescription and/or MD signed Prior 1. The initial rental will be for three months.
Airway Pressure pressure (CPAP) device (E0601) is covered if Authorization/CMN Form. 2. Further approval requires:
Device the recipient has a diagnosis of obstructive sleep 2. Sleep Study (Diagnostic and Titrated sleep a. letter of compliance from the
CPAP (E0601) apnea (OSA) documented by complete studies). recipient; or
polysomnogram and meets either of the 3. Medical documentation supporting qualifying b. a completed form found on the QIO-
following criteria (a or b): factors. like vendor’s website; or
a. The AHI is > 15 events per hour; or 4. MSRP Invoice is required when no rate is c. follow up notes from physician
b. The AHI is from five to 14 events per hour established by the DHCFP. documenting compliance with the
with documented symptoms of: 5. Refer to specific documentation requirements CPAP; or
1. Excessive daytime sleepiness, impaired specified in the Qualifications section for each d. a readout/printout from the CPAP
cognition, mood disorders or insomnia; scenario. supplier documenting regular usage of
or the CPAP.
2. Hypertension, ischemic heart disease, 3. CPAP replacement requires proof of
or history of stroke. compliance or medical necessity.
Note: The AHI must be calculated based on a Note: The CPAP will be rented until the
minimum of two hours of recorded sleep and must purchase price is reached; this includes the
be calculated using actual recorded hours of sleep initial three-month rental period.
(e.g., the AHI may not be an extrapolated or a
projected calculation).
2. Continued coverage of an E0601 device beyond
the first three months of therapy requires that, no
sooner than the 31st day but no later than 91 days
after initiating therapy, the supplier ascertain
from either the recipient or the treating
physician that the recipient is continuing to use
February 26, 2020 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 61
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) the CPAP device. Continued use is defined as an
Continuous Positive average of four hours per 24-hour period.
Airway Pressure
Device A “Usage Evaluation” form FH-1A, found on the
CPAP (E0601) QIO-like vendor’s website is available for use at:
https://www.medicaid.nv.gov/, select “Provider”
then “Forms.” It is not mandatory that this form be
used as long as the previously listed is provided by
the treating physician.
The supplier cannot provide answers to any of the
information, as it must be obtained from the
recipient, caregiver, spouse or attending physician.
Information should include:
a. Number of hours a day the machine is used.
b. Number of months using machine.
c. Will the recipient continue to use the machine
in the future?
Identify who has answered the information
(cannot be the supplier).
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 62
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
High Frequency FDA-approved high frequency chest compression 1. Physician’s order/prescription. 1. Disease conditions such as: cystic fibrosis
Chest Wall Oscillation (HFCC) device (vest coupled to a pneumatic 2. Completed prior authorization form. (CF), bronchiectasis and immotile cilia
Air-Pulse Generator compressor) is a covered benefit for recipients who 3. Physician’s assessment to include the syndrome can lead to abnormal airway
System (E0483) meet all of the following qualifications: diagnosis for treatment. Clearly defined clearance which is a source of increased
1. Documented medical justification for the need and medical need for airway clearance as sputum production, often purulent and
(Rental and the initial length of time the HFCC system will be utilized; evidenced by retained secretions, prior tenacious; chest physiotherapy (CPT)
purchase includes and history of pneumonia or other significant becomes necessary. In conditions such as
hose and vest) 2. Recipient must have one of the following worsening pulmonary function, presence of CF, excessive tenacious secretions
diagnoses which causes excessive, tenacious atelectasis caused by mucus plugging by necessitate routine CPT to prevent airway
Replacement secretions and impairs ability to clear secretions: report. obstruction leading to secondary infection,
Items: a. Cystic fibrosis; 4. Documented failure of CPT, type used, the principal cause of morbidity and
b. Chronic bronchiectasis; or frequency, duration of use and outcomes. mortality.
High Frequency Chest c. Chronic neuromuscular disorder with prior 5. Current medications, route of administration, 2. The standard method of CPT is manual
Wall Oscillation history of pneumonia or other significant dosage and frequency. percussion and postural drainage. In the
Systems Vest, for worsening of pulmonary functioning; 6. Diagnostic studies such as high resolution, home setting, CPT is administered to the
the use with recipient 3. Well-documented failure of other methods, or spiral or standard CT scan. recipient by a trained adult one to three
owned equipment inability to use other airway clearance therapies 7. Number of times per day recipient requires times a day for 20 - 30 minutes per session.
(A7025) including chest physical therapy (CPT), flutter CPT. 3. FDA approved HFCC (oscillating
valve, etc. to adequately mobilize retained 8. Age of recipient. devices) have been utilized as an
High Frequency Chest secretions; 9. Identify primary caregiver and the caregiver alternative to conventional manual chest
Wall Oscillation 4. Documentation of physician’s treatment plan that availability. physical therapy to promote the clearance
System Hose, for includes external manipulation of the thorax at 10. The prescribing physician will need to of respiratory secretions in patients with
use with recipient least daily to release retained secretions; submit periodic follow-up reports. impaired ability to cough or otherwise
owned equipment 5. Documented evidence that recipient is having 11. MSRP Invoice is required when no rate is expel them on their own.
(A7026) difficulty with secretion clearance, or presence of established by the DHCFP. 4. For purchase to be considered, a three-
atelectasis caused by mucus plugging confirmed month trial period on a rental basis is
by high resolution, spiral or standard CT scan; required. After the trial period and receipt
6. Age greater than 2 years; and of the follow up documentation showing
7. Recipient and caregiver cannot adequately evidence of compliance and effectiveness,
perform the needed bronchial drainage treatment the HFCC device may be approved for
(such as having more than one child requiring CPT purchase.
or a valid medical reason that prohibits the CPT). 5. The QIO-like vendor will provide
authorization to include the 61st through
120 days if medically necessary.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 63
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) Recipients who have a documented diagnosis, other Not Medically Necessary
High Frequency than those listed under Item 2, which causes 1. When the criteria in this policy are not
Chest Wall Oscillation excessive, tenacious secretions and impairs ability to met.
Air-Pulse Generator clear secretions may be reviewed on a case-by-case 2. Recipient receiving duplication of
System (E0483) basis to determine Medical Necessity (e.g., not services.
experimental or investigational). For consideration, 3. The DHCFP will not reimburse providers
(Rental and the initial the recipient must meet the following qualifications: for bronchial drainage performed by a
purchase includes 1. Recipient meets qualifications 1 through 7, therapist or other health care professional
hose and vest) excluding item 2; and while the recipient has the bronchial
2. Documented evidence of a recent prior history of drainage vest (e.g., home health services
Replacement pneumonia or other significant worsening where a physical therapist, nurse and/or
Items: pulmonary functioning. aide is performing CPT and postural
drainage).
High Frequency Chest Qualifications for Continued Use 4. Recipients who have contraindication of
Wall Oscillation external manipulation of the thorax as
Systems Vest, for Continued coverage of the HFCC device beyond the defined by American Association of
the use with recipient three-month trial of therapy requires documentation Respiratory Care (AARC) contained in
owned equipment dated no sooner than the 61st day, but not later than their clinical practice guidelines for
(A7025) 120 days after initiating therapy in one of the Postural Drainage Therapy which include,
following formats: but are not limited to:
High Frequency Chest 1. The treating physician submits documentation to a. unstable head or neck injury;
Wall Oscillation include the effectiveness of treatment, recipient’s b. active hemorrhage with
System Hose, for compliance and tolerance of the therapy; or hemodynamic instability;
use with recipient 2. Report via monthly usage meter checks c. subcutaneous emphysema;
owned equipment documenting use at least 67% of prescribed d. spinal fusion or spinal anesthesia;
(A7026) frequency. e. recent skin grafts or flaps on the
thorax;
f. burns, open wounds;
g. skin infections of the thorax;
h. recently placed trans-venous
pacemaker or subcutaneous
pacemaker;
i. suspected pulmonary tuberculosis;
j. lung contusion;
k. bronchospasm;
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 64
MTL 08/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) l. osteoporosis;
High Frequency m. osteomyelitis of the ribs;
Chest Wall Oscillation n. coagulopathy; and/or
Air-Pulse Generator o. complaint of significant chest wall
System (E0483) pain.
Note: The DHCFP will not reimburse
(Rental and the initial providers when items are provided prior to PA
purchase includes approval.
hose and vest)
Replacement
Items:
High Frequency Chest
Wall Oscillation
Systems Vest, for
the use with recipient
owned equipment
(A7025)
High Frequency Chest
Wall Oscillation
System Hose, for
use with recipient
owned equipment
(A7026)
Humidifiers and 1. Medical evidence/documentation recipient is a 1. Prescription and/or MD signed Prior 1. Reference DMEPOS PT 33 fee schedule.
Supplies new start or compliant with current positive Authorization Form
airway pressure therapy. 2. Medical documentation supporting qualifying
2. Sleep study or equipment fitting documentation factors.
showing recommended type and sizing.
3. Quantity limited to reimbursable guidelines.
May 1, 2016 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 65
MTL 27/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
Nebulizers and 1. A small volume nebulizer (A7003, A7004, 1. Prescription and/or MD signed Prior 1. Reference DMEPOS PT 33 fee
Compressors A7005) and related compressor (E0570, E0571) Authorization Form. schedule.
are covered when: 2. Medical documentation supporting qualifying 2. Small volume ultrasonic nebulizer
a. It is medically necessary to administer beta- factors. (E0574) and large volume ultrasonic
adrenergics, anticholinergics, nebulizer (E0575) will be reimbursed at
corticosteroids and cromolyn for the the least costly alternative of a
management of obstructive pulmonary pneumatic compressor (E0570).
disease;
b. It is medically necessary to administer
gentamicin, tobramycin, amikacin or
dornase alfa to a recipient with cystic
fibrosis;
c. It is medically necessary to administer
pentamidine to recipients with HIV and
complications of organ transplants; or
d. It is medically necessary to administer
mucolytics (other than dornase alpha) for
persistent thick or tenacious pulmonary
secretions.
Note: For criterion (a) to be met, the physician must
have considered use of a metered dose inhaler (MDI)
with and without a reservoir or spacer device and
decided that, for medical reasons, it was not
sufficient for the administration of needed inhalation
drugs. The reason for requiring a small volume
nebulizer and related compressor/generator instead
of or in addition to an MDI must be documented in
the recipient's medical record and be available to
Medicaid on request.
2. A large volume nebulizer (A7017), related
compressor (E0565 or E0572), and water or
saline (A7018 or A4216) are covered when it is
medically necessary to deliver humidity to a
recipient with thick, tenacious secretions, who
has cystic fibrosis, a tracheobronchial stent.
October 1, 2015 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 66
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
(continued) Combination Code E0585 will be covered for the
Nebulizers and same indications. An E0565 or E0572 compressor
Compressors and filtered nebulizer (A7006) are also covered
when it is medically necessary to administer
pentamidine to recipients with HIV. If a large
volume nebulizer, related compressor/generator
and water or saline are used predominantly to
provide room humidification it will be denied as
non-covered.
Oximeter: 1. The DHCFP covers Pulse Oximetry in the home 1. Prescription by physician; 1. Initial approval may be for 30-90 days.
E0445- device for as medically necessary when one of the following 2. Prior authorization; and 2. Approval for a Continuous Oximeter
measuring blood criteria is met: 3. Documentation by the physician of recipient’s model requires medical necessity for all
oxygen levels, non- a. Any age determination: medical condition, which documents the need additional features i.e.: pulse, Alarm, O2
invasive 1. Recipient is dependent on both a for in-home use of an oximeter, finger or Stats, etc.
ventilator and supplemental oxygen; continuous models, duration of use and 3. Oximeter testing is not a reimbursable
Accessories: 2. Recipient has a tracheostomy and is responses for decreased O2. service for DME providers.
Oxygen probe oxygen dependent; 4. MSRP Invoice is required when no rate is 4. Requires plans for training/instructions
(A4606) for use with 3. Recipient is on supplemental oxygen established by the DHCFP. of family/caregiver.
continuous oximeter and weaning is in process; or Recertification of Prior Authorization:
device, replacement 4. Recipient is discharged from inpatient 1. Recertification is allowed until the recipient no
stay for pulmonary diagnosis. longer meets criteria, the device is removed
from the home or purchase price has been met;
and
2. Physician progress notes/narratives to
substantiate the continued need to use the
oximeter for decreased O2 saturations.
Allowable notations to include family, recipient
and/or caregivers’ responses.
Oxygen (O2): 1. Arterial blood gases or an ear oximetry reporting: 1. Prescription and/or MD signed Prior 1. Oximetry test must be performed by a
Concentrators a. PO2 Level of 60 mmHG or less on room air; Authorization/CMN Form. physician or qualified laboratory. O2
Portables or 2. Oximetry spot check or overnight tape results. saturations (sats) will not be accepted
Regulators 3. Medical documentation supporting qualifying from an oxygen supplier.
factors.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 67
MTL 07/18
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY APPENDIX B
Subject:
MEDICAID SERVICES MANUAL COVERAGE AND LIMITATIONS POLICIES
Policy: RESPIRATORY SERVICES
EQUIPMENT OR QUALIFICATIONS FORMS AND DOCUMENTATION MISCELLANEOUS POLICY
ITEM REQUIREMENTS STATEMENTS
O2 Carts b. 80 mmHG or less on O2; or 2. Liquid oxygen and related equipment
c. O2 saturation (sat) level of 89% or less; and are non-covered Medicaid services
Oxygen Supplies: d. Medical Necessity; unless recipient does not have electrical
Tubing e. Must list conditions of study (rest, sleeping, utilities at residence. Reimbursement
Cannulas exercising, room air, on oxygen). will be only for stationary at the same
O2 Masks 2. CHILDREN: 92% or less room air saturation, at rate as concentrator.
Humidifiers rest.
O2 sats must be performed within 60 days of
requested dates of service.
Respirometers 1. Medical evidence/documentation supporting a
related diagnosis for equipment.
Suction Pumps 1. Recipients who have difficulty raising and 1. Prescription and/or MD signed Prior 1. Reference DMEPOS PT 33 Fee
clearing secretions due to: Authorization Form. Schedule for quantity limits.
a. Cancer or surgery of the throat or mouth; 2. Medical documentation supporting qualifying
b. Dysfunction of the swallowing muscles; factors.
c. Unconsciousness or obtunded state; or
d. Tracheostomy (V44.0).
Ventilators 1. Medical evidence/documentation supporting a 1. Prescription and/or MD signed Prior 1. Medical Supplier must keep back up
related diagnosis for equipment (e.g., Authorization Form. inventory available for rented
tracheostomy). 2. Medical documentation supporting qualifying equipment in emergent situations.
factors. Reimbursement for a backup ventilator
3. MSRP Invoice is required when no rate is provided in the recipient’s home will
established by the DHCFP. only be allowed if it is medically
prohibitive for a provider to respond in
an emergent situation such as a recipient
being on 24-hour ventilation support.
June 27, 2018 DME, DISPOSABLE SUPPLIES AND SUPPLEMENTS Appendix B Page 68
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
November 8, 2011
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: MARTA E. STAGLIANO, CHIEF, COMPLIANCE / Marta Stagliano/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1400 – HOME HEALTH AGENCY
BACKGROUND AND EXPLANATION
Medicaid Services Manual (MSM) Chapter 1400, Home Health Agency, has been revised to
remove the Definitions and References/Cross References sections. The Definitions were moved
to the MSM Addendum and the References/Cross References to MSM Chapter 100.
These policy changes are effective November 9, 2011.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 26/11 MTL 35/03, 23/07, 11/09
CHAPTER 1400 – HOME HEALTH CHAPTER 1400 – HOME HEALTH
AGENCY AGENCY
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1402 Reserved Removed Definition Section.
1405 References and Removed References.
Cross References
Page 1 of 1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
HOME HEALTH AGENCY
1400 INTRODUCTION ...............................................................................................................................1
1401 AUTHORITY ......................................................................................................................................1
1402 RESERVED .........................................................................................................................................1
1403 POLICY ..............................................................................................................................................1
1403.1 POLICY STATEMENT ......................................................................................................................1
1403.1A COVERAGE AND LIMITATIONS ...................................................................................................1
1403.1B PROVIDER RESPONSIBILITY.........................................................................................................5
1403.1C RECIPIENT REPONSIBILITY ..........................................................................................................9
1403.1D AUTHORIZATION PROCESS AND REIMBRUSEMENTS .........................................................11
1403.2 SKILLED NURSING SERVICES (SN) ...........................................................................................16
1403.2A COVERAGE AND LIMITATIONS .................................................................................................17
1403.2B PROVIDER RESPONSIBILITY.......................................................................................................20
1403.2C RECIPIENT RESPONSIBILITY ......................................................................................................20
1403.2D AUTHORIZATION PROCESS ........................................................................................................20
1403.3 SKILLED PHYSICAL THERAPY SERVICES ...............................................................................20
1403.3A COVERAGE AND LIMITATIONS .................................................................................................20
1403.3B PROVIDER RESPONSIBILITY.......................................................................................................21
1403.3C RECIPIENT RESPONSIBILITY ......................................................................................................21
1403.3D AUTHORIZATION PROCESS ........................................................................................................21
1403.4 SKILLED OCCUPATIONAL THERAPY SERVICES ...................................................................21
1403.4A COVERAGE AND LIMITATIONS .................................................................................................22
1403.4B PROVIDER RESPONSIBILITY.......................................................................................................22
1403.4C RECIPIENT RESPONSIBILITY ......................................................................................................22
1403.4D AUTHORIZATION PROCESS ........................................................................................................22
1403.5 SKILLED SPEECH LANGUAGE PATHOLOGY SERVICES ......................................................22
1403.5A COVERAGE AND LIMITATIONS .................................................................................................23
1403.5B PROVIDER RESPONSIBILITY.......................................................................................................23
1403.5C RECIPIENT RESPONSIBILITY ......................................................................................................23
1403.5D AUTHORIZATION PROCESS ........................................................................................................24
1403.6 RESPIRATORY THERAPY SERVICES .........................................................................................24
1403.6A COVERAGE AND LIMITATIONS .................................................................................................24
1403.6B PROVIDER RESPONSIBILITY.......................................................................................................24
1403.6C RECIPIENT RESPONSIBILITY ......................................................................................................24
1403.6D AUTHORIZATION PROCESS ........................................................................................................24
1403.7 REGISTERED DIETICIAN SERVICES ..........................................................................................24
1403.7A COVERAGE AND LIMITATIONS .................................................................................................24
1403.7B PROVIDER RESPONSIBILITY.......................................................................................................25
1403.7C RECIPIENT RESPONSIBILITY ......................................................................................................25
1403.7D AUTHORIZATION PROCESS ........................................................................................................25
Page 1 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
1403.8 HOME HEALTH AIDE SERVICES ................................................................................................25
1403.8A COVERAGE AND LIMITATIONS .................................................................................................25
1403.8B PROVIDER RESPONSIBILITY.......................................................................................................26
1403.8C RECIPIENT RESPONSIBILITY ......................................................................................................26
1403.8D AUTHORIZATION PROCESS ........................................................................................................26
1403.9 END STAGE RENAL DISEASE (ESRD) SERVICES ....................................................................26
1403.9A COVERAGE AND LIMITATIONS .................................................................................................26
1403.9B PROVIDER RESPONSIBILITY.......................................................................................................26
1403.9C RECIPIENT RESPONSIBILITY ......................................................................................................26
1403.9D AUTHORIZATION PROCESS ........................................................................................................26
1403.10 OUT-OF-STATE SERVICES ...........................................................................................................27
1403.10A COVERAGE AND LIMITATIONS .................................................................................................27
1403.10B PROVIDER RESPONSIBILITY.......................................................................................................27
1403.10C RECIPIENT RESPONSIBILITY ......................................................................................................27
1403.10D AUTHORIZATIONS PROCESS ......................................................................................................28
1403.11 EARLY & PERIODIC SCREENING, DIAGNOSIS AND TREATMENT
(EPSDT) ............................................................................................................................................28
1403.11A COVERAGE AND LIMITATIONS .................................................................................................28
1403.11B PROVIDER RESPONSIBILITY.......................................................................................................28
1403.11C RECIPIENT RESPONSIBILITY ......................................................................................................28
1403.11D AUTHORIZATION PROCESS ........................................................................................................28
1403.12 SERVICES TO CHILDREN .............................................................................................................29
1403.12A COVERAGE AND LIMITATIONS .................................................................................................29
1403.12B PROVIDER RESPONSIBILITY.......................................................................................................29
1403.12C RECIPIENT RESPONSIBILITY ......................................................................................................29
1403.12D AUTHORIZATION PROCESS ........................................................................................................29
1403.13 FAMILY PLANNING .......................................................................................................................29
1403.13A COVERAGE AND LIMITATIONS .................................................................................................29
1403.13B PROVIDER RESPONSIBILITY.......................................................................................................30
1403.13C RECIPIENT RESPONSIBILITY ......................................................................................................30
1403.13D AUTHORIZATION PROCESS ........................................................................................................30
1404 HEARINGS .........................................................................................................................................1
Page 2 of 2
MTL 35/03
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1400
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
1400 INTRODUCTION
HOME HEALTH AGENCY (HHA) SERVICES
The Division of Health Care Financing and Policy (DHCFP) Home Health Agency (HHA)
Program is a mandated home health care benefit provided to recipients in his/her residence. HHA
services are a component in the continuum of care which allows recipients to remain in his/her
home. HHA services may be provided to eligible recipients, based on medical necessity, program
criteria, utilization control measures and the availability of the state’ resources to meet recipient
needs. HHA services are provided on an intermittent basis, certified by a physician and provided
under a physician approved Plan of Care (POC). The Home Health Agency (HHA) service benefit
provides Skilled Nursing (SN) services, and other therapeutic services such as Physical Therapy
(PT), Occupational Therapy (OT), Speech Therapy (ST), and Home Health Aides or Certified
Nursing Aides (CNAs). Respiratory Therapists (RT) and Registered Dieticians (RD) are also a
benefit with limitations. Services are generally provided on a short-term basis as opposed to long-
term custodial services.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up, with the exception of the four areas where Medicaid and Nevada Check Up policies
differ as documented in Chapter 3700.
September 23, 2003 HOME HEALTH AGENCY Section 1400 Page 1
MTL 35/03
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1401
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
1401 AUTHORITY
A. The Home Health Agency (HHA) program is a mandatory benefit under 1905(1)(18) of
the Social Security Act.
B. The citation, which explains and interprets the federal regulations governing Home Health
services, is found in the Code of Federal Regulations (CFR) Title 42, Part 440.70 and
441.15.
September 23, 2003 HOME HEALTH AGENCY Section 1401 Page 1
MTL 26/11
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1402
Subject:
MEDICAID SERVICES MANUAL RESERVED
1402 RESERVED
November 9, 2011 HOME HEALTH AGENCY Section 1402 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1403
Subject:
MEDICAID SERVICES MANUAL POLICY
1403 POLICY
1403.1 POLICY STATEMENT
The home health care benefit reimburses for medically necessary and appropriate home visits by
skilled nurses, physical therapists, occupational therapists, speech therapists, respiratory
therapists, dieticians and home health aides to Medicaid recipients. A home health agency
provides skilled services and non-skilled services to recipients on an intermittent and periodic
basis.
Services are intended to provide skilled intervention with emphasis on recipient/caregiver
teaching. Legally responsible adults, willing caregivers and recipients are expected to be taught
care which can be rendered reasonably and safely by non medical persons.
1403.1A COVERAGE AND LIMITATIONS
1. PROGRAM ELIGIBILITY CRITERIA
To be determined eligible for HHA services, the following are necessary:
a. The recipient must be program eligible for Title XIX (Medicaid) or Title XXI
(Nevada Check Up) services;
b. A Legally Responsible Adult (LRA) or other willing caregiver is not available or
capable of providing all services;
c. The recipient must have a need for a qualifying skilled service.
d. Services must be reasonable and necessary for the diagnosis and treatment of the
recipient’s illness or injury within the context of the recipients’ unique medical
condition and the standard of practice within the community.
e. Services must be sufficient in amount, duration and scope to reasonably achieve its
purpose;
f. Services must be provided under a Plan of Care (POC) signed by the physician;
g. Services must be provided on an intermittent and periodic basis;
h. Services must have prior authorization;
i. Services must be provided in the recipient’s place of residence;
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1403
Subject:
MEDICAID SERVICES MANUAL POLICY
j. Services cannot be provided in a physician’s office, clinic or other outpatient
setting.
k. Home care services may be appropriate when one or more of the following
situations exist:
1. The recipient’s illness, injury or disability precludes going to the
physician’s office, clinic or outpatient setting;
2. A hardship would occur if service were provided outside the home, i.e., a
recipient just out of the hospital following major surgery;
3. The service is contraindicated outside the home based on recipient’s
medical condition, i.e., a recipient who must be protected from infection;
4. The service outside the home would interfere with the effectiveness of the
service, i.e., traveling an extreme distance or a recipient whose frequent
service need, such as IV therapy three times per day, cannot reasonably be
accommodated outside the home;
5. The recipients documented medical condition is so fragile or unstable that
the physician state that leaving the home is undesirable; and
6. The service, such as teaching, can be more effectively accomplished at
home.
2. COVERED SERVICES
a. Skilled nursing services provided by a licensed nurse performing skilled
interventions to maintain or improve the recipient’s health status.
b. Physical therapy services provided by a licensed physical therapist to restore,
maintain or improve muscle tone, joint mobility or physical function.
c. Occupational therapy services provided by a licensed occupational therapist to
improve or restore function.
d. Speech therapy provided by a licensed speech pathologist for the treatment of
speech and language disorders, communicative disabilities or swallowing
disorders.
e. Respiratory therapy provided by a licensed respiratory therapist.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
f. Dietician services provided by a registered dietician for consultative services for
nutritional deficits or recipients at risk of nutritional deficits.
g. Home Health Aide services provided by a Certified Nursing Aide (CNA) under the
supervision of a registered nurse and in accordance with the Nurse Practice Act.
3. NON-COVERED HHA SERVICES
No reimbursement or coverage will be provided for:
a. Services provided to a recipient that is ineligible or becomes ineligible for Title
XIX or Nevada Check Up;
b. Services normally provided by an immediate relative, legally responsible adult or
other willing and capable caregiver;
c. Services provided to a recipient who is a resident in a hospital, skilled nursing
facility including a Nursing Facility for the Mentally Ill (NF/MI) or Intermediate
Care Facility for the Mentally Retarded (ICF/MR) or an institution for the
treatment of chemical addiction;
d. Services rendered to recipients in pediatric or adult day care centers;
e. Services rendered at school sites which provide “school based health service”
pursuant to IDEA 300.24;
f. Services provided to someone other than the intended recipient;
g. Services that the DHCFP determines could reasonably be performed by the
recipient;
h. Services provided without authorization;
i. Services provided by the HHA that were not noted on the initial physician or
subsequent medical orders, or Plan of Care (POC);
j. Service requests that exceed program limits;
k. Services provided at a recipients home that could have been obtained in an
outpatient setting (e.g. lab work for an ambulatory recipient);
l. Services determined not medically necessary by DHCFP;
December 11, 2007 HOME HEALTH AGENCY Section 1403 Page 3
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
m. Homemaker services;
n. Medical Social Services (MSS);
o. Companion care that is intended to provide friendly or social time with a recipient;
p. Sitter or services that are intended for individuals to watch or supervise a recipient
in the absence of a legally responsible adult or primary caregiver and that provide
no skilled care;
q. Respite care;
r. Duplication of services;
s. Transportation of recipients to Medicaid reimbursable settings, unless the HHA is
a Medicaid transportation provider. Refer to Chapter 1900;
t. Travel time to and from the recipients residence;
u. Routine services such as physical checkups or assessments that are performed
without relationships to a treatment of diagnosis for a specific illness;
v. Routine newborn teaching and post-partum follow ups and assessments;
w. Skilled nursing visits to children for the administration of Synagis outside the
guidelines of Nevada Medicaid policy;
x. Routine supplies customarily used during the course of HHA visits. These supplies
are included in the staff’s supplies and are not designated for a specific recipient.
Routine supplies may include but are not limited to non-sterile gloves and
thermometer covers. These supplies are included in the cost-per-visit of HHA
service;
y. Routine personal hygiene supplies may include, but are not limited to such items
as shampoos, soaps, lotions or powders, toothpaste, combs, etc.;
z. Routine disposable supplies required on a monthly basis. These supplies must be
obtained from a DME or pharmacy provider (refer to Chapters 1200 and 1300);
aa. Personal comfort items which do not contribute to the treatment of an illness or
injury or the functioning of a malformed body part. Personal comfort items may
include but are not limited to items such as air conditioner, radios, etc.
December 11, 2007 HOME HEALTH AGENCY Section 1403 Page 4
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1403
Subject:
MEDICAID SERVICES MANUAL POLICY
1403.1B PROVIDER RESPONSIBILITY
The provider shall furnish skilled nursing services and other therapeutic services such as physical
therapy, occupational therapy, speech therapy, home health aides or certified nursing aides,
respiratory therapists and registered dieticians to eligible recipients as identified in the physician’s
written Plan of Care (POC). Services are to be provided as specified in this Chapter.
1. PROVIDER QUALIFICATIONS
The provider must be enrolled as a Medicare Certified Home Health Agency (HHA)
licensed and authorized by state and federal laws to provide health care services in the
home.
2. MEDICAID ELIGIBILITY
HHAs must verify the recipient’s eligibility for Medicaid. Authorization for home health
care is valid only if the recipient is eligible for Medicaid during the month the service is
provided. The provider must verify each month the continued Medicaid eligibility for each
recipient. Verification of Medicaid eligibility is the responsibility of the HHA.
3. THIRD PARTY LIABILITY (TPL)
HHAs must determine, on admission to HHA services, the primary payer. If Medicaid is
not the primary payer, the provider must bill the third party payor before billing Medicaid.
4. PHYSICIANS ORDER AND PLAN OF CARE
HHA services are initiated per a physicians order. HHA program services are provided per
the Plan of Care (POC) which is documented on a CMS 485. The POC is a written set of
medical orders signed by the physician which certify the specific HHA services that will
be provided, the frequency of the services, and the projected time frame necessary to
provide such services. The Plan of Care is reviewed by the physician every 60 days. A
new POC is required when there is a change in the recipient's condition, change in orders
following hospitalization, and/or change in the physician.
5. PRIOR AUTHORIZATION
HHAs must obtain proper authorization for all Home Health Agency services prior to the
start of care. Refer to the authorization process 1403.1D.
6. PLACE OF SERVICE
HHA services must be provided in the recipient’s place of residence.
December 11, 2007 HOME HEALTH AGENCY Section 1403 Page 5
MTL 23/07
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1403
Subject:
MEDICAID SERVICES MANUAL POLICY
7. HOME HEALTH AGENCY VISITS
a. Evaluation visit
HHA's are required to have written policies concerning the acceptance of the
recipient by the agency. This includes consideration of the physical facility
available in the recipient’s place of residence, homebound status and the attitudes
of family members for the purpose of evaluating the feasibility of meeting the
recipient’s medical needs in the home health setting.
When personnel of the HHA make an initial visit to assess the recipient the cost of
the visit is considered an administrative cost and is not reimbursable as a visit at
this point since the recipient has not been accepted for care. If during the course of
the initial visit, the recipient is determined appropriate for home health care by the
agency and the recipient received the first skilled service as ordered under the
POC, the visit becomes the first billable visit as an RN extended visit.
b. Supervisory visit
A supervisory visit made by a registered nurse to complete a recertification visit or
to evaluate the delivery of specific needs of the recipient by a CNA or LPN can be
authorized only once every 60-62 days. This is authorized as a RN extended visit.
c. Visit types
Two types of visits may be provided under skilled nursing. These are: An extended
visit, which is defined as any visit exceeding 30 minutes but not more than 90
minutes; and the nurse's brief visit, which is defined as a visit of 30 minutes or
less. Visits for certified nursing aides are approved for the first hour and each
additional ½ hour thereafter.
8. RECIPIENT RIGHTS
The Home Health Agency (HHA) has an obligation to protect and promote the exercise of
the recipient rights. A patient has the right to exercise his rights as a patient of the
provider. A patient’s family or guardian may exercise a patient’s rights when a patient has
been judged incompetent. The recipient has the right to be notified in writing of his rights
and obligations before treatment is begun. HHA’s must provide each patient and family
with a written copy of the recipient’s bill of rights. A signed and dated statement
acknowledging receipt of the patient’s Bill of Rights will be included in the patient’s
medical record. Refer to recipient rights later in this Chapter.
December 11, 2007 HOME HEALTH AGENCY Section 1403 Page 6
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1403
Subject:
MEDICAID SERVICES MANUAL POLICY
9. NOTIFICATION OF SUSPECTED ABUSE/NEGLECT
The Division expects that all Medicaid providers will be in compliance with all laws
relating to incidents of abuse, neglect, or exploitation.
a. CHILD ABUSE
State law requires that certain persons employed in certain capacities must make a
report to a child protective services agency or law enforcement agency
immediately, but in no event later than 24 hours, after there is reason to suspect a
child has been abused or neglected. For minors under the age of 18, the Division of
Child and Family Services (DCFS) or the appropriate county agency accepts
reports of suspected abuse.
Refer to NRS 432B regarding child abuse or neglect.
b. ELDER ABUSE
For adult aged 60 and over, the Division for Aging Services (DAS) accepts reports
of suspected abuse, neglect or self-neglect, exploitation or isolation.
Refer to NRS 200.5091 regarding elder abuse or neglect.
c. OTHER AGE GROUPS
For all other individuals, contact local social services and/or law enforcement
agencies.
10. COMPLAINT RESOLUTION
The provider must respond to all complaints in a reasonable and prompt manner. The
provider must perform recipient/provider problem solving and complaint resolution.
a. The provider must maintain records that identify the complaint, the date received
and the outcome; and
b. The provider must submit documentation regarding the complaint to Nevada
Medicaid Central office (NMCO) immediately upon request.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1403
Subject:
MEDICAID SERVICES MANUAL POLICY
11. TERMINATION OF SERVICES
a. The provider may terminate services for any of the following reasons:
1. The recipient or other persons in the household subjects home care staff to
physical or verbal abuse, sexual harassment, and/or exposure to the use of
illegal substances, illegal situations, or threats of physical harm;
2. The recipient is ineligible for Medicaid;
3. The recipient requests termination of services;
4. The place of service is considered unsafe for the provision of HHA
services;
5. The recipient is admitted to an acute hospital setting or other institutional
setting;
6. The recipient or caregiver refuses to comply with the physician’s POC;
7. The recipient or caregiver is non cooperative in the establishment or
delivery of services;
8. The recipient no longer meets the criteria for HHA services;
9. The recipient refuses service of a skilled nurse based solely or partly on the
race, religion, sex, marital status, color, age, disability or national origin;
10. The provider is no longer able to provide services as authorized (i.e. no
qualified staff).
Note: A provider’s inability to provide services for a specific recipient does not
constitute termination or denial from Nevada Medicaid’s HHA program. The
recipient may choose another provider.
b. IMMEDIATE TERMINATION
The provider may terminate HHA services immediately for reasons one through
five listed above.
Note: The nurse provider must comply with 632.895.6 of the Nurse Practice Act.
Other licensed professionals must comply within their standard practice act.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1403
Subject:
MEDICAID SERVICES MANUAL POLICY
c. ADVANCE NOTICE TERMINATION
The provider must provide at least five calendar days advance written notice to
recipients when HHA services are terminated for reasons six through ten listed
above.
d. NOTIFICATION REQUIREMENTS
The provider must notify the recipient and all other appropriate individuals and
agencies when services are to be terminated. The QIO-like vendor must be
informed of the termination of services as the Nevada Medicaid District Office
(NMDO) Care Coordinator within two working days. The provider must submit
written documentation regarding the termination to the NMDO within five
working days.
12. RECORDS
The provider must maintain medical records which fully disclose the extent and nature of
the service provided to the recipient and which supports fees or payments made. Medical
and financial records and all other records provided must be maintained for an interval of
not less than six years. Following HIPAA Privacy Regulations contained in 45 CFR 160
and 164, the provider must make records available upon request to the Division.
1403.1C RECIPIENT RESPONSIBILITY
1. The recipient or personal representative shall:
a. Provide the HHA with a valid Medicaid card;
b. Provide the HHA with accurate and current medical information, including
diagnosis, attending physician, medication regime, etc.;
c. Notify the HHA of all insurance information, including the name of other third
party insurance coverage, such as Medicare, CHAMPUS and Veterans
Administration;
d. Inform the HHA of any other home care benefit that he or she is receiving through
state plan services, such as Personal Care Aide (PCA) services, Private Duty
Nursing (PDN) visits or therapy services. Services provided through another
agency or program such as respite, case management or participation in a Waiver
program must also be identified;
e. Sign the HHA visit form to verify services were provided;
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f. Cooperate in establishing the need for and the delivery of services;
g. Comply with the delivery of service as outlined in the Plan of Care;
h. Notify the HHA when scheduled visits cannot be kept or services are no longer
required;
i. Notify the HHA of unusual occurrences or complaints regarding delivery of
services or dissatisfaction with specific staff;
j. Provide the HHA with a copy of Advance Directives, if applicable;
k. Not request the provider agency staff to work more hours than authorized or to
change the days/hours approved;
l. Not request the provider agency staff to provide care to non-recipients or to
provide service not on the POC (babysitting, housekeeping tasks, etc.); not subject
the provider to physical and/or verbal abuse, sexual harassment, exposure to the
use of illegal substances or threats of physical harm; and
m. Not refuse service of a provider based solely or partly on the provider’s race,
creed, religion, sex, marital status, color, age, disability, and/or national origin.
2. Recipient Rights
Every Medicaid recipient, their LRA or legal guardian is entitled to receive a statement of
“Patient Rights” from their provider. The recipient should review and sign a statement
acknowledging receipt of this document. The patient rights should include, at a minimum,
the following:
a. A patient has the right to courteous and respectful treatment, privacy, and freedom
from abuse;
b. A patient has the right to be free from discrimination because of race, creed, color,
sex, national origin, sexual orientation, and diagnosis;
c. A patient has the right to have his property treated with respect;
d. A patient has the right to confidentiality with regard to information about his
health, social and financial circumstances, and about what takes place in his home;
e. A patient has the right to access information in his own record upon written
request;
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f. A patient has the right to voice grievances regarding treatment of care that is, or
fails to be furnished, or regarding the lack of respect for property by anyone who is
furnishing services on behalf of the HHA and must not be subjected to
discrimination or reprisal for doing so;
g. A patient has the right to be informed of the provider’s right to refuse admission
to, or discharge any patient whose environment, refusal of treatment, or other
factors prevent the HHA from providing care;
h. A patient has the right to be informed of all services offered by the agency prior to,
or upon admission to the agency;
i. A patient has the right to be informed of his condition in order to make decisions
regarding his or her home health care;
j. The HHA must advise a patient in advance of the disciplines that will be furnished,
the care to be furnished, and the frequency of visits;
k. The patient must be notified in advance of any changes in the plan of care before
the change is made;
l. A patient has the right to participate in the development of the plan of care,
treatment, and discharge planning;
m. A patient has the right to refuse services or treatment; and
n. A patient has the right to request a Fair Hearing when disagreeing with the
DHCFP’s action to deny, terminate, reduce or suspend service.
1403.1D AUTHORIZATION PROCESS AND REIMBURSEMENTS
1. PRIOR AUTHORIZATION
Home Health Agency (HHA) services may be authorized after providers fax a completed
Home Health Prior Authorization form to Nevada Medicaid’s Quality Improvement
Organization (QIO-like vendor). The request should be submitted two days prior to the
start of care. The QIO-like vendor will review and complete the authorization process for
Home Health Agency (HHA) services utilizing criteria identified in a clinical decision
support guide. QIO-like vendor staff will use this criterion to review for medical necessity
and utilization control procedures.
The authorization number will be issued by the QIO-like vendor using a numbering
system. The QIO-like vendor will fax the authorization to the requesting provider with the
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authorization number. The QIO-like vendor will specify the exact number of services
approved. The QIO-like vendor will generate the Notice of Decision (NOD) if the services
approved are less than requested and/or constitute an adverse action. A copy will be sent
to the recipient and the provider.
All requests, except initial assessments, require prior authorization request. The Home
Health prior authorization form must be complete, including the primary diagnosis, ICD-9
codes, descriptions of wound(s), social situation, Dates of Service (DOS), Third Party
Liability (TPL), Plan of Care (POC), and specific services requested. Processing may be
delayed, or a technical denial issued, if information submitted is illegible or incomplete.
In an emergent situation when the QIO-like vendor is closed, such as nights or weekends,
the request for authorization must be submitted to the QIO-like vendor within two
working days after the start date. An emergent situation exists when skilled nursing
services are required to be implemented immediately such as in the case of wound care, IV
medication, etc.
2. HOLIDAY RATES
For recipients who require seven day-per-week home care service, an increased rate will
be paid for visits made on State recognized holidays. The holiday rate must be requested
on the Home Health Prior Authorization form, which covers the certification period in
which the State recognized holiday(s) occur.
Nevada Medicaid currently recognizes the following holidays: New Year’s Day, Martin
Luther King Day, President’s Day, Memorial Day, Independence Day, Labor Day,
Nevada Admission Day (last Friday in October), Veteran’s Day, Thanksgiving Day,
Family Day (the day after Thanksgiving), and Christmas Day. The recognized holiday is
the same days that State offices are closed.
Reimbursement: Time and one-half will be reimbursed for State recognized holidays. Use
modifier TV to designate holiday rate.
a. PRIOR RESOURCES
When the HHA has a recipient that has another insurance (Medicare or Private
Insurance) and the agency has identified the services requested are not a covered
benefit of the third party payor, HHA must request “bypass Medicare” or “bypass
other” when requesting prior authorization.
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b. DISPOSABLE MEDICAL SUPPLIES
Disposable medical supplies require a prior authorization request at the time of
request for HHA services and are to be listed on the Home Health Prior
Authorization Form. Wound care supplies will be authorized for the HHA for a ten
day period only. Supplies will be authorized only for the specific procedure or
treatment requested. Each item must be listed separately. Supplies must be
specifically prescribed by the physician and designated in the POC. A copy of the
physician's orders specifying supplies required for home care should be retained in
the recipient's HHA file and submitted to Nevada Medicaid upon request. Routine
supplies or disposable supplies must be obtained from a Durable Medical
Equipment (DME) or pharmacy provider.
Reimbursement: Unit price per fee schedule. Refer to reimbursement code table
for specific billing code.
c. MILEAGE
Actual mileage is reimbursed one way from the HHA office to the recipient’s
residence. Actual mileage should be listed on the Home Health prior authorization
request form to establish a base line for reimbursement. Reimbursement: Mileage
is paid per actual miles. Refer to the reimbursement code table for specific billing
code.
3. AUTHORIZATION INTERVALS
Services will be authorized for three distinct periods. They are:
a. The initial authorization for all requests. Services may be authorized up to a 60 day
interval, beginning with the start date.
b. The reauthorization covers an additional 60 day interval following the completion
of the initial visits. This applies to the recipient who requires an extension of the
same services that were requested during the initial authorization period. This
period, combined with the initial authorization may be up to 120 days.
c. The long-term authorization covers the recipient with continued needs following
120 day episode. This additional authorization interval may be up to one year if
services are documented as medically necessary and are expected to continue
unchanged for a prolonged interval. (i.e. monthly suprapubic catheter change).
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4. ONGOING AUTHORIZATION
Request for continuing HHA services must be submitted to the QIO-like vendor a
minimum of ten working days but no more than 30 days prior to the expiration of the
current authorization.
The authorization request must include adequate information to support medical necessity,
availability of willing and able caregiver or the presence of a qualified LRA. The QIO-like
vendor will review for appropriate number of hours using the decision guide and based on
program criteria. HHA services may be authorized for a maximum authorization period of
one year.
5. ADDITIONAL AUTHORIZATION
An additional authorization request for an additional/PRN one time only visit during a
current authorization period may be submitted for authorization approval. Information
must be submitted that supports the need for the additional visit. (i.e. foley catheter
leaking and a needed replacement). In this situation, the Prior Authorization Request
(PAR) must be submitted within 30 days of the service being provided.
6. REVIEW FOR RETROACTIVE AUTHORIZATION
If Medicaid eligibility is established retroactively, Medicaid may authorize retroactive
payment to the agency for covered services within limitations of program criteria. The
Home Health Prior Authorization form must include the Date of Determination (DOD) of
eligibility. Retroactive authorization must be requested within 30 days from the DOD.
7. WOUND MANAGEMENT
a. Authorization for wound care will be based on the clinical decision support guide
(Interqual) based on the data submitted following a skilled nursing assessment.
The assessment should include the primary diagnosis, pertinent medical, surgical
and social history, medication, wound history (e.g. onset, longevity, current
management) and pain. Clinical data should include a complete wound assessment
(e.g. location, size, depth, partial/full thickness, tissue appearance, sinus tracts,
tunneling, stages for pressure ulcers, status of wound edges, condition of skin
around the wound, exudates (color, odor, amount) other wound characteristics, and
the treatment plan as prescribed by the physician.
b. All initial requests for wound care will be authorized for up to a 60 day interval.
All Home Health Prior Authorization forms must be submitted with the required
information.
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c. Ongoing request for additional visits will be approved according to the criteria
identified in the clinical decision support guide. Supporting information must be
submitted to the QIO-like vendor. For long-term authorizations, diagnostics studies
and nutritional assessments or other evaluations may be required. Authorizations
for identified services, such as a registered dietician will be approved if identified
as medically necessary.
d. Disposable wound supplies will be authorized for the Home Health Agency (HHA)
for an initial ten-day supply only. Thereafter the supplies must be obtained from a
Durable Medical Equipment or Pharmacy provider.
e. Specialty beds or other wound care items must be obtained as required per Nevada
Medicaid Services Manual, Chapter 1300.
8. ORAL MEDICATIONS
The recipient is expected to self-administer his or her oral medications. The authorization
of daily visits for the administration of oral medications is not a covered benefit. A weekly
visit for a medication set up may be authorized. Whether it is a brief or extended visit
depends on the number of medications and the number of times per day the medications
are taken. One visit may be authorized per week. A request should include a substantiating
diagnosis, such as mental illness that would limit the recipient’s ability to set up his/her
own medications. The names and frequency of the medication taken should be on the
request.
9. INJECTIONS
Requests for injections are and routinely covered and must meet medical necessity for
HHA service. If determined to be medically necessary Intramuscular (IM) or
Subcutaneous (SC) may be approved for brief visits only. The sole exception for this is
Synagis injections. Synagis may be approved for an RN/LPN extended visit. No more than
two brief visits per day may be approved (usually this is for administration of insulin). The
recipient, LRA and other willing caregivers should be taught this skill.
10. LABORATORY DRAWS
Requests for laboratory draws may be authorized for brief RN visits only. An extended
visit may be authorized, if there is supporting documentation that it was a difficult blood
draw and required multiple attempts.
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11. HOME HEALTH AGENCY CLAIMS/BILLING GUIDELINES
The Division of Health Care Financing and Policy establishes reimbursement rates for
covered services. Providers submit claims using an established revenue code, HCPCS
code and modifier. Reimbursement codes for HHA services are listed in the QIO-like
vendor billing manual or via mail with a hard copy of the form.
a. Third Party Liability
If there is another insurance that covers or partially covers HHA services, a claim
must be submitted to that entity first and a copy of the EOB must be attached to the
Medicaid reimbursement claim. For services that are not a benefit of Medicare or
other private insurance, it is not necessary to bill the other insurance first. Instead,
note on each claim the date, phone number and the name of the person from whom
the information on the insurance status was obtained. Indicate “Bypass Medicare”
or “Bypass Private Insurance” (specify insurance name) on the claim.
b. HOME HEALTH AGENCY RATE
Home Health Agency rates are based on the recipient’s place of residence at the
time the service is rendered.
Reimbursement: Reimbursement is made according to regions, urban, rural and out
of state, defined in the following manner:
1. Urban: In Southern Nevada, urban is Boulder City and the portion of Clark
County within Las Vegas Valley including the cities of Las Vegas, North
Las Vegas, Henderson and the urbanized townships. In Northern Nevada,
urban includes the cities of Reno, Sparks, and Carson City, and
unincorporated areas of Washoe County that are within 30 miles of Reno,
as approved by the District Office.
2. All other areas within Nevada are classified as rural. Providers should
utilize modifiers related to service area when billing to assure appropriate
payment. Instructions for claims coding can be found in the Fiscal Agent’s
Nevada Medicaid and Nevada Check Up UB-92 Provider Billing Manual.
3. All outside Nevada services use Rural modifier TN.
1403.2 SKILLED NURSING SERVICES (SN)
Skilled nursing services are a covered service when provided by a registered nurse or a licensed
practical nurse under the supervision of a registered nurse in accordance with the POC, to be safe
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and effective. In determining whether a service requires the skill of a nurse, consideration must be
given to the inherent complexity of the service, the condition of the patient and the accepted
standards of medical and nursing practice.
1403.2A COVERAGE AND LIMITATIONS
1. Observation and Assessment
Nursing visits for observation and assessment will be reimbursed by the home health
agency benefit when:
a. There is a reasonable likelihood that the recipient will experience an acute episode;
b. There is reasonable likelihood that the recipient will develop a complication (either
as a result of his/her disease process or as a result of prescribed medical therapy);
c. The skills of a nurse are required to assess the recipient's health status and identify
significant change;
d. The change in the recipient's health status (as a result of another acute episode or
complication) is likely to respond to a change in the recipient's plan of treatment or
prescribed medical therapy.
2. Performance of Skilled Procedures
Nursing visits for the performance of skilled procedures of a nurse in the home setting will
be reimbursed as a skilled nursing service when the procedure can only be performed
safely by a nurse.
Factors that the DHCFP considers when determining if the performance of a specific
procedure requires the skill of a nurse include:
a. The complexity of the procedure to be performed;
b. The recipient's physical and functional status;
c. The presence/absence of a willing, able, and competent caregiver in the home; and
d. The service is reasonable and necessary to the treatment of the patient.
3. Examples of covered skilled nursing procedures include but are not limited to:
a. Administration of intravenous, intra-muscular, or subcutaneous medications or
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infusions;
b. Vitamin B-12 injections, when administered for the treatment of certain
conditions, such as pernicious anemia, megaloglastic anemia, fish tapeworm
anemia, certain gastrointestinal disorders or certain neuropathics with the
supporting lab work;
c. Insulin administration when the recipient is unable to self-administer the insulin
and there is no other willing and able caregiver available. The recipient's plan of
care must continue to document that there is no willing and able caregiver
available and the recipient continues to be unable to self administer the insulin
with each re-certification period. Nursing visits to perform glucometer testing are
not covered as it does not require the skill of a nurse to perform;
d. The administration of Synagis for recipients under the age of two years who meet
established Medicaid criteria;
e. Skilled nursing visits for venipuncture are covered when the collection of the
specimen cannot be performed in the cause of regularly scheduled absences from
the home and is necessary for the monitoring of therapeutic blood levels of
medications, monitoring of blood counts and electrolyte levels when affected by
the recipient’s medication regimen, and related to the recipient’s illness or medical
condition;
f. Nasogastric tube and gastronotomy tube feeding;
g. Ostomy care during the immediate post-operative period;
h. Tracheotomy aspiration;
i. Catheter care (uretenal or suprapublic) insertion and replacement (every 30 days
for jelly or 60-90 for silicone catheters) and irrigation;
j. Wound care, when the skills of the nurse are required to safely/effectively perform
the wound care; and
k. Total Parenteral Nutrition (TPN).
4. Teaching Recipient/Family to Manage Care at Home
Teaching the recipient/family/caregiver how to manage the recipient’s care at home will
be reimbursed on a limited and short term basis as a skilled nursing service when the
teaching or training is appropriate to the recipient’s functional loss, illness or injury.
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Teaching and/or training activities must include a time frame in the POC when goals will
be accomplished. Teaching visits will be authorized according to the following criteria:
a. The skills of the nurse are required to teach the recipient/family/caregiver how to
manage the recipient's care at home. The care itself may be considered to be
“unskilled” (not requiring the skills or expertise of the nurse to perform the care),
but the amount of skill needed to teach the care must require the skills of a nurse;
b. The teaching is reasonable and necessary for the treatment/management of the
recipient's health problem(s);
c. The initial authorization for teaching visits will be authorized according to the
criteria identified in the clinical decision support guide. The initial authorization
may be up to a 60 day interval. Additional teaching visits may be authorized if
documentation is submitted that supports the ability of the recipient and/or the
caregiver to learn the material. The content or skill covered by the teaching is new
to the learner and does not represent reinforcement or review of previously
learned, repeated, or taught content. Teaching will not be covered when the
recipient or caregiver is not able to learn or be trained.
Examples of teaching and training activities which require the skill of a licensed nurse
include, but are not limited to the following:
d. Self administration of injectable medications;
e. New complex medications;
f. Complex wound care;
g. Self catherization;
h. Administration of enteral feedings; and
i. Care and maintenance of intravenous or central lines and administration of
medication through such lines.
5. Skilled Psychiatric Nursing Services
Evaluation of the recipient and the performance of psychotherapy require the skills of a
nurse who meets criteria for credentialing as a psychiatric nurse. Services of a non-
psychiatric nurse may be ordered by the psychiatrist for visits to administer injections or
behavior modifying medications.
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Psychiatric mental health services are covered services and are authorized according to the
criteria identified in the clinical decision support guide, when the following conditions are
met:
a. The psychiatric mental health services are reasonable and necessary for the
treatment of the recipient's health status; and
b. The home care services are ordered by a psychiatrist and provided under a written
POC. Medical orders must be established and reviewed by the primary physician.
1403.2B PROVIDER RESPONSIBILITY
Refer to Section 1403.1B of this Chapter.
1403.2C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C of this Chapter.
1403.2D AUTHORIZATION PROCESS
Refer to Section 1403.1D of this Chapter.
1403.3 SKILLED PHYSICAL THERAPY SERVICES
Periodic home visits may be made by licensed physical therapists, to provide services as ordered
by a physician and identified in the POC, when the services are inherently complex and can only
be performed safely and effectively by a skilled therapist, and when the recipient cannot access
out-patient services.
Reimbursement is based on the diagnosis of a medical condition plus the presence of functional
limitations, which can respond or improve as a result of the prescribed POC. There must be an
expectation the condition will improve in a reasonable, predictable period of time.
1403.3A COVERAGE AND LIMITATIONS
Skilled physical therapy services may be authorized for home care recipients; HHA visits are
included in the total available outpatient limits up to 24 visits per year. These include visits for
one or more of the following:
1. Assessment of the recipient's rehabilitation needs and potential;
2. Development and implementation of a physical therapy program when it is medically
necessary to the recipient's treatment;
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3. Objective tests and measurements such as range of motion, strength, balance coordination,
endurance, and functional ability;
4. Performance of therapeutic exercises which require the skills and expertise of a physical
therapist to implement safely/effectively;
5. Gait evaluation and gait training for persons who have an impaired ability to ambulate
secondary to a neurological, muscular, or skeletal abnormality;
6. Services are required to maintain a person's function that involves complex and
sophisticated procedures and the judgment/skill of a physical therapist;
7. Administration of ultrasound treatments; and
8. Administration of heat treatments only when the recipient's overall condition is such that
the skills and judgment of a physical therapist are required to safely administer these
treatments.
1403.3B PROVIDER RESPONSIBILITY
In addition to 1403.1B, the provider must monitor that the total number of paid visits, do not
exceed the total available therapy visits (24) per year.
1403.3C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C
1403.3D AUTHORIZATION PROCESS
Refer to Section 1403.1D
In addition to 1403.1D the physical therapist must submit the completed evaluation along with the
Home Health Prior Authorization form to the QIO-like vendor. The provider should contact the
QIO-like vendor to determine the number of authorized visits.
1403.4 SKILLED OCCUPATIONAL THERAPY SERVICES
Periodic home visits may be made by licensed occupational therapists to provide services as
ordered by the physician and identified in a signed POC. Reimbursement is based on the
diagnosis of a medical condition plus the presence of a limitation, which can respond or improve
as a result of the prescribed POC. There must be an expectation that the condition will improve in
a reasonable period of time.
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1403.4A COVERAGE AND LIMITATIONS
Skilled occupational therapy services may be authorized for home care recipients. HHA visits are
included in the total available outpatient limits of up to 24 visits per year. These visits include one
or more of the following:
1. Assessment of the recipient’s rehabilitation potential and needs.
2. Plan/implement/supervise a therapeutic program to:
a. Restore physical function;
b. Restore sensory-integrative function;
c. Provide individualized therapeutic activity as part of an overall active treatment
program for persons with diagnoses of psychiatric illness;
d. Teach compensatory techniques to improve functional independence in the
performance of activities of daily living; and
e. Provide vocational and prevocational assessment and training that is directed
toward the restoration of function in ADL’s lost due to illness or injury.
1403.4B PROVIDER RESPONSIBILITY
Refer to Section 1403.1B.
1403.4C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C.
1403.4D AUTHORIZATION PROCESS
A Home Health Prior Authorization form must be submitted along with the completed evaluation
to the QIO-like vendor prior to the initiation of service. The initial evaluation does not require
prior authorization. Refer to Section 1403.1D.
1403.5 SKILLED SPEECH LANGUAGE PATHOLOGY SERVICES
Nevada Medicaid may pay for the services of a licensed speech pathologist to provide service as
ordered by the physician and identified in a signed POC. Reimbursement is based upon diagnosis
and treatment of speech and language disorders that result in communications disabilities and for
the diagnosis and treatment of swallowing disorders, regardless of the presence of a
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communication disability. There must be an expectation that the condition will improve in a
reasonable period of time.
1403.5A COVERAGE AND LIMITATIONS
Skilled speech language therapy service may be authorized for home care recipients. HHA visits
are included in the total outpatient limits up to 24 visits per year. These include visits for the
following:
1. Diagnosis and treatment of expressive and receptive communication disorders;
2. Diagnosis and treatment of swallowing disorders;
3. Assessment of a recipient's rehabilitation needs and potential;
4. Services directed toward specific speech or voice production if a deficit exists resulting
from an illness or an injury; Establishment of a hierarchy of speech-voice-language
communication tasks and cueing that is directed toward the achievement of specific
communication goals;
5. Training the recipient/family/caregiver to augment: the speech language communication;
treatment; or to establish a maintenance program;
6. Assisting persons who are aphasic in rehabilitation of speech and language skills; and
7. Assisting a person with voice disorders to learn to control vocal or respiratory systems for
correct voice production.
1403.5B PROVIDER RESPONSIBILITY
Refer to Section 1403.1B of this Chapter.
1403.5C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C of this Chapter.
1403.5D AUTHORIZATION PROCESS
Refer to Section 1403.1D of this Chapter.
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1403.6 RESPIRATORY THERAPY SERVICES
Respiratory therapy is a covered service through a HHA provider, when it is prescribed by a
physician and provided under assigned plan of care by a licensed respiratory therapist.
1403.6A COVERAGE AND LIMITATIONS
The services of a respiratory therapist that may be provided to recipients in a home setting
include:
1. Ventilator management.
a. Weaning the recipient off a ventilator; and
b. Changing settings on ventilators, C-PAP, Bi-PAP, Bi-PAP-ST.
2. Drawing arterial blood gases when a nurse is incapable of doing so. The services of a
respiratory therapist will not be reimbursed for the setting up of rental equipment.
1403.6B PROVIDER RESPONSIBILITY
Refer to Section 1403.1B of this Chapter.
1403.6C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C of this Chapter.
1403.6D AUTHORIZATION PROCESS
Refer to Section 1403.1D of this Chapter.
1403.7 REGISTERED DIETICIAN SERVICES
Registered dietician services are covered by the Medicaid HHA program. A registered dietician
may provide consultative services when the recipient has a nutritional deficit or is at risk for a
deficit.
1403.7A COVERAGE AND LIMITATIONS
Home health agency dietician services are appropriate for but not limited to recipients with
diagnoses of cachexcia, failure to thrive, poor wound healing and newly diagnosed diabetics who
are unable to go outside the home for dietician services.
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1403.7B PROVIDER RESPONSIBILITY
Refer to Section 1403.1B.
1403.7C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C.
1403.7D AUTHORIZATION PROCESS
In addition to Section 1401.1D the provider must submit a copy of the completed evaluation must
be submitted to the QIO-like vendor along with the Home Health Prior Authorization Form. The
QIO-like vendor will review the evaluation to determine if medical necessity has been met. The
initial evaluation does not require prior authorization.
1403.8 HOME HEALTH AIDE SERVICES
To receive home health aide services through the HHA program, the recipient must have a
qualifying skilled service and must have an impairment or deficit so that he/she requires
assistance with routine activities of daily living. Services must be reasonable and necessary to the
treatment of the recipient’s illness or injury. Home health aides can be appropriately utilized to
assist in carrying out the plan of care. Home health aide services must be incorporated into an
outcome specific nursing plan. Home health aides must meet the qualifications specified by 42
CFR 484.36. When it is identified that recipient has an ongoing need for assistance with ADLs,
the HHA must advise the recipient and/or caregiver about other available services (e.g. personal
care aide services) that may be more appropriate to their needs.
1403.8A COVERAGE AND LIMITATIONS
Home Health Aide services may provide assistance with:
1. Personal care services, such as bathing;
2. Simple dressing changes that do not require the skills of a licensed nurse;
3. Assistance with medications that are self administered;
4. Assistance with activities that are directly supportive of skilled therapy services but do not
require the skills of a therapist, such as, routine maintenance exercise;
5. Routine care of prosthetic and orthotic device;
6. Monitoring vital signs;
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7. Reporting of changes in recipient condition and needs;
8. Any task allowed under Nevada Revised Statutes (NRS), Chapter 632 – Nursing, and
directed in the physician’s approved plan of care (POC).
1403.8B PROVIDER RESPONSIBILITY
In addition to Section 1401.1B the HHA RN must make a supervisory visit to the recipient’s
residence at least once every 60 days.
1403.8C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C of this Chapter.
1403.8D AUTHORIZATION PROCESS
Refer to Section 1403.1D of this Chapter.
1403.9 END STAGE RENAL DISEASE (ESRD) SERVICES
ESRD recipients may qualify for HHA services. A recipient diagnosed with ESRD must meet all
the general requirements for the HHA program plus the recipient must require skilled services
that are not directly related to his/her dialysis treatments.
1403.9A COVERAGE AND LIMITATIONS
Refer to Section 1403.1A of this Chapter.
1403.9B PROVIDER RESPONSIBILITY
Refer to Section 1403.1B of this Chapter.
1403.9C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C of this Chapter.
1403.9D AUTHORIZATION PROCESS
Refer to Section 1403.1D of this Chapter.
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1403.10 OUT-OF-STATE SERVICES
HHA services are allowed out-of-state for Medicaid recipients absent from the state pursuant to
42 CFR 431.52. Payment for services furnished in another state are reimbursed to the same extent
that Nevada would pay for services provided within Nevada boundaries. Out-of-state HHA
services are reimbursed at the rural rate, using rural modifier TN.
1403.10A COVERAGE AND LIMITATIONS
Out-of-state services may be allowed when:
1. There is a medical emergency and the recipient’s health would be endangered if he/she
were required to return to the State of Nevada to obtain medical services;
2. The recipient travels to another state because DHCFP has determined the required medical
services are not available in Nevada, or it is determined that the needed medical services
or necessary supplementary resources are more readily available in another state;
3. DHCFP determines that it is general practice for recipients in a particular locality to use
medical services in another state (e.g., Nevada counties that border other state lines);
4. The recipient is on personal business. DHCFP may reimburse for these services; however,
they will be limited to those currently listed on the recipient’s Plan of Care (POC).
1403.10B PROVIDER RESPONSIBILITY
1. The out-of-state provider must contact First Health Services Corporation (FHSC) provider
enrollment unit to become enrolled as a DHCFP Home Health Agency provider.
2. The out-of-state provider must also comply with all provisions in Section 1403.1D.
1403.10C RECIPIENT RESPONSIBILITY
1. The recipient or their personal representative must contact Home Health Agency providers
in the geographic region of which they wish service to be provided, to determine the
availability of HHA service providers.
2. The recipient must notify an out-of-state provider who is not a DHCFP provider, but who
is interested in becoming a provider to contact the QIO-like vendor.
3. The out-of-state provider must also comply with all provision in Section 1403.1C.
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1403.10D AUTHORIZATION PROCESS
Refer to Section 1403.1D of this Chapter.
1403.11 EARLY & PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)
Nevada Medicaid may authorize HHA services for medically necessary therapies on children ages
0-20 with chronic special health care needs who are referred to the program through an EPSDT
screening. Physical therapy, speech therapy and occupational therapy may be authorized for six
months at a time when the child has an EPSDT screening examination, which identifies the
medical diagnosis and the need for such therapy. EPSDT screening examinations for these
services must be updated at six-month intervals. EPSDT therapies may be authorized beyond the
24 visits per year, if medically necessary as determined by DHCFP.
Reimbursement is based on the diagnosis of a medical condition plus the presence of functional
limitations, which can respond or improve as a result of the prescribed POC. There must be an
expectation the condition will improve significantly in a reasonably, predictable period of time.
1403.11A COVERAGE AND LIMITATIONS
Refer to Section 1403.1A.
1403.11B PROVIDER RESPONSIBILITY
The therapist must complete the initial evaluation; identify the treatment need, therapy goals,
frequency and expected duration of therapy treatment whether for occupational therapy, physical
therapy, and/or speech therapy. The provider must comply with all other requirements in Section
403.1B.
1403.11C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C.
1403.11D AUTHORIZATION PROCESS
The following documentation needs to be provided:
1. A completed Home Health Prior Authorization Form requesting therapy(s);
2. A copy of the evaluation and/or POC which includes therapy goals, frequency and
expected duration;
3. Referral from EPSDT Screening; and
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4. The provider must also comply with all other requirements of Section 1403.1D.
1403.12 SERVICES TO CHILDREN
HHA services are not intended to relieve a parent of their child caring or other legal
responsibilities. HHA services for children may be appropriate when the parent is unqualified or
otherwise unable to provide care. Home health agency services are intended to provide
intermittent skilled intervention with emphasis on caregiver education. Legally responsible adults
and other willing primary caregivers are expected to be taught care which can be rendered
reasonably and safely by non-medical persons.
1403.12A COVERAGE AND LIMITATIONS
Children are not considered homebound based upon their age. Home health, intermittent skilled
nursing and therapy services are available only when the child is considered so medically fragile
that leaving the home poses eminent danger to the health of the child. Home health agency
services are not to be provided as a convenience to parents, the physician or the physician
supplier. In authorizing services to children, consideration will be given to the inherent
complexity of the skilled intervention, the capacity of available primary caregivers to be taught,
and the availability of these caregivers. It is expected that the legally responsible adult or willing
caregiver, after demonstrating competency, will provide the service.
1403.12B PROVIDER RESPONSIBILITY
Verify the availability and capability of the legally responsible adult or primary caregiver and
include such information with request.
1403.12C RECIPIENT RESPONSIBILITY
Refer to Section 1403.1C of this Chapter.
1403.12D AUTHORIZATION PROCESS
Refer to Section 1403.1D of this Chapter.
1403.13 FAMILY PLANNING
Home health agencies providing post partum home visiting service to Medicaid eligible women,
may bill for family planning education.
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1403.13A COVERAGE AND LIMITATIONS
This service must be provided:
1. In conjunction with the newborn assessment screening;
2. Be provided by a registered nurse; and
3. Consist of counseling and education about:
a. Appropriate spacing of pregnancies
b. Family planning options.
1403.13B PROVIDER RESPONSIBILITY
Refer to Section 1401.1B of this Chapter.
1403.13C RECIPIENT RESPONSIBILITY
Refer to Section 1401.1C of this Chapter.
1403.13D AUTHORIZATION PROCESS
No prior authorization is required. Submit on UB-92 0581 -- H1011 FP, TD (Old CPT Code =
C98970).
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1404 HEARINGS
Please reference Medicaid Services Manual, Chapter 3100 Hearings, for hearing procedures.
September 23, 2003 HOME HEALTH AGENCY Section 1404 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
December 19, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: CODY L. PHINNEY, DEPUTY ADMINISTRATOR /Cody Phinney/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1500 – HEALTHY KIDS PROGRAM
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1500 – Healthy Kids Program
Attachment B Applied Behavior Analysis (ABA) are being proposed to move this section to
establish a new chapter for ABA in MSM Chapter 3700. This MSM Chapter will have policy for
ABA only.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: This proposed change affects all Medicaid-enrolled providers
delivering ABA type of services. Those provider types (PT) include but are not limited to Applied
Behavior Analysis (PT 85).
Financial Impact on Local Government: None known.
These changes are effective January 1, 2020.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL N/A MTL N/A
MSM Ch 1500 Healthy Kids Program MSM Ch 1500 Healthy Kids Program
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Attachment B Applied Behavior Removal of ABA policy. Language moved and
Analysis (ABA) revised into MSM Chapter 3700.
Page 1 of #
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
HEALTHY KIDS PROGRAM
1500 INTRODUCTION .............................................................................................................................. 1
1501 AUTHORITY ..................................................................................................................................... 1
1502 RESERVED ........................................................................................................................................ 1
1503 POLICY .............................................................................................................................................. 1
1503.1 EARLY PERIODIC SCREENINGS .................................................................................................. 1
1503.1A COVERAGE AND LIMITATIONS .................................................................................................. 1
1503.1B PROVIDER RESPONSIBILITY........................................................................................................ 2
1503.2 INTERPERIODIC SCREENINGS ..................................................................................................... 3
1503.2A COVERAGE AND LIMITATIONS .................................................................................................. 4
1503.3 COMPREHENSIVE SCREENING EXAMINATION ...................................................................... 4
1503.3A COVERAGE AND LIMITATIONS .................................................................................................. 4
1503.4 DIAGNOSTIC SERVICES ................................................................................................................ 9
1503.4A COVERAGE AND LIMITATIONS .................................................................................................. 9
1503.5 TREATMENT .................................................................................................................................... 9
1503.5A COVERAGE AND LIMITATIONS .................................................................................................. 9
1503.6 FAMILY PLANNING ...................................................................................................................... 10
1503.6A COVERAGE AND LIMITATIONS ................................................................................................ 10
1503.7 TRANSPORTATION ....................................................................................................................... 10
1503.7A COVERAGE AND LIMITATIONS ................................................................................................ 10
1503.8 PREGNANCY RELATED ONLY ................................................................................................... 10
1503.8A COVERAGE AND LIMITATIONS ................................................................................................ 10
1504 HEARINGS ........................................................................................................................................ 1
ATTACHMENT A
POLICY #15-1 CLINICAL STUDIES ........................................................................................................... 1
POLICY #15-2 EXPERIMENTAL TREATMENT ........................................................................................ 3
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1500 INTRODUCTION
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are preventive and
diagnostic services available to most recipients under age 21. In Nevada, the EPSDT program is
known as Healthy Kids. The program is designed to identify medical conditions and to provide
medically necessary treatment to correct such conditions. Healthy Kids offers the opportunity for
optimum health status for children through regular, preventive health services and the early
detection and treatment of disease.
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1501 AUTHORITY
A. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are a
mandatory benefit under the Medicaid program for categorically needy individuals under
age 21.
Services available under the Healthy Kids Program are provided as defined in the
following:
1. Omnibus Budget Reconciliation Act of 1989;
2. Social Security Act 1905 (a) and (r);
3. Social Security Act 1902 (a);
4. Social Security Act 1903 (i);
5. 42 Code of Federal Regulations (CFR), Subpart B, 441.50 – 441.62;
6. State Medicaid Manual (Part 5); and
7. Nevada Medicaid’s State Plan.
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1502 RESERVED
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1503 POLICY
1503.1 EARLY PERIODIC SCREENINGS
A child’s health is assessed as early as possible in the child’s life, in order to prevent or find
potential diseases and disabilities in their early stages, when they are most effectively treated.
Assessment of a child’s health at regularly scheduled intervals assures that a condition, illness or
injury is not developing or present. The Healthy Kids program has established a periodicity
schedule for screening, vision, hearing and dental services based upon the American Academy of
Pediatrics (AAP). The periodicity schedule utilized by the Healthy Kids program can be found at
the Bright Futures/AAP website: http://brightfutures.aap.org.
1503.1A COVERAGE AND LIMITATIONS
1. The Healthy Kids program encourages providers to follow the recommended schedule for
developmental screenings offered by the AAP. Recipients will be sent letters by the
Division’s Quality Improvement Organization (QIO)-like vendor reminding them to
schedule a screening visit on a periodic basis.
2. Dental services are outlined in Medicaid Services Manual (MSM) Chapter 1000, Dental.
Dental services can occur at intervals outside the established periodicity schedule when
indicated as medically necessary to determine the existence of a suspected illness or
condition. At a minimum, they must include relief of pain and infection, restoration of
teeth, and maintenance of dental health. Generally, dental services should be age-
appropriate and must be provided at intervals which meet reasonable standards of medical
practice as recognized by medical organizations involved with child health care.
3. Vision services are outlined in MSM Chapter 1100, Ocular Services. Vision services can
occur at intervals outside the established periodicity schedule when indicated as medically
necessary to determine the existence of a suspected illness or condition. At a minimum,
services must include diagnosis and treatment for defects in vision, including eye glasses.
Generally, vision services should be age-appropriate and must be provided at intervals
which meet reasonable standards of medical practice as recognized by medical
organizations involved with child health care.
4. Hearing services are outlined in MSM Chapter 2000, Audiology. Hearing services can
occur at intervals outside the established periodicity schedule when indicated as medically
necessary to determine the existence of a suspected illness or condition. At a minimum,
services should be age-appropriate and must include diagnosis and treatment for defects in
hearing including hearing aids. Generally, hearing services must be provided at intervals
which meet reasonable standards of medical practice as recognized by medical
organizations involved with child health care.
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1503.1B PROVIDER RESPONSIBILITY
1. The provider is expected to follow the periodicity guidelines as recommended when
conducting Healthy Kids examinations whenever possible. The provider should offer
services as deemed medically appropriate.
2. The provider shall determine whether a screening request is medically necessary when it
falls outside the periodicity schedule and will conduct the intervention necessary to address
the suspected medical problems.
3. The provider should assure the elements listed in Section 1503.3A are included in a
screening examination. The provider should seek out and incorporate information
regarding the child’s usual functioning from parents, teachers and others familiar with the
child when conducting an examination. Medical records should document the assessments
and significant positive and negative findings. Discussions with the child and family about
the findings should be an integral part of every examination and documented as well. A
referral to another Medicaid provider should occur if the provider is unable to perform any
screening component. EPSDT screening forms and EPSDT Participation Reports can be
found on the Division of Health Care Financing and Policy (DHCFP) website:
https://dhcfp.nv.gov/epsdt.htm.
4. Medical records should contain the following information specific to EPSDT screening
services:
a. Reason for the visit;
b. The date screening services were performed, the specific tests or procedures
performed, the results of these tests and the person who provided the service;
c. Documentation of medical contraindication or a written statement from a parent or
a guardian of a screened child, for whom immunizations were due and not given
and attempts the screening provider made to bring the child up-to-date on
immunizations;
d. Identification of any screening component not completed, the medical
contraindication or other reason why it could not be completed, and attempts the
screening provider made to complete the screening;
e. Documentation of a medical contraindication or other reason for delay in vision or
hearing screening if not performed on the same day as the medical screening;
f. Documentation of declination of screening services by the parent;
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g. Referrals made for diagnosis, treatment or other medically necessary health
services for conditions found in the screenings;
h. Date the next screening is due; and
i. Documentation of direct referral for age-appropriate dental services.
5. Providers should submit claims using the established billing codes related to the Healthy
Kids screening examination. These examination codes can be found in the Hewlett Packard
Enterprise Services (HPES) Billing Guide, Physician Billing Guide.
6. The provider should make referrals for diagnostic testing after discussing the need for such
services with the recipient/parent/legal guardian during a post screening interview. The
physician’s progress notes should indicate the need for such testing.
7. A dated written referral should be given to the recipient or parents or forwarded to the
referral service provider. The referral should include the following information:
a. The name of the child;
b. The Medicaid ID number of the child;
c. The date of the screening;
d. The abnormality noted;
e. The name, address, telephone and fax numbers of the child’s primary physician if
different from the screening provider; and
f. The physician to whom the referral applies if known.
8. The provider should advise recipients of possible resources for obtaining testing as
appropriate.
1503.2 INTERPERIODIC SCREENINGS
Healthy Kids screenings are provided to all eligible persons under the age of 21, which may include
medically necessary intervals that are outside an established periodicity schedule, also known as
interperiodic screenings.
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1503.2A COVERAGE AND LIMITATIONS
1. The DHCFP has identified a periodicity schedule that allows for access to screening,
vision, hearing and dental services at intervals which meet reasonable standards of medical
practice. The periodicity schedule can be found at the Bright Futures/AAP website:
http://brightfutures.aap.org.
2. A recipient may request a health care screening or any component of the health screening
at any time. Screening services which are medically necessary, such as when a new health
problem has occurred or when a previously diagnosed condition has become more severe
or changed sufficiently to require a new examination, will be offered, regardless of whether
the request falls into the periodicity schedule established by the State.
1503.3 COMPREHENSIVE SCREENING EXAMINATION
A comprehensive child health assessment is provided to determine if a child has a condition, illness
or injury that should be referred for further evaluation and/or treatment. A Healthy Kids screening
examination must comply with 1905(r) of the Social Security Act (SSA).
http://www.socialsecurity.gov/OP_Home/ssact/title19/1905.htm.
1503.3A COVERAGE AND LIMITATIONS
1. Screening services are designed to evaluate the general physical and mental health, growth,
development and nutritional status of infants, children and adolescents.
The following is a description of each of the required age-appropriate screening
components:
a. COMPREHENSIVE HEALTH AND DEVELOPMENTAL/BEHAVIORAL
HISTORY
At the initial screening, the provider must obtain a comprehensive health,
developmental/behavioral, mental health and nutritional history from the child’s
parents or a responsible adult familiar with the child, or directly from an adolescent,
when appropriate. This history should be gathered through an interview or
questionnaire. A comprehensive initial history includes a review of the:
1. Family medical history (health of the parents and current family members,
identification of family members with chronic, communicable or hereditary
diseases);
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2. Patient medical history (prenatal problems, neonatal problems,
developmental milestones, serious illnesses, surgeries, hospitalizations,
allergies, current health problems and medications);
3. Nutritional history;
4. Immunization history;
5. Environmental risk;
6. Family background of emotional problems, problems with drinking or
drugs, or history of violence or abuse;
7. Patient history of behavioral and/or emotional problems;
8. History of sexual activity, if appropriate; and
9. Menstrual and obstetrical history for females, if appropriate.
b. DEVELOPMENTAL/BEHAVIORAL ASSESSMENT
1. Assessment of developmental and behavioral status should be completed at
each visit by observation, interview, history and appropriate physical
examination. The developmental assessment should include a range of
activities to determine whether or not the child has reached an age-
appropriate level of development.
2. Nevada Medicaid will reimburse separately for developmental screenings,
provided that a valid, standardized developmental screening tool, (i.e.
Parents Evaluation of Developmental Status (PEDS), Ages and Stages,
Early Language Milestone Screen) has been utilized and entered into the
child’s health care record. Although the American Academy of Pediatrics
recommends the use of a standardized screening tool at ages 9, 18 and 30
months, and three and four years of age, the exact frequency of standardized
testing depends on the clinical setting and provider’s judgment as to medical
necessity. Asking questions about development as part of the general
informal developmental survey or history is not a “standardized screening”
and is not separately reportable. Providers may be subject to a random audit
of records to assure the use of the screening tool. For billing instructions,
see the HPES Billing Manual at:
http://www.medicaid.nv.gov/providers/BillingInfo.aspx.
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c. COMPREHENSIVE UNCLOTHED PHYSICAL EXAM
A completed unclothed physical examination must be performed at each screening
visit. The examination must be conducted using observation, palpation,
auscultation and other appropriate techniques. The examination must include all
body parts and systems listed below:
1. Cranium and face;
2. Hair and scalp;
3. Ears;
4. Eyes;
5. Nose;
6. Throat;
7. Mouth and teeth;
8. Neck;
9. Skin and lymph nodes;
10. Chest and back;
11. Abdomen;
12. Genitalia;
13. Musculoskeletal system;
14. Extremities; and
15. Nervous system.
16. The examination should include screening for congenital abnormalities and
responses to voices and other external stimuli.
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d. APPROPRIATE IMMUNIZATIONS
1. The child’s immunization status must be reviewed each screening visit.
Appropriate immunizations that are due must be administered during the
screening visit and according to the schedule established by the Advisory
Committee on Immunization Practices (ACIP) for pediatric vaccines:
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html.
2. Nevada Medicaid cannot reimburse for immunizations (except
administration fees) that are available through the State Health Division as
part of the Vaccines for Children (VFC) program. Providers are encouraged
to enroll with the VFC program which provides the VFC vaccines at no cost
to eligible children. Medicaid cannot be billed for the cost of a vaccine
obtained through VFC, (even if the provider is not enrolled with VFC)
unless there is a documented statewide shortage. To become a VFC
provider, please access the website via http://health.nv.gov/.
3. Nevada Check Up (NCU) provides the same vaccines through a different
funding source, but providers must use the same billing guidelines.
4. For specific guidelines for the Human Papilloma Virus (HPV) vaccine,
please refer to MSM Chapter 1200, Pharmacy Services.
e. LABORATORY PROCEDURES
Age-appropriate laboratory procedures must be performed at intervals in
accordance with the Healthy Kids periodicity schedule. These include blood lead
level assessment appropriate to age and risk, urinalysis, Tuberculin Skin Test
(TST), Sickle-cell, hemoglobin or hematocrit and other tests and procedures that
are age-appropriate and medically necessary, such as Pap smears.
f. HEALTH EDUCATION
1. Health education related to the physical assessment should be provided at
each screening visit. It is designed to help children and their parents
understand the health status of the child as well as provide information
which emphasizes health promotion and preventive strategies. Health
education explains the benefits of a healthy lifestyle, prevention of disease
and accidents, normal growth and development and age-appropriate family
planning services.
2. Anticipatory guidance should be offered which includes discussion of
information on what to expect in the child’s current and next developmental
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phase. It is given in anticipation of health problems or decisions which may
occur before the next periodicity visit.
3. Information should also include a summarization of the results of the
screening and laboratory tests, review of the child’s health status and
discussion regarding any specific problems detected in the screening.
g. VISION SCREENING
The purpose is to detect potentially blinding diseases and visual impairments, such
as congenital abnormalities and malformations, eye diseases, color blindness and
refractive errors. The screening should include distance visual acuity, color
perception and ocular alignment tests. The vision screening is part of the complete
physical examination and should be given by age three. Screening for amblyopia
may be separately reimbursed.
h. HEARING SCREENING
The purpose is to detect sensorineural and conductive hearing loss, congenital
abnormalities, noise-induced hearing loss, central auditory problems or a history of
conditions that may increase the risk for potential hearing loss. The examination
must include information about the child’s response to voice and other auditory
stimuli, speech and language development and specific factors or health problems
that place a child at risk for hearing loss.
i. DENTAL SCREENING
An oral inspection must be performed by the screening provider as part of each
physical examination for a child screened at any age. Tooth eruption, caries, bottle
tooth decay, developmental anomalies, malocclusion, pathological conditions or
dental injuries should be noted. The oral inspection is not a substitute for a complete
dental screening examination provided by a dentist. An initial dental referral should
be provided on any child age three or older unless it is known that the child is
already receiving regular dental care. When the screening indicates a need for
dental services at an earlier age, referral must be made. The importance of regular
dental care should be discussed with the family (and the child as appropriate) on
each screening visit for children three years and older.
2. Immunizations and laboratory tests should be billed separately from the screening visit.
Objective vision and hearing testing performed during the same visit as the physical
examination should not be billed separately, with the exception of testing for amblyopia.
If hearing and vision testing needs to be performed separately from the exam, these
procedures should be billed as outlined in applicable MSM chapters.
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3. Nevada Medicaid does not cover “sick kid” visits under the Healthy Kids program. A
majority of the screening elements should be completed during a screening appointment to
be billed as a Healthy Kids screening. The screening visit should be rescheduled if the child
is too ill to complete the examination and the current visit should be billed using a routine
office visit code.
1503.4 DIAGNOSTIC SERVICES
Nevada Medicaid provides diagnostic services as indicated through a Healthy Kids screening.
1503.4A COVERAGE AND LIMITATIONS
1. Any condition discovered during a screening should be followed up for diagnosis. Prior
authorization is not necessary for these diagnostic examinations if they are part of or
referred through a Healthy Kids screening. Referrals can include but are not limited to:
a. Vision Services.
b. Dental Services.
c. Hearing Services.
d. Other Necessary Health Care.
2. Although preferred, a Healthy Kids screening is not a requirement for medically necessary
diagnostic services.
1503.5 TREATMENT
Nevada Medicaid provides for medically necessary treatment as indicated through a Healthy Kids
screening and diagnosis.
1503.5A COVERAGE AND LIMITATIONS
1. Health care and treatment is available to correct or improve defects and physical and mental
illnesses or conditions discovered by Healthy Kids screening and diagnostic services.
Covered services include all mandatory and optional services that a state can cover under
the benefit plan, whether or not such services are covered for adults. The scope of medical
services available are described in the SSA, Section 1905(a).
2. Services that are not medical in nature, including educational interventions, are excluded.
Treatment must be medically necessary and prior authorized if not typically included in the
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benefit plan. The QIO-like vendor will review the suggested treatment to ensure it meets
with current medical practice standards for the given diagnosis.
3. When treatment is needed to correct or improve identified conditions, the DHCFP’s
established requirements for prior authorization apply. See the MSM Chapters related to
the requested service to determine if prior authorization is needed before treatment is
rendered.
4. Although it is preferred, a Healthy Kids screening is not a requirement for medically
necessary treatment under EPSDT guidelines (SSA, Section 1905(r).
1503.6 FAMILY PLANNING
Family planning services are available to recipients.
1503.6A COVERAGE AND LIMITATIONS
Family planning information should be offered during a Healthy Kids examination as appropriate
and requested.
1503.7 TRANSPORTATION
Assistance with transportation is available to and from a Healthy Kids examination. (Please
reference MSM Chapter 1900, Transportation).
1503.7A COVERAGE AND LIMITATIONS
Nevada Medicaid pays for transportation in order for a recipient to receive medically necessary
care and services. Transportation requires prior authorization in all but emergency situations. The
guidelines outlined in MSM Chapter 1900 should be followed.
1503.8 PREGNANCY RELATED ONLY
The Healthy Kids benefit package is not available to recipients who are eligible solely because of
pregnancy.
1503.8A COVERAGE AND LIMITATIONS
A recipient who is less than 21 years old and whose eligibility status is pregnancy related only (P)
is not eligible for Healthy Kids. She is eligible for pregnancy related services only, which includes
prenatal care, labor and delivery services and postpartum care for 60 days after the date of delivery,
including the month in which the 60th day falls. The recipient may be eligible for services that
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relate to conditions that might complicate the pregnancy, but those services cannot be billed as a
Healthy Kids service.
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1504 HEARINGS
Please reference MSM Chapter 3100 for Medicaid Recipient Hearing process policy.
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ATTACHMENT A
POLICY #15-1 EFFECTIVE DATE:
CLINICAL STUDIES NOVEMBER 1, 2014
DESCRIPTION
Nevada Medicaid covers the routine costs of qualifying phase III and IV clinical trials for children less than 21
years of age. Reasonable and necessary items and services used to diagnose and treat complications arising from
participation in phase III and IV clinical trials are covered. These services must be a Nevada Medicaid covered
service.
POLICY
Any clinical trial receiving Medicaid coverage of routine costs must meet the following requirements:
1. The subject or purpose of the trial must be the evaluation of an item or service that is covered by Nevada
Medicaid (e.g., physicians’ service, Durable Medical Equipment (DME), diagnostic test) and is not
excluded from coverage (e.g., cosmetic surgery);
2. The trial must not be designed exclusively to test toxicity or disease pathophysiology, it must have
therapeutic intent;
3. Trials of therapeutic interventions must enroll patients with diagnosed disease rather than healthy
volunteers; and
4. The clinical trial is approved by one of the following:
a. National Institute of Health (NIH);
b. Department of Defense (DOD);
c. Veterans Affairs (VA);
d. Centers for Disease Control (CDC);
e. Centers for Medicare & Medicaid Services (CMS);
f. Agency for Healthcare Research & Quality (AHRQ); or
g. National Cancer Institute (NCI).
PRIOR AUTHORIZATION IS REQUIRED
Clinical trials that meet the qualifying coverage criteria will receive Medicaid coverage of routine costs after prior
authorization from the Quality Improvement Organization (QIO)-like vendor.
January 1, 2016 HEALTHY KIDS PROGRAM Attachment A Page 1
ATTACHMENT A
POLICY #15-1 EFFECTIVE DATE:
CLINICAL STUDIES NOVEMBER 1, 2014
COVERAGE AND LIMITATIONS
Covered Services
1. Items or services that are typically provided absent a clinical trial (e.g., conventional care);
2. Items or services required solely for the provision of the investigational item or service (e.g.,
administration of a non-covered chemotherapeutic agent), the clinically appropriate monitoring of the
effects of the item or service or the prevention of complications; and
3. Items or services needed for reasonable and necessary care arising from the provision of an investigational
item or service in particular, for the diagnosis or treatment of complications.
Non-Covered Services
1. Phase I or II clinical trials.
2. Items and services provided solely to satisfy data collection and analysis needs and that are not used in
the direct clinical management of the patient (e.g., monthly Computed Tomography (CT) scans for a
condition usually requiring only a single scan).
3. Items and services customarily provided by the research sponsors free of charge for the enrollee in the
trial.
4. For items and services, including items and services for which Medicaid reimbursement is not available,
Medicaid only covers the treatment of complications arising from the delivery of the non-covered item or
service and unrelated reasonable and necessary care. However, if the item or service is not covered by
Medicaid and is the focus of a qualifying clinical trial, the routine costs of the clinical trial (as defined
above) will be covered by Medicaid but the non-covered item or service, itself, will not.
NOTE: For policy regarding pharmaceutical clinical studies, please refer to MSM Chapter 1200,
Prescribed Drugs.
January 1, 2016 HEALTHY KIDS PROGRAM Attachment A Page 2
ATTACHMENT A
POLICY #15-2 EFFECTIVE DATE:
EXPERIMENTAL TREATMENT NOVEMBER 1, 2014
DESCRIPTION/POLICY
Nevada Medicaid does not cover any item or service that is not medically necessary, that is unsafe or is not
generally recognized as an accepted method of medical practice or treatment.
PRIOR AUTHORIZATION IS REQUIRED
If experimental treatment is medically necessary, providers must request prior authorization for services which
may fall into the above category prior to rendering service.
COVERAGE AND LIMITATIONS
Nevada Medicaid completes prior authorization on medical services to assure that the care and the services
proposed are actually needed, are equally effective, less expensive alternatives have been given consideration and
the proposed service and materials conform to commonly accepted standards.
Nevada Medicaid’s QIO-like vendor completes the authorization review.
January 1,2016 HEALTHY KIDS PROGRAM Attachment A Page 3
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
July 21, 2011
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: MARTA E. STAGLIANO, CHIEF, COMPLIANCE
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1600 – INTERMEDIATE CARE FOR THE MENTALLY
RETARDED
BACKGROUND AND EXPLANATION
The policy has been revised in the area of transportation to provide examples of services not
reimbursable to the facility and refer the reader to Medicaid Services Manual (MSM) Chapter
1900, Transportation Services. The changes reduce conflict of information between program
chapters and provide additional direction regarding transportation to an Adult Day Health Care
(ADHC) setting. The second revision addresses a provider’s use of ADHC services. Further
changes direct the provider to the Rates and Cost Containment Unit for information regarding the
Uniform Cost Report. Lastly, additional direction has been provided for the management of a
patient’s trust fund account.
To bring the chapter into formatting consistent with other manual chapters the Definitions
section and the References and Cross References section have been deleted and are being
reserved for future use.
Throughout the chapter, grammar, punctuation, and capitalization changes were made,
duplications removed, acronyms used and standardized, and language reworded for clarity.
Renumbering and re-arranging of sections was necessary.
These policy changes are effective July 22, 2011.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 12/11 MTL 36/03, 38/08, 21/10
CHAPTER 1600 - INTERMEDIATE CARE CHAPTER 1600 - INTERMEDIATE CARE
FOR THE MENTALLY RETARDED FOR THE MENTALLY RETARDED
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1602 Definitions The section was deleted and is being reserved for
Page 1 of 2
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
future use.
1603.4 Transportation Added types of transportation a facility must
provide that are not reimbursable, the word
“ambulance” to specify the type of emergency
transportation that is reimbursable, and reference to
Chapter 1900 as the authority regarding
transportation policy.
1603.6 Professional Added explanation of ADHC as part of an Active
Services Treatment Program but separate reimbursement is
not allowed.
1603.7 Reimbursement Revisions made to directions regarding contact and
Rate and instructions for Uniform Cost Report. Added new
Allowable Costs sub-section “Patient Trust Fund Management”
explaining the handling of patient trust funds and
refers reader to MSM Chapter 500, Nursing
Facilities
1605 References and The section was deleted and is being reserved for
Cross References future use.
Page 2 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
INTERMEDIATE CARE FOR THE MENTALLY RETARDED
1600 INTRODUCTION ................................................................................................................................1
1601 AUTHORITY .......................................................................................................................................1
1602 RESERVED .........................................................................................................................................1
1603 POLICY................................................................................................................................................1
1603.1 POLICY STATEMENT ......................................................................................................................1
1603.1A COVERAGE AND LIMITATIONS ....................................................................................................1
1603.1B PROVIDER RESPONSIBILITY .........................................................................................................2
1603.1C RECIPIENT RESPONSIBILITY.......................................................................................................10
1603.1D AUTHORIZATION PROCESS .........................................................................................................11
1603.2 READMISSION PROCEDURES ......................................................................................................13
1603.2A COVERAGE AND LIMITATIONS ..................................................................................................13
1603.2B PROVIDER RESPONSIBILITIES ....................................................................................................13
1603.3 OUT-OF-STATE ICF/MR PLACEMENT ........................................................................................15
1603.3A COVERAGE AND LIMITATIONS ..................................................................................................15
1603.3B PROVIDER RESPONSIBILITY .......................................................................................................16
1603.4 TRANSPORTATION ........................................................................................................................17
1603.5 ABSENCES........................................................................................................................................17
1603.5A COVERAGE AND LIMITATIONS ..................................................................................................17
1603.6 PROFESSIONAL SERVICES ...........................................................................................................18
1603.6A COVERAGE AND LIMITATIONS ..................................................................................................18
1603.7 REIMBURSEMENT RATE AND ALLOWABLE COSTS .............................................................28
1603.7A COVERAGE AND LIMITATIONS ..................................................................................................28
1603.7B PROVIDER RESPONSIBILITY .......................................................................................................30
1603.8 PATIENT LIABILITY (PL) ..............................................................................................................30
1603.8A COVERAGE AND LIMITATIONS ..................................................................................................30
1603.8B PROVIDER RESPONSIBILITY .......................................................................................................31
1603.8C RECIPIENT RESPONSIBILITY.......................................................................................................31
1604 HEARINGS ..........................................................................................................................................1
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1600 INTRODUCTION
Nevada Medicaid’s Intermediate Care Facilities for the Mentally Retarded (ICF/MR) Program
was established in 1971 to provide reimbursement for individuals residing in institutions for
people with mental retardation or other related conditions. The Social Security Act specifies that
these institutes must provide active treatment in addition to other Conditions of Participation.
Many of the residents who are served by the program are also non-ambulatory, may have seizure
disorders, behavioral problems, mental illness, can be visually or hearing impaired or have a
combination of these conditions.
The Division of Health Care Financing and Policy (DHCFP) has opted to provide services for
people residing in an ICF/MR as a benefit under the State Plan for Medical Assistance.
All DHCFP (Nevada – Medicaid) policies and requirements (such as prior authorization, etc.) are
the same for Nevada Check Up (NCU), with the exception of the areas where Medicaid and
NCU policies differ as documented in the NCU Manual Chapter 1000.
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1601 AUTHORITY
Federal Statutes, Regulations, and Policies Governing the Intermediate Care Facility for the
Mentally Retarded (ICF/MR) Program.
The following are the relevant statutes, regulations, and State Operations Manuals (SOM) that
govern the ICF/MR Program.
FEDERAL STATUTES governing ICF/MR – Social Security Act:
• Section 1905(d) – Defines ICF/MR
• Section 1905(a)(15) – Defines ICF/MR
• Section 1902(a)(33) – Directs Centers for Medicare and Medicaid Services (CMS) to
make independent and binding determinations
• Section 1902(i)(1) – State plans for medical assistance and the ICF/MR program.
• Section 1922 – Correction and Reduction Plans for ICF/MR
• REGULATIONS governing the ICF/MR program – Title 42 of the Code of Federal
Regulations (CFR)
• 42 CFR 435.1009 – Definitions relating to institutional status for the purpose of Federal
Financial Participation (FFP)
• 42 CFR 440.150 – ICF/MR services
• 42 CFR 440.220 – Required services for the medically needy
• 42 CFR 442.118-119 – Denial of new admissions
• 42 CFR 483.10 – Resident Rights
• 42 CFR 483.400-480 – Conditions of Participation for ICF/MR
• 42 CFR 498.3-5 – Appeals procedures for determinations that affect participation in the
Medicare program and for determinations that affect the participation of ICF/MR and
certain Nursing Facilities in the Medicaid program.
• SURVEY procedures governing the ICF/MR program – State Operations Manual (SOM),
Chapters 1, 2, 3, 9 – Exhibit 80 and Appendix J.
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1602 RESERVED
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1603 POLICY
1603.1 Intermediate Care Facilities for the Mentally Retarded (ICF/MR) must be certified and comply
with all Federal Conditions of Participation in eight areas, including management, client
protections, facility staffing, active treatment services, client behavior and facility practices,
health care services, physical environment and dietetic services.
In Nevada, the Bureau of Health Care Quality and Compliance (HCQC) of the State Health
Division licenses ICF/MR facilities, conducts surveys and recommends certification of the
facilities as Medicaid providers.
1603.1A COVERAGE AND LIMITATIONS
1. ADMISSION AND CONTINUED STAY CRITERIA
a. The recipient must be diagnosed as mentally retarded or have a condition related
to mental retardation. Some standardized scales which can be used to determine
level of mental retardation include, but are not limited to, the Vineland Social
Maturity Scale, the Adaptive Behavior Scale, and the Behavior Development
Survey.
b. The recipient must have an Individual Program Plan (IPP).
c. A physician must certify the need for ICF/MR care prior to or on the day of
admission (or if the applicant becomes eligible for Medicaid while in the
ICF/MR, before the Nevada Medicaid Office (NMO) authorizes payment).
d. The certification must refer to the need for the ICF/MR level of care, be signed
and dated by the physician, and be incorporated into the resident's record in the
physician's orders.
e. Recertification by a physician or a nurse practitioner of the continuing need for
ICF/MR care is required within 365 days of the last certification.
In no instance is recertification acceptable after the expiration of the previous
certification.
f. The physical exam must document the resident does not have any active
communicable, contagious, or infectious disease.
g. The Interdisciplinary Team (IDT) evaluation documents that the recipient needs
more intensive treatment than can be provided in a day treatment program or a
community residential program.
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The IDT evaluation documents that the recipient needs and can probably benefit
from the active treatment program. The program is directed toward the acquisition
of behaviors necessary to maximize the recipient’s possible independence and self
determination or to prevent or decelerate regression or loss of the recipient’s
current level of functioning for a recipient for whom no further positive growth is
demonstrable.
h. The IDT has developed an appropriate IPP based on its evaluation and
reevaluated the plan as required.
i. The recipient had Medicaid Eligibility on the date(s) of service.
j. Services are provided in a Medicaid certified participating facility.
1603.1B PROVIDER RESPONSIBILITY
1. MEDICAID ELIGIBILITY
The provider is responsible to verify a recipient’s Medicaid eligibility. The Electronic
Verification System (EVS) may be used.
Refer to Chapter 100 of the Medicaid Services Manual (MSM) for detailed information
on application and eligibility categories.
2. FACILITY CERTIFICATION
Certification of compliance with federal requirements for participation in the Medicaid
program is required; contact the HCQC of the State Health Division for information and
procedures.
The facility must also have a valid Provider Agreement with the Nevada Medicaid
Office; the Agreement must be co-terminus with Medicaid's period of certification,
including any automatic cancellation dates imposed by Centers for Medicare and
Medicaid Services (CMS). The maximum duration of a Provider Agreement is 12
months.
3. PRELIMINARY ASSESSMENT
The IDT must complete a preliminary assessment of each recipient prior to admission to
the facility.
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The preliminary assessment must include background information and current valid
assessments of functional, developmental, behavioral, social, health, and nutritional status
to determine if the facility can provide for the recipient's needs, if the recipient is likely to
benefit from placement in the facility, and what services are needed to meet those needs.
4. PSYCHOLOGICAL EVALUATION
There must be a psychological evaluation documenting the need for care which must be
completed within three months before admission and prior to authorization of payment.
For an urgent or emergency initial ICF/MR placement, a psychologist may review the
most recent psychological evaluation and document with a progress note or addendum to
the psychological evaluation that the recipient is eligible and needs ICF/MR placement.
The note or addendum must confirm the recipient's specific level of retardation or
identify the condition related to mental retardation and be signed and dated within 90
days prior to admission or on the admission date. This progress note or addendum must
be attached to the most recent psychological evaluation.
For readmission and discharge to another ICF/MR, a new psychological evaluation is not
required unless the IDT determines the existing evaluation is no longer accurate.
5. PHYSICIAN'S CERTIFICATION AND MEDICAL PLAN OF CARE
The physician must complete a medical plan of care if the resident requires 24-hour
licensed nursing care. It must include:
a. Diagnoses, symptoms, complaints, and complications indicating the need for
admission;
b. Any orders for:
1. medications;
2. treatments;
3. restorative and rehabilitative services;
4. activities;
5. therapies;
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6. diet;
7. medical equipment utilized to help treat medical conditions, such as
helmets or orthopedic splints; and
8. special procedures designed to meet the objectives of the plan of care.
6. THIRTY–DAY EVALUATION RECORD REQUIREMENTS
Within 30 days of admission, the following assessments and evaluation which were
completed (as appropriate to the recipient's needs) must be entered in the resident's
record.
a. A physical examination and history which was completed within five days prior
to or 30 days after admission. The examination and history may be conducted by
an advanced practitioner of nursing or physician's assistant, if within their scope
of practice, or a physician. The examination must include screening for vision and
hearing.
b. A complete dental examination which is completed within 12 months prior to or
one month after admission.
c. Evaluation of nutritional status which includes the determination of diet
adequacy, total food intake, potential need for additives or supplements, and the
skills associated with eating or feeding, food services practices, monitoring, and
supervision of the resident's own nutritional status.
d. Routine laboratory examinations as determined necessary by a physician.
e. Speech and language screening.
f. Social assessment which includes, but is not limited to, family history, social
relationships and interactions with peers, friends and relatives, and social
development.
g. Active Treatment Schedule.
h. A nursing assessment which includes medication and immunization history,
developmental history, and current health care needs.
i. Assessment of sensorimotor development which includes the development of
perceptual skills which are involved in observing the environment and making
sense of it; the development of those behaviors which primarily involve muscular,
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neuromuscular, or physical skills and varying degrees of physical dexterity;
identifying the extent to which corrective, orthotic, prosthetic, or support devices
would impact on functional status.
j. Assessment of affective development which includes the development of
behaviors which relate to the recipient's interests, attitudes, values, and emotional
expressions.
k. Assessment of cognitive development which refers to the development of those
processes by which information received by the senses is stored, recovered, and
used including the development of the processes and abilities involved in memory
and reasoning.
l. Assessment of adaptive behaviors and independent living skills which includes
the effectiveness or degree with which individuals meet the standards of personal
independence and social responsibility expected of their age and cultural group
and skills such as meal preparation, laundry, bed making, budgeting.
m. Assessment of vocational or prevocational development, as applicable, which
includes work interests, work skills, work attitudes, work related behaviors and
present and future employment options.
All of the assessments must describe what recipients can and cannot do in terms of skills
needed within the context of their daily lives.
In addition, the assessments must:
n. Identify the recipient's present problems and disabilities and where possible, their
causes;
o. Identify the recipient's specific developmental strengths;
p. Identify the recipient's specific developmental and behavioral management skills;
q. Identify the recipient's need for services without regard to the actual availability
of services needed.
7. INDIVIDUAL PROGRAM PLAN (IPP)
a. Within 30 days of admission, the IDT develops an IPP for each resident based on
the interdisciplinary professional comprehensive evaluations.
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b. The purpose of the IPP is to help the individual function at the greatest physical,
intellectual, social, or vocational level the recipient has presently or can
potentially achieve.
c. The interdisciplinary team must prepare an IPP which includes opportunities for
individual choice and self management and identifies the discrete measurable
criteria-based objective the recipient is to achieve, and the specific individualized
program of specialized and generic strategies, supports and techniques to be
employed. The IPP must be directed toward the acquisition of the behaviors
necessary for the recipient to function with as much self-determination and
independence as possible, and the prevention or deceleration of regression or loss
of current optimal functional status.
8. IMPLEMENTATION OF CONTINUOUS ACTIVE TREATMENT
a. The ICF/MR must provide active treatment. Once the IDT has developed the
recipient’s IPP, the recipient must receive a continuous active treatment program
consisting of needed interventions and services in sufficient number and
frequency to support the achievement of the objectives identified in the plan.
b. The individual’s time in the home or living unit must maximize toward further
development and refinement (including self-initiation) of appropriate skills.
c. For the active treatment process to be effective, the overall pattern of interaction
between staff and a recipient must be related to the comprehensive functional
assessment and the IPP.
d. Except for those facets of the IPP which must be implemented by licensed
personnel, each recipient's program plan must be implemented by all staff who
work with the recipient, including professional, para-professional, and other staff,
including direct care staff.
e. The facility must ensure that during staff time spent with each recipient, the staff
members are able to provide needed interventions or reinforce acquired skills in
accordance with the program plan. The activities of the ICF/MR must be
coordinated with other habilitation and training activities in which the recipient
may participate outside of the ICF/MR and vice versa, i.e. school or Community
Training Center (CTC).
9. ACTIVE TREATMENT SCHEDULE
Within 30 days of admission to the facility, staff must develop an active treatment
schedule which outlines the current active treatment program and is readily available for
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review by relevant staff. The schedule should direct the intensity of the daily work of the
staff and the recipient in implementing the individual program plan. To the extent
possible, the schedule should allow for flexible participation of the recipient in a broad
range of options, rather than on a fixed regimen.
The facility must develop an active treatment schedule for each recipient which:
a. Does not allow for periods of unscheduled activity of longer than three continuous
hours;
b. Allows free time for individual or group activities using appropriate materials;
c. Includes planned outdoor period year-round;
d. Reflects some of the specific programs for the individual rather than a facility or
unit-wide generic calendar.
10. QUALIFIED MENTAL RETARDATION PROFESSIONAL (QMRP) REVIEWS
a. Reviews
A facility must have one or more QMRP’s review the IPP and assure it is revised
as necessary. The frequency of the QMRP reviews are determined by the facility.
The duties of the QMRP are:
1. Monitoring the delivery of each IPP;
2. Integrating and coordinating the various aspects of the active treatment
program;
3. Reviewing each recipient's program plan and insuring it is revised as
necessary, including but not limited to, situations in which the recipient:
a. Has successfully completed an objective or objectives identified in
the IPP;
b. Is regressing or losing skills already gained;
c. Is failing to progress toward identified objectives after reasonable
efforts have been made; or
d. Is being considered for new training.
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4. Obtaining input and review by other IDT members when the revisions
result in significant differences from the team’s original intent;
5. Documents information relevant to the IPP, assuring it is recorded as
changes occur.
11. ANNUAL INTERDISCIPLINARY TEAM (IDT) REVIEW
Within one year of the resident's admission date and at least once annually thereafter, the
IDT must re–evaluate each recipient and revise the IPP. Revisions must be developed and
implemented and recommendations acted upon within 30 days of the IDT meeting, unless
other time frames are justified.
a. The annual review must include:
1. The advisability of continued ICF/MR placement versus an alternative
placement;
2. When the recipient is an adult, the need for guardianship and how the
recipient can exercise his/her civil and legal rights;
3. The continuing appropriateness of the IPP objectives;
4. The continuing appropriateness of services provided to reach the plan's
objectives;
5. The progress or failure to progress toward the plan's objectives;
6. Modification of the activities, objectives and/or training programs of the
IPP as are necessary; and
7. A comprehensive functional reassessment to be based upon:
a. Physical examination including a vision and hearing screening,
which may be completed by a physician or an advanced nurse
practitioner;
b. Dental examination;
c. Social reassessment;
d. Physician's recertification of need for ICF/MR;
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e. Nursing reassessment;
f. Routine screening laboratory tests as determined necessary by the
physician;
g. Nutritional reassessment;
h. The IDT must determine whether other assessments are still
accurate.
8. Accurate assessments must include:
a. Current, relevant and valid data;
b. Skills, abilities and training needs identified which correspond to
the resident's actual status; and
c. The cultural background and experiences of the resident are
reflected in the choice, administration and interpretation of the
assessments.
Assessments which are no longer accurate must be revised. The case
record must document that the IDT has reviewed the assessments and
determined which need updating.
Assessments which must be reviewed by the IDT and revised as
recommended by the IDT are:
d. Sensorimotor, affective and cognitive development;
e. Adaptive behaviors and independent living skills; and
f. Vocational and prevocational development as applicable.
12. OCCUPANCY REPORTS
To assist in appropriate use of available beds, the facility must complete the Monthly
Facility Occupancy Report indicating the actual census as of the first day of each month.
This report is due by the fifth day of each month. The occupancy report may be submitted
by fax to Division of Health Care Financing and Policy (DHCFP), Continuum of Care
Unit, (775) 687-8724.
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13. INCIDENT REPORTS
Incidents involving any potential harm to a resident in or around the facility must be:
a. Recorded on an adequate form;
b. Reported to the resident's physician or his alternate immediately if there is serious
harm;
c. Reported to the family member, authorized representative or legal guardian; and
d. Evaluated by a nurse.
Incident documentation may be maintained apart from the resident's chart but, upon
request, must be made available to authorized representatives of the DHCFP and/or
Nevada State Health Division.
A facility must report to the Nevada Medicaid Office by telephone, within 48 hours, any
incident in or about the facility that results in the death of or serious injury to any
Medicaid resident by other than natural causes.
1603.1C RECIPIENT RESPONSIBILITY
1. Recipients and/or their authorized representative are responsible to apply for and to
maintain Nevada Medicaid eligibility by cooperating with the Division of Welfare and
Supportive Services (DWSS) in providing information necessary to determine eligibility.
2. Application for services is made directly through the service provider in conjunction with
the Health Division’s Mental Health and Development Services (MHDS).
3. The recipient and the recipient’s family/guardian should participate in developing the IPP
unless the QMRP documents that such participation is inappropriate or unobtainable. If
the recipient is a legally competent adult, he/she may request that his/her family not be
involved in the planning process.
4. The recipient is responsible to participate in the active treatment program as described in
the IPP.
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1603.1D AUTHORIZATION PROCESS
1. GENERAL REQUIREMENTS
a. Prior authorization by the Quality Improvement Organization (QIO-like vendor)
is required for payment for care in an Intermediate Care Facility for the Mentally
Retarded (ICF/MR).
b. Authorization will be given only after a determination by the QIO-like vendor that
ICF/MR admission criteria have been met.
c. Authorization cannot be given for a resident whose eligibility status is pending.
However, if eligibility is established retroactively, Medicaid may authorize
retroactive payment to the facility for necessary services at the ICF/MR level of
care which have been certified by a physician.
2. ICF/MR TRACKING FORM
The facility must submit an ICF/MR Tracking Form within 72 hours of an admission,
readmission, discharge, Medicaid eligibility determination or annual continued stay
review.
This form is to be submitted to the DHCFP or their QIO-like vendor. Failure to submit
the Tracking form may result in a delay or denial of payment.
3. PRE-PAYMENT REVIEW
Pre-Payment Review packets must be submitted to Nevada Medicaid’s QIO-like vendor
within 45 days of admission, readmission, or newly Medicaid eligible (first time billing).
The below required attachments are referred to as a Pre-Payment Review packet. The
pre-payment review packet serves as documentation to assess the appropriateness of
placement. Once the Pre-Payment Review packet has been approved the facility will be
notified by receiving a Billing Authorization letter. An ICF/MR will not be able to bill for
services until they have received the Billing Authorization letter.
a. Required Attachments for Pre-Payment Review Packets
1. Copy of the original ICF/MR Tracking Form;
2. History & Physical Examination (most recent);
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3. Acute Discharge Summary (if there was a hospital stay which lasted
longer than 48 hours);
4. The most recent psychological test results documenting the recipient's
level of retardation or existence of a "related condition";
5. Minutes of the most recent IDT meeting (Initial, Readmission, or Annual)
that includes a dated sign-in sheet, a Nursing Assessment, Nutritional
Assessment, Social Services Assessment and documentation of a dental
exam within the past year.
6. The current IPP developed by the IDT and Active Treatment Schedule.
7. Physicians admission orders and certification for ICF/MR level of care.
b. Complete Pre-Payment Review Packet
If the packet has information which is incomplete or inaccurate, the packet will be
returned to the facility, with the Additional Information form identifying the
problem. The facility must review this request, make necessary corrections or
provide additional information to assure all areas are addressed prior to
resubmitting the packet. A facility staff member(s) must initial any alterations.
4. ANNUAL CONTINUED STAY PAYMENT REVIEW PACKET
Annually, the ICF/MR must submit to Nevada Medicaid documentation verifying the
need for a recipient’s continued stay.
a. Required attachments for the Annual Continued Stay Payment Review Packets:
1. Most recent annual IDT review with signatures and titles of the
participants.
2. The Physician’s signed recertification of continued need for ICF/MR level
of care.
3. Most recent annual History and Physical with listed diagnoses.
4. Copy of the ICF/MR Tracking form.
Continued payment will not be approved without the annual review packet.
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1603.2 READMISSION PROCEDURES
1603.2A COVERAGE AND LIMITATIONS
Refer to Section 1603.1A of this Chapter.
1603.2B PROVIDER RESPONSIBILITIES
1. HOSPITAL OR NURSING FACILITY DISCHARGE/READMISSION
If a recipient is discharged to a hospital or nursing facility from the ICF/MR and returns
to the same ICF/MR, the following procedures are required:
a. Within 72 hours of the recipient's discharge, the facility must complete and
submit to the DHCFP QIO-like vendor an ICF/MR Tracking Form.
b. Within 72 hours of the recipient's return to the ICF/MR, the facility must
complete and submit the ICF/MR Tracking form.
c. Prior to or on the date of return to the ICF/MR, a physician must complete the
physician's certification and update the physician's orders.
d. The IDT determines whether assessments are still accurate. Assessments which
are not accurate must be revised. The case record must show that the IDT has
reviewed all assessments and determined which need updating. This could be
noted on each assessment which does not need revising or in the minutes of the
IDT meeting.
On or prior to the date of admission, the IDT must review and revise the IPP. If
the IDT finds the objectives are appropriate and do not need revising, they must
so note in the case records. This notation may be in the IDT minutes or on the
plan objectives which are not being revised.
e. The facility must obtain the hospital's discharge summary if the hospital stay was
for longer than 48 hours and file it in the recipient's record.
f. Within 45 days submit the Pre-Payment packet to Nevada Medicaid’s QIO-like
vendor.
g. If the recipient has been out of the ICF/MR for more than 30 days, all the
requirements for a new admission must be met.
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h. Admission to an ICF/MR from another ICF/MR is a new admission to the
accepting facility. Each ICF/MR has a separate Medicaid provider number and
each is considered a separate facility even if multiple facilities share a governing
body.
2. DISCHARGE/READMISSION TO/FROM HOME OR COMMUNITY BASED
PLACEMENT
If a recipient is transferred from an ICF/MR into a residential community based home or
home placement, the following procedures apply:
a. The facility must submit the ICF/MR Tracking form to Nevada Medicaid’s QIO-
like vendor within 72 hours of when the recipient is transferred.
b. If the recipient returns to the ICF/MR within the trial placement period (within 30
days of leaving the ICF/MR) the facility must:
1. Complete the tracking form within 72 hours of the recipient's return and
submit it to Nevada Medicaid’s QIO-like vendor.
2. On or prior to the date of readmission, the IDT determines whether
assessments are still accurate. Assessments which are no longer accurate
must be revised. The case record must show that the IDT has reviewed all
assessments and determined which need updating.
c. If a recipient is transferred from one ICF/MR to another ICF/MR, the following
procedures must be followed:
1. The discharging facility must complete an ICF/MR tracking form within
72 hours of discharge and submit to Nevada Medicaid’s QIO-like vendor.
2. The discharging facility must develop a final summary of the recipient's
developmental, behavioral, social, health and nutritional status and plan to
help the recipient adjust to the new placement. With the consent of the
recipient/parents (if a minor child)/legal guardian, the summary must be
provided to authorized persons and agencies.
3. Within 30 days after admission, the admitting ICF/MR IDT must perform
accurate assessments or reassessments as needed (defined in Manual
Section 1603.1B11.a.8 of this chapter).
On or prior to the date of readmission, the IDT must review and revise the
IPP. If the IDT finds that the objectives are appropriate and do not need
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revising, it must be noted in the case record. This notation may be in the
IDT minutes or on the plan objectives which are not being revised.
a. Prior to or on the date of return to the ICF/MR, a physician must
complete the physician's certification (See Manual Section
1603.1A2) and update the physician's orders.
b. Within 45 days of the readmission, the facility must submit the
Pre-Payment Review Packet, defined in Manual Section 1603.1D.3
of this chapter, to Nevada Medicaid’s QIO-like vendor.
c. If the recipient returns to the ICF/MR after the trial placement
period has ended, all the requirements for a new admission must be
met with one exception.
The IDT determines whether assessments are still accurate.
Assessments which are not accurate must be revised. The case
record must show that the IDT has reviewed all assessments and
determined which need updating. This could be noted on each
assessment which does not need revising or in the minutes of the
IDT meeting.
1603.3 OUT-OF-STATE ICF/MR PLACEMENT
Nevada Medicaid must prior authorize all out-of-state ICF/MR placements for all Medicaid
recipients arranged by any agency, individual, or district office. Nevada Medicaid will issue a
Prior Authorization (PA) to the out-of-state facility and the Medicaid District Office may assist
to arrange transportation. A recipient residing in an out-of-state facility without Medicaid
authorization may place the out-of-state facility at risk for delayed or non-payment of services
and the resident may be considered a resident of the state of location.
1603.3A COVERAGE AND LIMITATIONS
PRE-PLACEMENT PROCEDURES
The following pre-placement procedures must be followed before Nevada Medicaid will
authorize an out-of-state ICF/MR placement:
1. All appropriate facilities within Nevada must first be contacted for a possible placement.
The facilities contacted and reasons for not accepting the recipient must be documented.
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2. Documentation, if applicable, is required from a state or county agency verifying
responsibility for payment of educational expenses, since this is not a Medicaid benefit.
Documentation is required for recipients under age 22 and who have not completed state
schooling requirements.
3. If there is no burial coverage and family is not willing/able to purchase it, a burial
guarantee must be obtained from the Division of Child and Family Services (DCFS), or
the county of origin.
4. If the individual is incompetent or suffers from diminished capacity and there is no
family, legal guardian or significant other involvement, efforts must be made to have the
Public Administrator or a guardian appointed to handle possible legal, health or financial
matters prior to out-of-state placement.
5. The individual (and family or custodial agency if applicable) must agree in writing to out-
of-state placement.
6. The out-of-state ICF/MR must be a Nevada Medicaid provider.
1603.3B PROVIDER RESPONSIBILITY
All of the following are required for authorization for an out–of–state placement:
1. Completed Out–of–State Intake Questionnaire.
2. Current History and Physical exam and list of current medications.
3. Proof of burial coverage or guarantee (if available) and a signed statement from the
recipient or responsible party acknowledging that Medicaid benefits end with death of the
recipient.
4. Statement from the recipient, if a minor from his/her parent, or from a legal guardian
agreeing to an out–of–state placement.
5. A list of all Nevada ICF/MR facilities contacted including date contacted the name of the
person at the ICF/MR who denied placement and the reason for denial.
6. A letter verifying coverage of educational costs for a recipient who is under age 22 and
has not completed high school.
7. Social history and assessment.
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8. Psychological evaluation verifying the person with mental retardation or with a condition
related to mental retardation will benefit from placement in an ICF/MR.
All documents must be sent to the DHCFP, Attention: Out–of–State Placement Coordinator.
1603.4 TRANSPORTATION
Transportation for services that a facility is required to provide is not reimbursable, such as but
not limited to medical appointments, social events and Adult Day Health Care (ADHC)
attendance.
Medicaid will reimburse for ambulance transportation in a medical emergency situation.
Refer to MSM Chapter 1900, Transportation Services, for further details on transportation.
1603.5 ABSENCES
1603.5A COVERAGE AND LIMITATIONS
1. Payment for therapeutic leave of absence, or reserved beds, may be made to an ICF/MR,
subject to the following conditions:
a. The purpose of the therapeutic leave of absence is for rehabilitative home and
community visits including preparation for discharge to community living;
b. The patient’s attending physician authorizes the therapeutic leave of absence and
the plan of care provides for such absences;
c. An ICF/MR will be reimbursed their per diem rate for reserving beds for
Medicaid recipients who are absent from the facility on therapeutic leave up to a
maximum of twenty-four (24) days annually. For this purpose, annually is defined
as a calendar year beginning on January 1 and ending on December 31 of the
same year.
2. An absence for hospitalization or placement in a nursing facility which exceeds the
Medicaid authorized maximum is not reimbursable.
3. If a recipient does not return from a home visit or family emergency and if the absence
has been appropriately documented by the recipient's physician and the facility, the
facility will not be penalized for the recipient's failure to return. This absence will be
treated as a discharge effective the day the recipient was expected to return from leave.
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1603.6 PROFESSIONAL SERVICES
In order to qualify for Medicaid reimbursement and provide services necessary to assure a
comprehensive Active Treatment Program, ICF/MR employ or contract with individuals who
can assess recipient needs, participate in the IPP, and provide appropriate training and
habilitation services. These support staff assist in providing those physical and social
modifications or interventions allowing the recipient to function and adapt to his/her physical
and social environment.
ADHC services may be considered part of an Active Treatment Program. This service is not
Medicaid reimbursable outside of the facility’s routine per diem rate.
1603.6A COVERAGE AND LIMITATIONS
1. RECREATION
a. Services for Recipients with Handicapping Conditions
Multiple handicapped or non-ambulatory recipients must:
1. Spend a major portion of the waking day out of bed;
2. Spend a portion of the waking day out of the bedroom area;
3. Have planned daily activity and exercise periods;
4. Move around with various methods and devices whenever possible; and
5. Have recreation areas and facilities designed and constructed or modified
so that they, regardless of their disabilities, have access to them.
b. Coordination with the IPP
Recreation services should be a coordinated part of the recipient's IPP.
A recreation assessment must be completed or updated within 30 days of
admission into an ICF/MR. If recreation therapy is provided, an annual re-
evaluation by the recreational therapist is required. If the IDT recommends during
an IDT meeting that a re-assessment be completed by the recreational therapist,
one must be completed within 30 days of the recommendation.
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c. Recreation Services Objectives
Recreation services should:
1. Provide activities designed to meet individual, personal, and therapeutic
needs in self-expression, social interaction, and entertainment;
2. Develop skills, including physical and motor skills, and interests leading
to enjoyable and satisfying use of leisure time; and
3. Improve socialization and increase interaction with others.
d. Recreational Staff Qualifications
1. To be designated as a professional recreation therapist the staff member
must have a Bachelor’s Degree in recreation, or a related specialty area,
such as art, dance, music, or physical education.
2. Sufficient qualified staff and support staff should be available to carry out
recreational services in accordance with the stated objective(s) in the IPP.
2. SOCIAL SERVICES
a. Purpose of Social Services
Social Services must be directed toward:
1. Maximizing the social functioning of each recipient;
2. Enhancing the coping capacity of each recipient's family;
3. Asserting and safeguarding the human and civil rights of the recipient and
his/her family; and
4. Fostering the human dignity and personal worth of each recipient.
b. Pre-Admission Services
During the evaluation process to determine whether or not admission to the
ICF/MR is necessary, social workers must help the recipient and his/her family:
1. Consider alternative services, based on the individual's status and relevant
family and community factors; and
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2. Make a responsible choice as to whether and when residential placement
is indicated.
c. Ongoing Evaluation and Monitoring of Residents
Social workers must participate in the IDT meetings for each recipient for the
purposes of monitoring and following up on program plans.
d. Liaison with Recipient’s Family and the Community
The social worker must, as appropriate, provide liaison between the recipient, the
ICF/MR, the family, and the community.
e. Discharge Planning
1. In addition to participation in the development of the discharge plan,
social workers must:
a. Help the family participate in planning for the recipient's return to
home or other community placement; and
b. Provide systematic follow-up to assure referral to appropriate
community agencies after the recipient leaves the facility.
2. If a recipient is to be either transferred or discharged, the facility must:
a. Have documentation in the resident's record that the resident was
transferred or discharged for good cause.
Transfer means the temporary movement of an individual between
facilities or the permanent movement of an individual between living units
of the same facility. Discharge means the permanent movement of an
individual to another residence that is not under the jurisdiction of the
facility's governing body. Moving an individual for good cause means for
any reason that is in the best interest of the individual.
The recipient, his/her family, advocate and/or guardian should be involved
in any decision to move him/her.
b. Provide a reasonable time to prepare the recipient and his or her
parents or guardian for the transfer or discharge (except in
emergencies).
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f. Social Work Staff Qualifications
A social worker must be licensed as an Associate in Social Work or a Social
Worker by the Nevada State Board of Examiners for Social Work.
3. PSYCHOLOGICAL AND PSYCHIATRIC SERVICES
a. Purpose of Psychological Services
Psychological services must be provided to:
1. Maximize each recipient's development; and
2. Help recipients acquire:
a. Perceptual skills;
b. Sensorimotor skills;
c. Self-help skills;
d. Communication skills;
e. Social skills;
f. Self-direction;
g. Emotional stability; and
h. Effective use of time, including leisure time.
b. Psychological Services
The facility must provide a psychological service program for recipients which
includes:
1. Evaluations which must be done at least every three years for recipients
under age 18 and every five years for recipients aged 18 or older. The
evaluations must document that the resident has mental retardation. The
level of retardation may be two levels if the recipient's functioning is in
between them, e.g., moderate-severe.
2. Consultation;
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3. Therapy;
4. Program development;
5. Administration and supervision of psychological services;
6. Staff training;
7. Continuing inter-disciplinary evaluation of each recipient and
development of plans for habilitation services; and
8. When appropriate, periodic review and revision of program plans.
c. Psychological Staff Qualifications
1. A psychologist must have at least a Master's degree from an accredited
program and experience or training in the field of mental retardation. If
hired or subcontracted with after July 1, 1986, the psychologist must be
certified by the Nevada State Board of Psychological Examiners.
2. A psychologist who is the facility's QMRP must meet the qualifications in
Manual Section 1603.1B.10 of this chapter.
d. Psychiatric Services
1. Psychiatric services should be provided when indicated by the IDT for
psychotherapy, medication management and/or consultation.
2. To provide services in an ICF/MR a psychiatrist must be a medical doctor
licensed to practice psychiatry in the State of Nevada.
4. DENTAL SERVICES
Through a formal arrangement with a dentist licensed to practice dentistry or dental
surgery as defined in Nevada Revised Statutes (NRS) 631.215, the ICF/MR facility must
provide:
a. A comprehensive diagnostic dental examination within one month of admission to
the facility unless the recipient has had a dental examination within the 12 months
prior to admission.
b. Periodic examination and diagnosis done at least annually for each recipient.
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c. Necessary access to the services specified under the MSM Chapter 1000,
excluding sealants, orthodontia, pharmacy services, fluoride treatments, and
fluoride treatments with prophylaxis.
d. For children under 21 years of age residing in an ICF/MR referred for dental care
through the Healthy Kids Program, also known as Early and Periodic Screening
Diagnosis and Treatment (EPSDT), a Medicaid dental provider may bill directly
to Medicaid.
e. For adults 21 years and older residing in an ICF/MR, dental treatment for
emergency extractions, palliative care, and dentures can be billed to Medicaid by
a Medicaid dental provider in accordance with the MSM Chapter 1000 guidelines
and limitations.
f. If appropriate, the dentist or dental hygienist may participate in the development,
review, and updating of the IPP as part of the IDT process, either in person or by
written report.
5. PHARMACEUTICAL SERVICES
a. Pharmacist Duties
1. Upon admission, the pharmacist or registered nurse must obtain a history
of prescription and non-prescription drugs used and enter this in the
resident's record. This must be updated yearly.
2. The pharmacist must receive a copy for each resident of the physician's
drug treatment order.
3. The pharmacist must maintain for each resident a record of all prescription
and non-prescription medications dispensed including quantities and
frequency of refills.
4. As appropriate the pharmacist should participate in the ongoing IDT
evaluations and development of the individual program plan.
5. The pharmacist must establish quantity specifications for drug purchases
and insure that they are met.
6. The pharmacist must review each resident's drug regimen at least
quarterly.
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7. On a monthly basis the pharmacist must complete the Checklist for
Pharmacist Consultant (3232). The facility must retain the checklist for a
period of three fiscal years from the year to which they pertain (NRS
239.073).
b. Staff or Consultant
1. If a facility does not employ a licensed pharmacist, it must have an
agreement, with a licensed pharmacist to provide consultation on methods
and procedures for ordering, storage, administration, disposal, and
recording of drugs and biologicals.
2. Payment for consultant pharmacist services are separate from payment for
filling of prescriptions. With the consultant pharmacist, payment is made
by the facility for a service to the facility. In the case of prescribed drugs,
a provider payment is made by Medicaid to a pharmacy on behalf of the
recipient. The individual furnishing consultant pharmacist services to a
facility may or may not also be providing prescribed drugs to residents in
that facility. However, when it is feasible, separation of consultant
services and prescription services is encouraged.
c. Limitations
Nevada Medicaid reimburses the pharmaceutical provider directly for
prescriptions that meet the definition of essential in Section 1602.6 of this chapter.
The consultant pharmacist must review every drug ordered for compliance with
this definition.
If drug therapy is observed which does not meet the definition of essential as
stated in Section 1602.11 of this chapter, future charges for the medication will be
denied. Before this sanction is imposed, the facility and the pharmacy will receive
advance notice. If Nevada Medicaid does not receive appropriate justification
within 10 days from the date of notification, all future charges for the medication
will be denied.
6. PHYSICAL AND OCCUPATIONAL THERAPY (OT)
a. Services
1. Physical and OT staff must provide treatment training programs which are
designed to:
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a. Preserve and improve abilities for independent function such as
range of motion, strength, tolerance, coordination, and activities of
daily living; and
b. Prevent, insofar as possible, irreducible or progressive disabilities
through means such as the use of orthotic and prosthetic
appliances, assistive and adaptive devices, positioning, behavior
adaptations, and sensory stimulation.
2. Services must be coordinated with the recipient's physician and other
medical specialists.
3. Services must include:
a. Evaluation;
b. Participation in developing treatment objectives as part of the IPP;
c. Procedures to reach objectives; and
d. Revision of objectives and procedures based on progress (or lack
of progress).
b. Staff and Qualifications
1. The ICF/MR must have available enough qualified staff and support
personnel available either on staff or under contract to carry out the
various physical and occupational therapy services in accordance with
stated objectives in recipients' individual treatment plans.
2. Therapy assistants must work under the supervision of a qualified
therapist.
3. To be designated as an occupational therapist, an individual must have a
current registration issued by the American Occupational Therapy
Association or another comparable body.
4. To be designated as a physical therapist an individual must have a current
registration to practice physical therapy issued by the Nevada State Board
of Physical Therapy Examiners.
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7. SPEECH PATHOLOGY AND AUDIOLOGY SERVICES
a. Services
Speech pathology and audiology services available to the ICF/MR must include:
1. Screening of recipients with respect to hearing functions which is
completed by the physician or advanced nurse practitioner as part of the
annual physical examination, and screening of recipients regarding speech
functions;
2. Comprehensive audiological assessments of recipients as indicated by
screening results, which were part of the recipient's physical examination,
that include tests of puretone air and bone conduction, speech audiometry,
and other procedures, as necessary, and the assessment of the use of visual
cues;
3. Assessment of the use of amplification;
4. Provision for procurement, maintenance, and replacement of hearing aids,
as specified by a qualified audiologist;
5. Comprehensive speech and language evaluations of recipients as indicated
by screening results, including appraisal of articulation, voice, rhythm, and
language;
6. Participation in the IDT Process and IPP development for individual
recipients;
7. Treatment services as an extension of the evaluation process, which
include:
a. Direct counseling with recipients;
b. Consultation with appropriate staff for speech improvement and
speech education activities; and
c. Work with appropriate staff to develop specialized programs for
developing each recipient's communication skills in
comprehension, including speech, reading, auditory training,
hearing aid utilization, and skills in expression, including
improvement in articulation, voice, rhythm, and language;
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8. Participation in in-service training programs for direct-care and other staff.
b. Staff and Qualifications
A speech pathologist or audiologist must be licensed by the State of
Nevada Board of Audiology and Speech Pathology and have a current
certificate of clinical competence issued by the American Speech and
Hearing Association or a comparable body.
8. LABORATORY SERVICES
a. Management Requirements
If a facility chooses to provide laboratory services, the laboratory must:
1. Meet the management requirements specified in 42 CFR 405.1316; and
2. Provide personnel to direct and conduct the laboratory services.
b. Qualifications of Laboratory Director
The laboratory director must be technically qualified to supervise the laboratory
personnel and test performance and must meet licensing or other qualification
standards established by the State with respect to directors of clinical laboratories.
For those States that do not have licensure or qualification requirements
pertaining to directors of clinical laboratories the director must be either:
1. A pathologist or other doctor of medicine or osteopathy with training and
experience in clinical laboratory services; or
2. A laboratory specialist with a doctoral degree in physical, chemical, or
biological sciences, and training and experience in clinical laboratory
services.
c. Duties of Laboratory Director
The laboratory director must provide adequate technical supervision of the
laboratory services and assure that tests, examinations and procedures are
properly performed, recorded, and reported.
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The laboratory director must ensure that the staff:
1. has appropriate education, experience, and training to perform and report
laboratory tests promptly and proficiently;
2. is sufficient in number for the scope and complexity of the services
provided; and
3. receives in-service training appropriate to the type and complexity of the
laboratory services offered.
d. Other Laboratory Requirements
1. The laboratory must meet the proficiency testing requirements specified in
42 CFR 405.1314(a).
2. The laboratory must meet the quality control requirements specified in 42
CFR 405.1317.
3. If the laboratory chooses to refer specimens for testing to another
laboratory, the referral laboratory must be approved by the Medicare
program either as a hospital or an independent laboratory.
1603.7 REIMBURSEMENT RATE AND ALLOWABLE COSTS
1603.7A COVERAGE AND LIMITATIONS
1. PUBLIC ICF/MR – COST REIMBURSEMENT
A public ICF/MR is reimbursed under Medicare principles of retrospective
reimbursement described in the Medicaid State Plan, Attachment 4.19D and HCFA
Publication 15.
Each facility is paid the lower of either billed charges or an interim rate. In no case will
payment exceed audited allowable costs.
2. PRIVATE ICF/MR – SMALL PROSPECTIVE RATE
Non state-operated ICF/MR – Small is defined as a facility having six beds or less.
Private ICF/MR–Small facilities are paid a prospective payment rate for basic service
costs, other than day training costs and property costs, on a per–patient–day basis. Day
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training costs and property costs, excluded from the basic prospective rate, are
reimbursed under Medicare principles of retrospective cost reimbursement.
The daily rate is to include services and items such as, but not limited to nursing services,
dietary services, activity programs, laundry services, room/bed maintenance services,
medically related social services, routine personal hygiene supplies, and active treatment
programs.
Day training must be arranged by the ICF/MR, and must be approved by MHDS.
Refer to the Medicaid State Plan, Attachment 4.19-D and MSM Chapter 700, Rates and
Cost Containment, for additional details.
3. PRIVATE ICF/MR – LARGE
Non state-operated ICF/MR-Large (is defined as a facility having more than six beds). It
will be paid the lower of 1) billed charges or 2) an all-inclusive prospective per diem rate.
Refer to the Medicaid State Plan, Attachment 4.19-D and MSM Chapter 700, Rates and
Cost Containment, for additional details.
4. ALLOWABLE COSTS
Any question of an allowable cost that is not addressed within this chapter will be
resolved by reference to MSM Chapter 700, Rates and Cost Containment, and the CMS
Publication 15.
Nevada Medicaid allows the costs for nutritional supplements (e.g., Ensure, Pediasure,
etc.) when recommended in writing by a registered dietician and prescribed by a
physician. The cost is included in the facility cost reports under Raw Food or Dietary.
5. UPPER LIMITS
In no case may Medicaid payment for an ICF/MR exceed the facility's customary charges
to the general public.
In no case may Medicaid payment for an ICF/MR caring for more than 6 persons, exceed
an upper limit determined by application of principles of reimbursement for provider
costs under Title XVIII of the Social Security Act. All payment schedules under
Medicaid are subject to the general payment limits imposed in 1861(v) and 1866 of the
Act and implemented by regulations at 42 CFR 405.460 and 405.461.
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Refer to the Medicaid State Plan, Attachment 4.19-D and MSM Chapter 700, Rates and
Cost Containment, for additional details.
6. ANCILLARIES
Medicaid may make direct payment for ancillary services provided to recipients when:
a. Such services are not directly provided by the facility as part of the rate; and
b. Required prior authorization has been obtained from the Nevada Medicaid Office.
1603.7B PROVIDER RESPONSIBILITY
COST REPORTING AND AUDIT
To obtain the Uniform Cost Report and instructions for completion contact DHCFP’s Rates and
Cost Containment Unit. Submission of alternate forms or any forms other than the most current
does not constitute an acceptable filing.
A cost report must be submitted according to MSM Chapter 700, Rates and Cost Containment,
Section 703.4.
Each facility must maintain financial and statistical records sufficient to substantiate its reported
costs for three calendar years after submission. These records must be available upon request.
An annual audit of the facility's cost report will be completed by the DHCFP or its
representative.
Refer to MSM Chapter 700, Rates and Cost Containment, for additional details.
PATIENT TRUST FUND MANAGEMENT
The ICF/MR must follow the requirements for appropriate handling of patient trust funds. Refer
to MSM Chapter 500, Nursing Facilities, Section 503.8 and 42 CFR 483.420 for direction.
1603.8 PATIENT LIABILITY (PL)
DETERMINATION OF AMOUNT
PL is determined by eligibility personnel in the local DWSS district office.
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1603.8A COVERAGE AND LIMITATIONS
The regulations at 42 CFR 435.725 require that the State (Nevada Medicaid) reduce its payment
to the nursing facility by the amount of the PL. The established PL will be deducted from the
Medicaid reimbursement. If the PL does not exceed billed charges, Medicaid will reimburse the
difference between the established PL and the Medicaid maximum allowable. If the PL exceeds
the billed charges, no Medicaid reimbursement will be made. PL will also be applied to
subsequent claims submitted by providers entitled to PL until monthly obligations are fulfilled.
1603.8B PROVIDER RESPONSIBILITY
A nursing facility must notify the DWSS immediately whenever there is a change/difference in
any income source, as well as when any additional assets or resources come to the attention of
the nursing facility.
When PL is established or changes, the recipient, facility and the fiscal agent are notified of the
amount and effective date. Collection of PL is the facility’s responsibility. If a nursing facility
receives a notice adjusting the amount of the PL and facility has billed and received
reimbursement for services, the facility must send a corrected claim to the fiscal agent to receive
the appropriate adjustment within 60 days of the notice. The Surveillance and Utilization Review
Section will follow-up to assure the appropriate adjustment has been completed.
When a recipient is discharged to an independent living arrangement or expires mid-month, PL
is prorated by the Welfare District Office and a notice is sent regarding the PL adjustment. The
nursing facility must refund any remaining balance to the recipient or their legal representative as
required.
If a Medicaid recipient is transferred during a month from any provider entitled to collect PL, the
discharging provider collects the total PL amount up to billed charges. The balance of the
established PL must be transferred with the recipient at the time of transfer. The transferring and
receiving providers are responsible for negotiating the collection of PL.
The facility may not charge recipients for items and services such as diapers, over the counter
drugs (non-legend), combs, hairbrushes, toothbrushes, toothpaste, denture cream, shampoo,
shaving cream, laxatives, shaves, shampooing, skin-care items, bedside tissues, disposable
syringes, nail care, pads, catheters, laundry, durable or disposable medical equipment/supplies,
stipends paid, based on recipient's needs, as part of the active treatment program, or any item
covered by Medicaid in reimbursement to the facility or to other providers of care such as
pharmacies, therapists, etc.
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1603.8C RECIPIENT RESPONSIBILITY
PERSONAL NEEDS
If a recipient so requests, the facility may provide and charge the recipient for such items as
cosmetics, after shave lotion, non-medical equipment, smoking supplies, stationery, postage,
pens, pencils, newspapers, periodicals, alcoholic beverages, personal clothing, professional
haircuts, long-distance telephone calls, dry cleaning of personal clothing, and services in excess
of program limitations. If a recipient is charged for the above, accurate records must be kept
including the recipient's authorization for payment.
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1604 HEARINGS
Please reference Chapter 3100 for Medicaid Hearing process.
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TRANSMITTAL LETTER
September 29, 2015
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: TAMMY MOFFITT, CHIEF OF PROGRAM INTEGRITY
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1700 - THERAPY
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1700 are being proposed to comply
with the transition to International Classification of Disease 10th Revision, Clinical Modification
(ICD 10-CM) as required by the Health Insurance Portability and Accountability Act (HIPAA)
mandate. In order to be in compliance with this mandate, the Division of Health Care Financing
and Policy (DHCFP) is proposing the removal of ICD 9-CM codes and adding verbiage
regarding current diagnosis code(s).
These changes are effective October 1, 2015.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 28/15 MTL 16/11, 04/14
CHAPTER 1700 - THERAPY CHAPTER 1700 - THERAPY
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1703.1 Policy Added the word Registered to Advanced
Practitioner of Nursing to now read Advanced
Practitioner of Registered Nursing (APRN).
1703.2A.7 Covered Services Removed ICD-9-CM reference and added with
“current”
1703.3A.1 Coverage and Removed ICD-9-CM reference and added
Limitations “coverage is limited to non infectious disorders of
the lymphatic channels and hereditary edema of
legs”.
Page 1 of 1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
THERAPY
1700 INTRODUCTION ...........................................................................................................................1
1701 AUTHORITY ..................................................................................................................................1
1702 RESERVED .....................................................................................................................................1
1703 POLICY ..............................................................................................................................……….1
1703.2 COVERAGE AND LIMITATIONS ...............................................................................…............1
1703.2A COVERED SERVICES……………………………………………… ................................……...1
1703.2B PRIOR AUTHORIZATION REQUIREMENTS……………………………………… .………...3
1703.2C NON- COVERED SERVICES ........................................................................................................3
1703.2D PROVIDER RESPONSIBILITY………………………………………......................…………...4
1703.2E RECIPIENT RESPONSIBILITY…………………………………………… .................………...4
1703.3 LYMPHEDEMA THERAPY POLICY……………………..…………………… .......……….…4
1703.3A COVERAGE AND LIMITATIONS ...............................................................................................5
1703.3B PRIOR AUTHORIZATION REQUIREMENTS ............................................................................5
1703.3C NON- COVERED SERVICES ........................................................................................................5
1703.3D PROVIDER RESPONSIBILITIES .................................................................................................6
1703.3E RECIPIENT RESPONSIBILITIES ....................………………………………………………….6
1703.4 RESPIRATORY THERAPY POLICY ........……………………………………………………...6
1703.4A COVERAGE AND LIMITATIONS ...........................................................................................…6
1703.4B PRIOR AUTHORIZATION REQUIREMENTS .......................……………………………….…6
1703.4C NON- COVERED SERVICES ......………………………………………………………………..6
1703.5 MAINTENANCE THERAPY POLICY .....................................................................................…7
1703.5A DEFINITIONS ..............................................……………………………………………………...7
1703.5B COVERAGE AND LIMITATIONS ...............................................................................................7
1703.5C PRIOR AUTHORIZATION REQUIREMENTS ............................................................................8
1703.5D NON- COVERED SERVICES ........................................................................................................9
1704 HEARINGS .....................................................................................................................................1
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1700 INTRODUCTION
Nevada Medicaid reimbursement for outpatient Physical Therapy (PT), Occupational Therapy
(OT), Speech/Communication Therapy (ST) and Respiratory Therapy/Care (RT) is based on the
provision of medically necessary therapy services for an illness or injury resulting in functional
limitations which can respond or improve as a result of the prescribed therapy treatment plan in a
reasonable, predictable period of time. Therapy services must be prescribed by a physician,
physician’s assistant or an Advanced Practitioner of Nursing (APN).
Services related to activities for the general health and welfare of patients, e.g., general exercises
to promote overall fitness and flexibility and activities to provide diversion or general
motivation, do not constitute restorative or rehabilitative therapy services for Medicaid purposes.
Outpatient Physical, Occupational and Speech therapy under 42 Code of Federal Regulations
(CFR) 440.110 is an optional service under State Medicaid Programs.
Therapy services provided by the Home Health Agency (HHA) Program is a mandatory home
health care benefit provided to recipients in his/her residence. See Medicaid Service Manual
(MSM), Chapter 1400 for HHA Therapy coverage.
Nevada Medicaid provides therapy services for most Medicaid-eligible individuals under the age
of 21 as a mandated service, a required component of Early and Periodic Screening, Diagnosis
and Treatment (EPSDT) benefit.
Therapy services provided by an outpatient hospital under 42 CFR 440.20 is a mandatory service
under State Medicaid Programs.
All Medicaid policies and requirements are the same for Nevada Check Up (NCU), with the
exception of those listed in the NCU Manual, Chapter 1000.
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1701 AUTHORITY
1701.1 The citation denoting the amount, duration and scope of services are found in 42 Code of Federal
Regulations (CFR), Part 440, Subpart B and sections 1902(a), 1902(e), 1905(a), 1905(p), 1915,
1920 and 1925 of the Act.
1701.2 The State Legislature grants authority to the relevant professional licensure boards to set the
standards of practice for licensed professionals in the Nevada Revised Statutes (NRS) for the
following Specialists:
a. NRS Chapter 640 Physical Therapy (PT)
b. NRS Chapter 640A Occupational Therapy (OT)
c. NRS Chapter 637B Audiologists and Speech Pathologists
d. NRS Chapter 630 Practice of Respiratory Care
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1702 RESERVED
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1703 POLICY
1703.1 Medicaid will reimburse physical, occupational, speech therapy services rendered to eligible
Medicaid recipients and eligible participants in the Nevada Check Up (NCU) Program. Therapy
must be medically necessary (reference Medicaid Services Manual (MSM) Chapter 100; section
103.1) to restore or ameliorate functional limitations that are the result of an illness or injury
which can respond or improve as a result of the prescribed therapy treatment plan in a
reasonable, predictable period of time. It must be rendered according to the written orders of the
physician, physician’s assistant or an Advanced Practitioner of Registered Nursing (APRN) and
be directly related to the active treatment regimen designed by the therapist and approved by the
professional who wrote the order.
Requests for therapy must specify the functional deficits present and include a detailed
description assessing the measurable degree of interference with muscle and/or joint mobility of
persons having congenital or acquired disabilities, measurable deficits in skills for daily living,
deficits of cognitive and perceptual motor skills and integration of sensory functions. Identify
measurable speech and/or communication deficits through testing, identification, prediction of
normal and abnormal development, disorders and problems, deficiencies concerning the ability
to communicate and sensorimotor functions of a person’s mouth, pharynx and larynx.
A written individualized plan addressing the documented disabilities needs to include the therapy
frequency, modalities and/or therapeutic procedures and goals of the planned treatment. The
primary diagnosis must identify the functional deficit which requires therapeutic intervention for
the related illness or injury diagnosis.
Therapy services provided in the community-based and/or hospital outpatient setting are subject
to the same coverage and therapy limitations.
Services that are provided within the School Based Child Health Services (SBCHS) Program are
covered under MSM Chapter 2800.
1703.2 COVERAGE AND LIMITATIONS
1703.2A COVERED SERVICES
1. Medicaid covers outpatient therapy for individual and/or group therapy services
administered by the professional therapist within the scope of their license for the
following:
a. An individual therapy session may be covered up to a max of one hour when
service is provided to the same recipient by the same therapist on the same day.
b. Group therapy (comprised of no more than two to four individuals) may be
covered up to a max of 90 minutes per session when the service is provided to the
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same recipient by the same therapist on the same day. The leader of the group must be a
Medicaid provider. Documentation in the medical record is expected to be available on
each Medicaid recipient in the group.
2. Therapy services may be ordered under an EPSDT referral by a physician, physician’s
assistant or an APN. The examination must identify a functional limitation to either
acquire or correct/ameliorate a functional deficit/condition based upon medical necessity,
not withstanding in relation to illness or injury which includes realistic and obtainable
therapy goals.
3. The application of a modality that does not require direct (one-on-one) patient contact by
the licensed therapist may be provided by a licensed therapy assistant under the
supervision of the licensed Medicaid therapist.
4. Evaluations administered per therapy discipline within the scope of their license and
meets the following criteria:
a. Initial evaluations.
b. Re-evaluations may be covered when there is a break in service greater than 90
days.
5. To be considered reasonable and medically necessary all of the following conditions must
be met:
a. Meet the definition of medical necessity in MSM Chapter 100.
b. The service must be considered under accepted standards of medical practice to
be a specific and effective treatment for the patient’s functional deficit/condition.
c. The services must be of such a level of complexity and sophistication, or the
condition of the patient must be such, that the services required can be safely and
effectively performed only by a qualified therapist or qualified assistant under the
therapist’s supervision.
d. There must be an expectation that the functional deficit/condition will improve in
a reasonable, and generally predictable, period of time based on the assessment
made by the physician of the patient’s realistic rehabilitative/restorative potential
in consultation with the qualified therapist
e. The amount, frequency, and duration for restorative therapy services must be
appropriate and reasonable based on best practice standards for the illness or
injury being treated.
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6. Cochlear Implant Therapy: Speech and Language Pathologist (SLP) services are covered
under cochlear implantation protocol for speech evaluation and therapy services. Codes
used by speech therapists will require the appropriate therapy modifier. (Refer to MSM
Chapter 2000 for comprehensive cochlear policy.)
7. Therapy for Development Delay disorders may be covered for speech and language, fine
motor and/or gross motor skills development when the functional deficit(s), identified by
current diagnosis code(s) meet all medical necessity requirements.
8. Respiratory therapy is considered reasonable and necessary for the diagnosis and/or
treatment of an individual’s illness or injury when it is:
a. Consistent with the nature and severity of the recipient’s medical symptoms and
diagnosis;
b. Reasonable in terms of modality, amount, frequency and duration of the
treatment; or
c. Generally accepted by the professional community as being safe and effective
treatment for the purpose used.
9. In certain circumstances the specialized knowledge and judgment of a qualified therapist
may be covered when medically necessary to establish a safe and effective home
maintenance therapy program in connection with a specific disease state.
10. SLP evaluations may be covered according to MSM Chapter 1300, Appendix B for a
dedicated speech generating device evaluation and therapeutic services.
1703.2B PRIOR AUTHORIZATION REQUIREMENTS
1. With the exception of initial therapy evaluations and re-evaluations, all therapy services
must be prior authorized by the Quality Improvement Organization (QIO-like) vendor.
2. Initial and re-evaluations do not require prior authorization. Appropriate therapy
evaluations must be accomplished and submitted with prior authorization requests.
3. To obtain prior authorization for therapy services, all coverage and limitations
requirements must be met (Section 1703.2A).
1703.2C NON-COVERED SERVICES
1. Services which do not meet Nevada Medicaid medical necessity requirements.
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2. Personal comfort items, which do not contribute meaningfully to the treatment of an
illness or injury or the functioning of a malformed body part.
3. Services that do not require the performance or supervision of a licensed therapist, even if
they are performed or supervised by a licensed therapist.
4. Wound care requested by a therapist or a hospital based therapy department unless it is
part of a comprehensive therapy treatment plan, (e.g., whirlpool with debridement &
ROM exercises etc.).
5. Reimbursement for licensed nurses when wound care is ordered as a Physical Therapist
(PT) or Occupational Therapist (OT) service.
6. Outpatient therapy provided to patients admitted in an acute or rehabilitation hospital.
7. Reimbursement for an all inclusive Respiratory Rehabilitation Program.
8. Medicaid does not reimburse or require re-evaluations to update other third party payer
plans of progress for outpatient rehabilitation.
1703.2D PROVIDER RESPONSIBILITY
1. Providers must comply with prior authorization requirements set forth in the MSM,
Chapter 100 (Medicaid Program), Section 103.2 (Authorization).
2. The provider will allow, upon request of proper representatives of the Division of Health
Care Financing and Policy (DHCFP), access to all records which pertain to Medicaid
recipients for regular review, audit or utilization review.
3. Once an approved prior authorization request has been received, providers are required to
notify the recipient in a timely manner of the approved service units and service period
dates.
4. For Provider Responsibilities refer to MSM Chapter 100.
1703.2E RECIPIENT RESPONSIBILITY
For Recipient Responsibilities refer to MSM Chapter 100.
1703.3 LYMPHEDEMA THERAPY POLICY
Nevada Medicaid will reimburse a qualified lymphatic therapist (OT or PT) for a combination of
therapy techniques recommended by the American Cancer Society and the National
Lymphedema Network for primary and secondary lymphedema.
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1703.3A COVERAGE AND LIMITATIONS
1. Complete or Combined Decongestive Physiotherapy (CDP) coverage is limited to non
infectious disorders of the lymphatic channels and hereditary edema of legs when all of
the following conditions are met:
a. A treating or consulting practitioner (MD, DO, DPM, APN, and PA), within their
scope of practice, documents a diagnosis of lymphedema due to a low output
cause and specifically orders CDP therapy;
b. The lymphedema causes a limitation of function related to self-care, mobility,
and/or safety;
c. The recipient or recipient caregiver has the ability to understand and provide
home-based CDP;
d. CDP services must be performed by a health care professional who has received
CDP training;
e. The frequency and duration of the services must be necessary and reasonable; and
f. Lymphedema in the affected area is not reversible by exercise or elevation.
2. A CDP course of treatment by either OT or PT is considered a once in a lifetime benefit
consisting of 90 minutes (six units) per session, three to five times per week for a
maximum of three consecutive weeks with prior authorization.
1703.3B PRIOR AUTHORIZATION REQUIREMENTS
1. All lymphedema therapy services must be prior authorized by the QIO-like vendor.
2. To obtain prior authorization for therapy services, all coverage and limitations
requirements must be met (Section 1703.2A).
1703.3C NON-COVERED SERVICES
1. Non-covered services include the following:
a. Therapy limited to exercise or elevation of the affected area;
b. Other services such as skin care and the supplies associated with the compressions
wrapping (they are included in the services and are not paid separately);
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c. OT and PT services performed concurrently for the therapeutic exercise portion of
the session is duplicative (Only one service type per therapeutic session is
allowed); and
d. Therapy designed principally for temporary benefit/without ongoing patient
education.
1703.3D PROVIDER RESPONSIBILITIES
For Provider Responsibilities, refer to MSM Chapter 100.
1703.3E RECIPIENT RESPONSIBILITIES
For Recipient Responsibilities, refer to MSM Chapter 100.
1703.4 RESPIRATORY THERAPY POLICY
1703.4A COVERAGE AND LIMITATIONS
Medicaid will reimburse contracted practitioners of respiratory care for individual services
provided in the outpatient setting. See MSM Chapter 600 for outpatient services general
limitations. The term “respiratory care” includes inhalation and respiratory therapy, diagnostic
testing, control and care of persons with deficiencies and abnormalities associated with the
cardiopulmonary system.
1703.4B PRIOR AUTHORIZATION REQUIREMENTS
1. Respiratory therapy services must be prior authorized by the QIO-like vendor.
2. To obtain prior authorization for respiratory therapy services, all coverage and limitations
requirements must be met. (Section 1703.2A).
1703.4C NON-COVERED SERVICES
1. Reimbursement for an all inclusive Respiratory Rehabilitation Program is not a Medicaid
covered benefit, which may include the following:
a. Psychological monitoring.
b. Therapeutic procedures to increase strength or endurance.
c. Procedures to improved respiratory function, increase strength or endurance of
respiratory muscles.
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MEDICAID SERVICES MANUAL POLICY
1703.5 MAINTENANCE THERAPY POLICY
The DHCFP will reimburse for skilled therapy necessary to develop and safely implement a
maintenance program. During the last visits of a rehabilitative treatment, the clinician may
develop a maintenance program. The goals of a maintenance program are to maintain functional
status at a level consistent with the patient’s physical or mental limitations or to prevent decline
in function. Maintenance therapy is a covered service when the specialized skill, knowledge and
judgment of a therapist are required to design or establish the plan, assure patient safety, train the
patient, family members and/or unskilled personnel and make necessary reevaluations of the
plan.
1703.5A DEFINITIONS
Skilled activities include:
1. Ongoing evaluation of patient performance.
2. Adjustments to the maintenance program that help the patient achieve appropriate
functional goals.
Unskilled activities are:
1. Repetitive tasks or exercises that do not involve any variation in complexity, level of
cueing or progressive independence.
2. Observations of a patient or caregiver’s performance of a learned activity with no
feedback and/or modification of the plan.
1703.5B COVERAGE AND LIMITATIONS
1. Evaluation and development of a maintenance plan without rehabilitative treatment- An
initial evaluation of the extent of the disorder, illness or injury is required. If the treating
skilled therapist determines after the initial evaluation the potential for rehabilitation is
insignificant, prior to discharge an appropriate maintenance program may be established.
Services are covered when the skills of the therapist are required for the development of
the maintenance program and training of the patient or caregivers.
2. Skilled maintenance therapy for safety- Due to the severity or complexity of the therapy
procedures to maintain function, the judgment and skill of a therapist may be necessary to
implement the safe and effective delivery of the maintenance program. When the
patient’s safety is at risk, those reasonable and necessary services will be covered for the
initiation of the maintenance program, even if the skills of a therapist are not ordinarily
needed to carry out the activities performed as part of the maintenance program.
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Subject:
MEDICAID SERVICES MANUAL POLICY
3. Maintenance therapy must meet at least one of the following:
a. Prevent decline of function;
b. Provide interventions, in the case of a chronic or progressive limitation, to
improve the likelihood of independent living and quality of life; or
c. Provide treatment interventions for recipients who are making progress, but not at
a rate comparable to the expectations of restorative care.
4. Maintenance therapy must have expected outcomes that are:
a. Functional;
b. Realistic;
c. Relevant;
d. Transferable to the recipients current or anticipated environment; and
e. Consistent with best practice standards and accepted by the professional
community as being safe and effective treatment for the purpose used.
5. Documentation requirements
a. Plan of care must address a condition for which therapy is an accepted method of
treatment as defined by standards of medical practice.
b. Plan of care must be for a condition that establishes a safe and effective skilled
maintenance program.
6. Management of a maintenance program is covered only when provided by a skilled
therapist (reference MSM Section 1701.2).
1703.5C PRIOR AUTHORIZATION REQUIREMENTS
1. All Maintenance therapy services require prior authorization.
2. Services are limited to ten sessions every three years per each recipient, from the date of
initial visit. EPSDT is exempt from service limitations.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
1703.5D NON-COVERED SERVICES
1. Services which are not authorized.
2. Services, which do not require the management of a skilled therapist for the oversight of
the maintenance program, will no longer be considered reasonable and necessary and are
excluded from coverage.
3. Maintenance program is not safe and/or effective.
October 1, 2015 THERAPY Section 1703 Page 9
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1704
Subject:
MEDICAID SERVICES MANUAL HEARINGS
1704 HEARINGS
1704.1 Please reference Medicaid Services Manual (MSM) Chapter 3100 for hearings procedures.
October 1, 2015 THERAPY Section 1704 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
February 25, 2020
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: CODY L. PHINNEY, DEPUTY ADMINISTRATOR /Cody L. Phinney/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1800 – 1915(i) HCBS STATE PLAN OPTION
ADULT DAY HEALTH CARE AND HABILITATION
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1800 – Adult Day Health Care (ADHC)
are being proposed to encompass all 1915(i) services in one MSM. Changing the name of MSM
1800 – Adult Day Health Care to 1915(i) – Home and Community Based State Plan Option Adult
Day Health Care and Habilitation Services. Addition of federal regulations to become in
compliance and necessary changes to be aligned with concurrent state plan amendment changes.
Throughout, language specific to Adult Day Health Care were replaced with general 1915(i)
requirements and the ADHC service was moved further in the chapter with the addition of two other
1915(i) services combined from MSM 2400.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
rearranging of sections was necessary.
Entities Financially Affected: This proposed change affects all Medicaid-enrolled provides
delivering Adult Day Health Care Services. Those Provider Types (PT) include Adult Day Health
Care services (PT 39) and Habilitation services (PT 55).
Financial Impact on Local Government: There is no anticipated fiscal impact known at this time.
These changes are effective March 1, 2020.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 07/20 MTL 15/12, 18/13
CHAPTER 1800 – 1915(i) HCBS CHAPTER 1800 – ADULT DAY HEALTH
STATE PLAN OPTION ADULT CARE
DAY HEALTH CARE AND
HABILITATION
Page 1 of 5
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
1800 INTRODUCTION Deleted language related to Adult Day Health
Care. Language added regarding “Section
1915(i) of the Social Security Act (SSA) and
eligibility differences between 1915(c)
waivers. Language was updated and/or
reworded for improved readability and clarity.
1801 AUTHORITY Moved language related to ADHC from this
section. Added language regarding Section
1915(i) of the Social Security Act “(1)(a)
through (j).” Added new language for Code of
Federal Regulations (CFR) “42 CFR 441.710;
441.715, 441.720, 441.725 and 441.730.”
1803.1 ADULT DAY HEALTH Renamed to “NEEDS-BASED ELIGIBLITY
CARE (ADHC) CRITERIA.” Added language regarding
SERVICES criteria for needs-based eligibility and whom
conducts the eligibility determinations.
1803.1A(1) COVERAGE AND Replaced “Eligible Recipients” with “Program
LIMITATIONS Eligibility.” Removed reference to
“Physician’s Evaluation.” Removed language
for “Eligible Providers” and moved language
for “Transportation.”
1803.1A(2) COVERED SERVICES Added new section for “Covered Services” and
defined services as “Adult Day Health Care,
Day Habilitation and Residential Habilitation.”
1803.1A(3) NON-COVERED Added new section for “Non-Covered Services”
SERVICES and language was updated and/or reworded for
improved for readability and clarity.
1803.1B PROVIDER Replaced subsection title “Medicaid Contract
RESPONSIBILITIES Requirements” with “Provider Qualifications.”
Added subsections and language related to
“Medicaid Eligibility,” “Direct Marketing” and
“Serious Occurrence Reports.” Language
moved to this section regarding “HIPAA,
Privacy and Confidentiality,” “Service Plan”
and “Training Requirements.” Removed
language related to “Criminal Background
Checks,” “Tuberculosis Testing,” language
was updated and/or reworded for improved
readability and clarity.
Page 2 of 5
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
1803.4 RECIPIENT Added language regarding individuals
RESPONSIBILITIES receiving 1915(i) services are “entitled to
privacy, to be treated with respect and free
from coercion and restraint.” Additional
language included that recipients or a
designated representative must adhere to
certain requirements.
1803.5 ADHC SERVICES Moved language from previous Section 1803.1
to this section.
1803.5A COVERAGE AND Added new section title “COVERAGE AND
LIMITATIONS LIMITATIONS” and included language moved
from Section 1803.1.
1803.5B PROVIDER Added new section “Provider Responsibilities”
RESPONSIBILITIES including subsection for “Provider
Qualifications” for ADHC services. Added
language regarding experience working with
“individuals with a history of aggressive
behavior” under Staffing Requirements.
Deleted language for “Physician Evaluation”
and “Universal Needs Assessment.” Moved
Service Plan to Section 1803.1B. Deleted
language regarding “Plan of Care.” Clarified
language under “Attendance Record and
Nursing Notes.” Deleted language for
“Employee Record Requirements,” “Recipient
Record Requirements,” “Confidentiality and
Release of Recipient Records” and “Provider
Liability.” Moved language for
“NOTIFICATION OF SUSPECTED ABUSE
AND NEGLECT” and “HIPAA, PRIVACY
AND CONFIDENTIALITY.” Deleted
language for “RECIPIENT
RESPONSIBILITIES.”
1803.6 DAY HABILITATION Added new section for “Day Habilitation”
services explaining the services included.
1803.6A COVERAGE AND New section with language that Day
LIMITATIONS Habilitation Services are targeted to
individuals with a Traumatic Brain Injury
(TBI) or Acquired Brain Injury (ABI).
Page 3 of 5
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
1803.7 RESIDENTIAL Added new section for “Residential
HABILITATION Habilitation” services explaining the services
included.
1803.7A COVERAGE AND New section with language for Residential
LIMITATIONS Habilitation Services are targeted to
individuals with a Traumatic Brain Injury
(TBI) or Acquired Brain Injury (ABI).
1803.7B PROVIDER Added new section “Provider Responsibilities”
RESPONSIBILITIES including subsection for “Provider
Qualifications” for Residential Habilitation
services.
1803.8 INTAKE AND Added new section and language for Intake and
ONGOING Ongoing Procedures. New subsections for
PROCOEDURES “Referral” including process for applying for
1915(i) services, subsection “Person-Centered
Plan of Care” detailing the process for
developing a Person-Centered Plan of Care and
subsection “Ongoing Procedures” detailing
process for retaining services.
1803.1E PRIOR Deleted language regarding “Prior
AUTHORIZATION Authorization Procedure” and “Provider
AND BILLING Billing.”
1803.09 TERMINATION OF New section added with language regarding the
1915(i) SERVICES “Termination of 1915(i) Services” including
details on the basis for denials to terminate
from 1915(i) services.
1804 RATES AND Added new section for “Rates and
REIMBURSMENT Reimbursement” and reference to billing guide
and reimbursement code.
1805 QUALITY ASSURANCE Renumbered to 1805 from 1804 and clarified
language. Removed language referring to
ADHC and provider reviews. Updated
language to referral to “Quality Improvement
Strategy outlined in the 1915(i) HCBS State
Plan.” Language was updated and /or reworded
for improved readability and clarify.
1806 TRANSPORTATION Renumbered and moved section from
1803.1A(3) to this new section. Language was
Page 4 of 5
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
updated and /or reworded for improved
readability and clarify.
1807 HEARINGS Renumbered and language was updated and/or
reworded for improved readability and clarity.
Page 5 of 5
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
1915(i) HCBS STATE PLAN OPTION ADULT DAY HEALTH CARE AND HABILITATION
1800 INTRODUCTION ............................................................................................................................ 1
1801 AUTHORITY ................................................................................................................................... 1
1802 RESERVED ...................................................................................................................................... 1
1803 POLICY ............................................................................................................................................ 1
1803.1 NEEDS-BASED ELIGIBILITY CRITERIA ................................................................................... 1
1803.1A COVERAGE AND LIMITATIONS ................................................................................................ 1
1803.1B PROVIDER RESPONSIBILITIES .................................................................................................. 2
1803.2 RECIPIENT RESPONSIBILITIES .................................................................................................. 5
1803.3 ADULT DAY HEALTH CARE (ADHC) SERVICES .................................................................... 6
1803.3A COVERAGE AND LIMITATIONS ................................................................................................ 6
1803.3B PROVIDER RESPONSIBILITIES .................................................................................................. 7
1803.4 DAY HABILITATION .................................................................................................................... 9
1803.4A COVERAGE AND LIMITATIONS ................................................................................................ 9
1803.4B PROVIDER RESPONSIBILITIES .................................................................................................. 9
1803.5 RESIDENTIAL HABILITATION ................................................................................................. 10
1803.5A COVERAGE AND LIMITATIONS .............................................................................................. 10
1803.5B PROVIDER RESPONSIBILITIES ................................................................................................ 10
1803.6 INTAKE AND ONGOING PROCEDURES ................................................................................. 11
1803.7 TERMINATION OF 1915(i) SERVICES ...................................................................................... 14
1804 RATES AND REIMBURSMENT ................................................................................................... 1
1805 QUALITY ASSURANCE ................................................................................................................ 1
1806 TRANSPORTATION ....................................................................................................................... 1
1807 HEARINGS ...................................................................................................................................... 1
MTL 07/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1800
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
1800 INTRODUCTION
Under Section 1915(i) of the Social Security Act (SSA) states can provide Home and Community-
Based Services (HCBS) to individuals who require less than institutional level of care and
therefore would otherwise not be eligible for such services through an 1915(c) HCBS Waiver.
Specifically, Section 1915(i) of the Act allows the Nevada Division of Health Care Financing and
Policy (DHCFP) to provide State Plan HCBS similar to that of a 1915(c) HCBS Waiver using a
needs-based eligibility criterion rather than an institutional level of care criteria. Additionally, a
1915(i) HCBS State Plan Option has no cost neutrality requirement as required under a 1915(c)
HCBS Waiver. This significant distinction affords the Nevada DHCFP the opportunity to offer
HCBS to recipients whose needs are substantial, but are not severe enough to qualify them for
institutional or waiver services.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
March 1, 2020 HEALTH CARE AND HABILITATION Section 1800 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1801
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
1801 AUTHORITY
Section 6086 of the Deficit Reduction Act, added Section 1915(i) to the SSA, allowing states the
option to offer home and community-based services previously only available through a traditional
1915(c) Waiver.
Statutes and Regulations:
• Social Security Act: 1915(i) (1)(a) through (j)
• Code of Federal Regulations (CFR)
o 42 CFR 441.710 State Plan Home and Community-Based Services under Section
1915(i)(1) of the Act
o 42 CFR 441.715 Needs-Based Criteria and Evaluation
o 42 CFR 441.720 Independent Assessment
o 42 CFR 441.725 Person-Centered Service Plan
o 42 CFR 441.730 Provider Qualifications
• Nevada Revised Statutes (NRS) Chapter 449
• Nevada Administrative Code (NAC) Chapter 449
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1802
Subject:
MEDICAID SERVICES MANUAL RESERVED
1802 RESERVED
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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1803 POLICY
1803.1 NEEDS-BASED ELIGIBILITY CRITERIA
The DHCFP 1915(i) Home and Community-Based Services (HCBS) State Plan Option utilizes a
needs-based criteria to evaluate and reevaluate whether an individual is eligible for services. The
criteria considers the individual’s support needs and risk factors.
In order to be eligible, a recipient must need assistance or prompting in at least two Activities of Daily
Living (ADL) which includes bathing, dressing, grooming, toileting, transfer, mobility, eating and
must also have one of the following risk factors:
1. At risk of social isolation due to lack of family or social supports;
2. At risk of a chronic medical condition being exacerbated if not supervised by a registered nurse
(RN); or
3. A history of aggressive behavior if not supervised or if medication is not administered by an
RN.
The DHCFP Health Care Coordinator (HCC) conducts the needs-based eligibility determinations.
1803.1A COVERAGE AND LIMITATIONS
1. PROGRAM ELIGIBILITY
a. An individual must meet and maintain Medicaid eligibility.
b. An individual must be 18 years of age or older.
c. An individual must meet the needs-based eligibility requirements.
d. The individual must reside in the community.
2. COVERED SERVICES
a. Adult Day Health Care.
b. Day habilitation-targeted to individuals with Traumatic Brian Injury (TBI) or
Acquired Brain Injury (ABI).
c. Residential Habilitation-targeted to individuals with TBI or ABI.
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Subject:
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3. NON-COVERED SERVICES
The following services are not covered benefits under the 1915(i) HCBS State Plan Option
and are therefore not reimbursable:
a. Services provided to an individual who is not eligible for Nevada Medicaid.
b. Services rendered to a recipient who no longer meets the needs-based eligibility
criteria.
c. Services rendered to a recipient who is no longer in the community setting but is
institutionalized (hospital, nursing facility, correction or Intermediate Care Facility
(ICF) for intellectual or developmental disabilities).
d. For Adult Day Health Care (ADHC), a recipient who resides in a residential setting
such as group home, assisted living or other type of residential facility where a per
diem rate is paid for 24-hour care is not eligible for ADHC services.
e. For Day Habilitation or Residential Habilitation, services provided to an individual
who does not have a TBI or ABI diagnosis.
1803.1B PROVIDER RESPONSIBILITIES
1. PROVIDER QUALIFICATION
In addition to this chapter, providers must also comply with rules and regulations for
providers as set forth in the MSM Chapter 100. Each 1915(i) service outlines specific
provider qualifications which must be adhered to in order to render that 1915(i) service.
2. MEDICAID ELIGIBLITY
All providers must verify each month continued Medicaid eligibility for each recipient.
This can be accomplished by utilizing the electronic verification system (EVS) or
contacting the eligibility staff at the welfare office hotline. Verification of Medicaid
eligibility is the sole responsibility of the provider.
3. DIRECT MARKETING
Providers shall not engage in any unsolicited direct marketing practices with any current
or potential Medicaid 1915(i) recipient. Providers may not, directly or indirectly, engage
in door-to-door, telephone, direct mail, email or other type of cold-call marketing activities.
All marketing activities must be limited to the general education about the benefits of
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
1915(i) services.
Marketing material must be accurate and not mislead, confuse or defraud current or
potential recipients. Statements considered inaccurate, false or misleading include, but are
not limited to, any assertion or statement that:
a. The recipient must enroll with a specific provider in order to obtain benefits or in
order to not lose benefits; or
b. The provider is endorsed, certified or licensed by the DHCFP.
Additionally, compensation or incentive of any kind which encourage a recipient to transfer
from one provider to another is strictly prohibited.
4. HIPAA, PRIVACY AND CONFIDENTIALITY
Refer to MSM Chapter 100 for information on HIPAA, privacy and confidentiality of
recipient records and other Protected Health Information (PHI).
5. NOTIFICATION OF SUSPECTED ABUSE OR NEGLECT
State law requires that persons employed in certain capacities must make a report to the
appropriate agency immediately, but in no event later than 24 hours after there is reason to
suspect abuse or neglect. The DHCFP expects that all providers be in compliance with the
intent of all applicable laws.
The Aging and Disability Services Division (ADSD) accepts reports of suspected abuse,
neglect or self-neglect, exploitation or isolation. Refer to NRS 200.5091 to 200.50995
regarding elder abuse or neglect.
6. SERIOUS OCCURRENCE REPORTS (SORS)
Providers must report any recipient incidents, or issues regarding the provider/employee’s
ability to deliver services. The 1915(i) Health Care Coordinator must be notified of serious
occurrences within 24 hours of discovery. Providers must complete the web-based Nevada
DHCFP SOR Form; this form is available at http://www.medicaid.nv.gov/ under Provider
Forms. A completed SOR must be made by a provider within five business days and
maintained in the provider’s recipient record.
Serious occurrences involving either the provider, employee or recipient may include, but
are not limited to the following:
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a. Suspected physical or verbal abuse;
b. Unplanned hospitalization;
c. Neglect, exploitation or isolation of the recipient;
d. Theft;
e. Sexual harassment or sexual abuse;
f. Injuries requiring medical intervention;
g. An unsafe working environment;
h. Any event which is reported to Adult Protective Services or law enforcement
agencies;
i. Death of the recipient during the rendering of 1915(i) services;
j. Loss of contact with the recipient for three consecutive scheduled days; or
k. Medication errors resulting in injury, hospitalization, medical treatment or death.
7. SERVICE PLAN
A service plan must be completed within 30 days of the recipient beginning services.
The service plan is developed by the provider using the 1915(i) HCBS Plan of Care (POC)
and includes the identified needs from the POC. The service plan must include the
description of services and amount of time (hourly, daily, weekly).
The provider must also ensure the recipient, or the recipient’s designated representative, is
fully involved in the treatment planning process which is documented on the Service Plan.
The recipient must provide a signature on the Service Plan. If the recipient is unable to
provide a signature due to cognitive and/or physical limitation, this must be clearly
documented in the recipient file. A designated representative may sign for the recipient.
The provider may create a signature page which can encompass a recipient signature for
the Service Plan and any other signature requirements. If the provider uses a signature page,
it must be included in the recipient file.
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8. TRAINING REQUIREMENTS
All employees must participate in a program of general orientation and must receive
training on a regular basis, but not less than 12 hours per year.
General orientation training includes, but is not limited to:
a. policies, procedures and expectations of the provider, including recipient and
provider rights and responsibilities;
b. record keeping and reporting including daily records and attendance records;
c. interpersonal and communication skills and appropriate attitudes for working
effectively with recipients including:
1. understanding care goals,
2. respecting recipient rights and needs.
d. respect for age, cultural and ethnic differences;
e. recognizing family relationships;
f. confidentiality;
g. respecting personal property;
h. ethics in dealing with the recipient, family and other providers;
i. handling conflict and complaints; and
j. other topics as relevant.
NOTE: At least one employee trained to administer first aid and cardiopulmonary
resuscitation (CPR) must be on the premises at all times.
1803.2 RECIPIENT RESPONSIBILITIES
Individuals receiving 1915(i) services are entitled to their privacy, to be treated with respect and be free
from coercion and restraint.
The recipient or the recipient’s designated representative will:
a. Notify the provider(s) and Health Care Coordinator of a change in Medicaid eligibility.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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b. Notify the provider(s) and Health Care Coordinator of changes in medical status, service
needs or changes of status of designated representative.
c. Initial and/or sign the provider service documentation logs as applicable, verifying services
were rendered unless otherwise unable to perform this task due to cognitive and/or physical
limitations.
d. Notify the Health Care Coordinator if services are no longer requested or required.
e. Notify the provider(s) and the Health Care Coordinator of unusual occurrences, complaints
regarding delivery of services or specific staff.
f. Not request a provider(s) to perform services not authorized in the plan of care.
g. Contact the Health Care Coordinator to request a change of provider.
1803.3 ADULT DAY HEALTH CARE (ADHC) SERVICES
Adult Day Health Care services provide assistance with the ADL, medical equipment and
medication administration. Services include health and social services needed to ensure the optimal
functioning of the participant. Services are generally furnished in four or more hours per day on a
regularly scheduled basis, for one or more days per week. The schedule may be modified as
specified in the plan of care.
1803.3A COVERAGE AND LIMITATIONS
Services provided by the appropriate professional staff include the following:
1. nursing services to include assessment, care planning, treatment and medication
administration, evaluation and supervision of direct care staff;
2. nutritional assessment and planning;
3. care coordination to assist the recipient and family to access services needed by the
recipient to maintain or improve their level of functioning or to minimize a decline in the
level of functioning due to the progression of a disease or other condition that may not be
remedied;
4. recipient training in ADL;
5. medical supervision and assistance to assure the recipient’s well-being and that care is
appropriate to meet the recipient’s needs;
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
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Subject:
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6. social and recreational activities to enhance the recipient’s functioning and/or to maintain
or improve the recipient’s quality of life; and
7. meals provided as a part of these services shall not constitute a “full regimen” which is
three meals per day.
NOTE: A recipient who resides in a residential setting such as group home, assisted living or other
type of residential facility where a per diem rate is paid for 24-hour care is not eligible for ADHC
services.
1803.3B PROVIDER RESPONSIBILITIES
In addition to the Provider Responsibilities listed in Section 1803.1B, providers must adhere to the
following requirements specific to rendering ADHC services:
1. PROVIDER QUALIFICATIONS
Each provider of ADHC services must obtain and maintain licensure as required in the
1915(i) State Plan and NAC Chapter 449. Furthermore, providers must adhere to all
requirements of NAC 449 as applicable to licensure.
2. STAFFING REQUIREMENTS
In addition to the requirements of NAC 449, each ADHC center must employ persons with
the necessary education, skills and training to provide the Medicaid required services.
Medical services must be provided by Nevada licensed/certified personnel and staff files
maintained as required by the licensing entity.
a. REGISTERED NURSE (RN)
The center must employ a full time RN to oversee and provide medical services,
particularly for physician ordered services. The RN must have at least one year of
experience with the senior population, individuals with disabilities or individuals
with a history of aggressive behavior. Within the first 30 days of admission, the RN
must develop a Service Plan to indicate the management of each recipient’s care
and treatment. An RN or Licensed Practical Nurse (LPN) under the supervision of
an RN, will administer medications provided to the recipient while in the center’s
care. An RN, or LPN under the supervision of an RN, must be physically on the
premises during the hours in which a Medicaid recipient is in attendance at the
center.
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b. PROGRAM DIRECTOR
The center must employ a full time Program Director who has a minimum of two
or more years of education and/or experience with the senior population,
individuals with disabilities or individuals with a history of aggressive behavior.
The duties of the Program Director will include at a minimum the development of
plans and policies for the center’s operation, recruitment, employment and training
of qualified staff, supervision and appropriate disciplinary action of staff,
maintenance of employee and recipient information and records, maintenance of
the center’s physical plant, housekeeping and nutritional services and the
development and implementation of an evaluation plan of recipient services and
outcomes.
c. DIRECT CARE STAFF
The center must have direct care staff who observes the recipient’s functioning and
provide assistance to the recipient in the skills of daily living. Direct care staff must
have education, experience and necessary qualifications to work with the senior
population, individuals with disabilities or individuals with a history of aggressive
behavior.
The center must also provide for janitorial, housekeeping and activity staff or other
staff as necessary to provide the required services and ensure each recipient’s needs
are met.
d. ATTENDANCE RECORD AND NURSING NOTES
The center must have documentation of daily attendance and notes that indicate the
health component of this service, which is maintained in the recipient’s file. This
documentation is verification of service provision and may be used to review claims
paid.
The delivery of specific services required by the POC and outlined in the Service
Plan must be documented in the daily records. The RN on duty or an LPN under
the supervision of an RN, during the provision of services is responsible for
documenting the recipient’s care.
The recipient and a center staff member must sign each record. If the recipient is
unable to provide a signature due to cognitive and/or physical limitation, this must
be clearly documented in the recipient file. A designated representative may sign
on behalf of the recipient.
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Subject:
MEDICAID SERVICES MANUAL POLICY
The center may create a signature page which can encompass a recipient signature
for the Service Plan and any other signature requirements.
1803.4 DAY HABILITATION
Day Habilitation services are regularly scheduled activities in a non-residential setting, separate
from the recipient’s private residence or other residential living arrangement. Services include
assistance with the acquisition, retention or improvement in self-help, socialization and adaptive
skills that enhance social development and develop skills in performing ADL and community
living.
Activities and environments are designed to foster the acquisition of skills, building positive social
behavior and interpersonal competence, greater independent and personal choice. Services are
identified in the recipient’s POC according to recipient’s need and individual choices. Meals
provided as part of these services shall not constitute a “full nutritional regimen” (three meals per
day).
Day Habilitation services focus on enabling the participant to attain or maintain his or
her maximum potential and shall be coordinated with any needed therapies in the recipient’s
POC such as physical, occupational or speech therapy.
1803.4A COVERAGE AND LIMITATIONS
Day Habilitation services are targeted to individuals who have a TBI or ABI.
1803.4B PROVIDER RESPONSIBILITIES
In addition to the Provider Responsibilities listed in Section 1803.1B, providers must adhere to the
following requirements specific to rendering Day Habilitation services.
1. PROVIDER QUALIFICATIONS
Each provider of Day Habilitation services must obtain and maintain certification as
required in the 1915(i) State Plan.
2. ATTENDANCE RECORDS AND DAILY LOGS
The provider must have documentation of daily attendance and notes that indicate the
health component of this service which is maintained in the recipient’s file. This
documentation is verification of service provision and may be used to review claims
paid. The delivery of specific services required by the POC and outlined in the Service
Plan must be documented in the daily records. The recipient and a center staff member
must sign each record. If the recipient is unable to provide a signature due to cognitive
and/or physical limitation, this must be clearly documented in the recipient file. A
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1803
Subject:
MEDICAID SERVICES MANUAL POLICY
designated representative may sign on behalf of the recipient. The center may create a
signature page which can encompass a recipient signature for the Service Plan and any
other signature requirements.
1803.5 RESIDENTIAL HABILITATION
Residential Habilitation means individually tailored supports that assist with the
acquisition, retention or improvement in skills related to living in the community. These
services include adaptive skill development, assistance with ADL, community inclusion,
adult educational supports, social and leisure skill development that assist the recipient to
reside in the most integrated setting appropriate to his/her needs. Residential habilitation also
includes personal care, protective oversight and supervision.
1803.5A COVERAGE AND LIMITATIONS
Residential Habilitation services are targeted to individuals who have a TBI or ABI.
Additionally, payment for room and board is prohibited.
1803.5B PROVIDER RESPONSIBILITIES
In addition to the Provider Responsibilities listed in Section 1803.1B, providers must adhere to
the following requirements specific to rendering Residential Habilitation services.
1. PROVIDER QUALIFICATIONS
Each provider of Residential Habilitation services must obtain and maintain certification
as required in the 1915(i) State Plan
2. ATTENDANCE RECORDS AND DAILY LOGS
The provider must have documentation of daily attendance and notes that indicate the
health component of this service which is maintained in the recipient’s file. This
documentation is verification of service provision and may be used to review claims paid.
The delivery of specific services required by the POC and outlined in the Service Plan must
be documented in the daily records. The recipient and a center staff member must sign
each record. If the recipient is unable to provide a signature due to cognitive and/or
physical limitation, this must be clearly documented in the recipient file. A designated
representative may sign on behalf of the recipient. The center may create a signature page
which can encompass a recipient signature for the Service Plan and any other signature
requirements.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1803
Subject:
MEDICAID SERVICES MANUAL POLICY
1803.6 INTAKE AND ONGOING PROCEDURES
The following procedures describe how a person can obtain 1915(i) services and the process
required to maintain services.
A. INTAKE PROCEDURES
1. A referral or inquiry for 1915(i) services may be initiated by phone, mail, fax, in
person or by another party on behalf of the potential applicant.
2. If an applicant appears to meet program criteria, a face-to-face visit will be
scheduled to assess needs-based eligibility using the Comprehensive Social Health
Assessment (CSHA) tool. The DHCFP Health Care Coordinator will contact the
applicant/representative within seven working days of the referral date to schedule
a time to conduct an assessment.
a. If an applicant or representative fails to respond to the contact, a notification
letter will be sent to the address on the referral form requesting contact
within 10 business days, otherwise the referral will be closed.
3. If during the face-to-face assessment, the Health Care Coordinator determines the
applicant does not appear to meet the needs-based criteria, a Notice of Decision
will be mailed to the address on file and the applicant will be referred to other
agencies for needed services or assistance not included under the 1915(i) program.
The following reasons will serve as a basis for denial:
a. The applicant is under the age of 18 years.
b. The applicant does not meet the needs-based criteria.
c. The applicant has withdrawn his or her request for 1915(i) services.
d. The applicant’s support system is not adequate to provide a safe
environment during the time when services are not being provided.
e. The DHCFP Health Care Coordinator has lost contact with the applicant.
f. The applicant has moved out of state.
g. Another agency or program will provide the services.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
h. The applicant is in an institution (hospital, nursing facility, correctional or
ICF) and discharge within 30 days is not anticipated.
i. The applicant has chosen a provider that is not an enrolled or qualified
Medicaid provider.
j. There are no enrolled Medicaid providers in the applicant’s area.
B. PERSON-CENTERED PLAN OF CARE
For applicants determined eligible for 1915(i) services, a person-centered POC will be
developed that includes, at a minimum, the individual's needs, goals to meet those needs,
identified risks and services to be provided. The recipient, family, support systems and/or
designated representatives are encouraged to participate in the development of the POC
and to direct the process to the maximum extent possible.
POC DEVELOPMENT PROCESS:
1. The initial POC is developed based on information obtained during the initial
assessment.
2. The POC is person-centered, based on personalized goals, needs, preferences and
developed with participation from the recipient, the family, the designated
representative and anyone else the recipient chooses. The Health Care Coordinator
documents this information in the CSHA narrative.
3. The POC reflects the recipient’s service needs and includes both 1915(i) and non-
1915(i) services in place at the time of POC completion, along with informal
supports that are necessary to address those needs. The Health Care Coordinator is
responsible for identifying services needed.
4. The POC development process considers risk factors, equipment needs, behavioral
status, current support system and unmet service needs (this list is not all inclusive).
The personalized goals are identified by the recipient and documented in the initial
POC and each time the POC is updated with information obtained during the
contacts with the recipient.
5. Facilitation of individual’s choice regarding services and supports and who
provides the services is given during the initial assessment. The recipient must sign
the Statement of Understanding (SOU) acknowledging they had the right to choose
the services and providers.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1803
Subject:
MEDICAID SERVICES MANUAL POLICY
6. The POC identifies the services required, including type, scope, amount, duration
and frequency of services. The service providers are contacted by the Health Care
Coordinator to establish availability and are given a copy of the recipient’s POC
prior to the initiation of services.
7. A recipient will receive a copy of the initial POC which must be signed within 60
calendar days of the date of the SOU. If the recipient signature cannot be
obtained due to extenuating circumstances, services can commence with
verbal approval from the recipient. The Health Care Coordinator document the
recipient’s verbal approval in the CSHA narrative and obtain the signature and
date on the finalized POC.
8. The provider must also sign and date a copy of all new, or a reported change, POCs
within 60 calendar days. The Health Care Coordinator ensures the provider returns
a signed copy of the POC for the case file.
9. The DHCFP Health Care Coordinators are responsible for prior authorizing 1915(i)
services.
C. ONGOING PROCEDURES
1. Once a recipient is authorized for 1915(i) program services, that authorization
period is for 12-months from the date of authorization.
a. Prior to the 12 month authorization period ending, the Health Care
Coordinator will contact the recipient within 30 days to initiate a re-
evaluation. The re-evaluation includes a face-to-face assessment to
determine whether the recipient continues to meet needs-based criteria. The
POC will be updated during the re-evaluation assessment and the
recipient/designated representative will receive a copy of the POC which
must be signed.
2. If a recipient has a change in condition during the authorization period, the Health
Care Coordinator will conduct a visit to update the POC with the
recipient/designated representative. A copy of the signed, updated POC will be
provided to the recipient and service provider.
3. During the provision of services, if a recipient chooses to transfer to a different
service provider, the recipient or representative must contact a DHCFP Health Care
Coordinator to initiate the transfer process including the prior authorization for the
new provider.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1803
Subject:
MEDICAID SERVICES MANUAL POLICY
1803.7 TERMINATION OF 1915(i) SERVICES
Once a recipient is eligible for 1915(i) services, there may be circumstances which result in a
recipient becoming ineligible for services. The following reasons serve as a basis for terminating
a recipient from the 1915(i) HCBS State Plan Option:
A. The recipient is no longer eligible for Medicaid.
B. The recipient no longer meets the 1915(i) needs-based criteria.
C. The recipient/designated representative has requested termination of services.
D. The recipient has failed to cooperate with the DHCFP service providers in establishing
and/or implementing the POC, implementing services or verifying eligibility for services.
(The recipient/designated representative signature is necessary on all required paperwork).
E. The recipient’s support system is not adequate to provide a safe environment during the
time when 1915(i) services are not being provided.
F. The recipient fails to show a continued need for the minimum number of authorized hours
for 1915(i) services.
G. The recipient has moved out of state.
H. The recipient chooses to transfer to a provider that is not an enrolled or qualified Medicaid
provider.
I. The recipient has signed fraudulent documentation on one or more of the providers.
J. Another agency or program will provide the services.
K. The applicant is in an institution (e.g. hospital, nursing facility, correctional, ICF) and
discharge within 30 days is not anticipated.
L. The DHCFP Health Care Coordinator has lost contact with the recipient.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1804
Subject:
MEDICAID SERVICES MANUAL RATES AND REIMBURSMENT
1804 RATES AND REIMBURSMENT
Refer to the provider billing guide for instructions and the reimbursement code table for specific
billing codes.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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MTL 07/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1805
Subject:
MEDICAID SERVICES MANUAL QUALITY ASSURANCE
1805 QUALITY ASSURANCE
The DHCFP will conduct an annual review consisting of the quality measures required in the
Quality Improvement Strategy outlined in the 1915(i) HCBS State Plan.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1806
Subject:
MEDICAID SERVICES MANUAL TRANSPORTATION
1806 TRANSPORTATION
Refer to MSM Chapter 1900 – Transportation Services, for requirements related to Emergency
and Non-Emergency Transportation to Medicaid covered services.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1807
Subject:
MEDICAID SERVICES MANUAL HEARINGS
1807 HEARINGS
Refer to MSM Chapter 3100, for the Medicaid Hearing process.
1915(i) HCBS STATE PLAN OPTION ADULT DAY
March 1, 2020 HEALTH CARE AND HABILITATION Section 1807 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
June 29, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, HIPAA PRIVACY AND CIVIL RIGHTS OFFICER
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1900 – TRANSPORTATION SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1900 – Transportation Services are being proposed
to align with the requirements outlined in the upcoming contract held with the current Non-Emergency
Medical Transportation (NEMT) vendor, Medical Transportation Management, Inc. (MTM). The proposed
changes include renaming the service “Non-Emergency Transportation (NET)” to “Non-Emergency
Medical Transportation (NEMT)” throughout the entire chapter. Transportation Network Companies are
being added as an approved mode of transport under NEMT services. Transportation requests to the
NEMT vendor because of a hospital discharge must now be provided within three hours of the request,
reduced from eight hours. Meal reimbursement and lodging are being added back in as a covered NEMT
benefit. In addition, the exclusion of travel costs for attendants accompanying a recipient to or from a
Residential Treatment Center (RTC) has been removed and will now be a covered benefit. Policy is also
being updated to require recipients to request transportation to non-urgent appointments at least three
days in advance instead of five days, and 14 days for out-of-area appointments instead of 21 days. The
NEMT vendor may bypass the public transportation assessment process for recipients who are considered
to have a high-risk pregnancy or are past their eighth month of pregnancy and should be authorized a
higher mode of transport. Minor revisions are also being proposed to the emergency transportation policy
section for clarity and improved readability.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and re-
arranging of sections was necessary.
Entities Financially Affected: This proposed change affects the following provider types (PT): Air or Ground
(PT 32:); Nevada Medicaid’s NEMT vendor: MTM, Inc.
Financial Impact on Local Government: There is no anticipated financial impact on local government that
is known at this time.
These changes are effective July 1, 2021.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 10/21 MTL 13/20, 18/20, 01/21
MSM 1900 – Transportation Services MSM 1900 – Transportation Services
Page 1 of 4
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1903.1 EMERGENCY MEDICAL Language reworded as “medical condition” instead of
TRANSPORTATION “physical emergency or behavioral health condition.”
Changed “member” to “recipient.” Removed language
regarding “serious physical harm to self or another
person.” Removed language regarding prior
authorization.
1903.1A(2)(c) NON-IMMEDIATE Removed language regarding facility-to-facility transfer
MEDICALLY NECESSARY of SMI adult and examples of non-immediate medically
TRANSPORTS necessary transports provided by NEMT broker.
1903.3 NON-EMERGENCY Removed language regarding specific waiver services.
MEDICAL Reworded language regarding ride scheduling for clarity.
TRANSPORTATION Rearranged order of NEMT modes, added
(NEMT) SERVICES Transportation Network Company and Rail service as an
approved mode.
1903.3A(1) PROGRAM ELIGIBLITY Language regarding ineligible recipients updated for
CRITERIA clarity. Removed language regarding special payment
arrangements with NEMT broker.
1903.3A(2) QUALIFYING Introduction language reworded for improved
CONDITIONS readability. Removed reference to LRIs. Changed bus
tickets to bus passes for consistency.
1903.3A(3) SCHEDULING Added subsection titled “Scheduling Timeframes” to
TIMEFRAMES include language that local, non-urgent trips should be
requested no less than three days in advance of
appointment when possible; with moved language and
new language specifying NEMT that should be
scheduled in advance versus same day services.
Removed repetitive language regarding level of care
exceeding scope of services of an EMT basic and
reference to NCU funds.
1903.3A(4)(b) SPECIAL POPULATIONS Added language that certain Medicaid populations such
as those with an intellectual disability can be allowed to
select their preferred NEMT provider within authorized
mode. Added language that the NEMT vendor may
bypass public transportation for high-risk pregnancy
patients or patients past eighth month of pregnancy and
may authorize higher mode. Language added to specify
Emergency Medical Only (EMO) recipients may utilize
NET only if they are authorized for Dialysis services.
Page 2 of 4
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1903.3A(4)(c) GAS MILEAGE Changed term “volunteer drivers” to “community non-
REIMBURSEMENT professional drivers.” Added family members and
friends as being eligible for regular gas mileage
reimbursement (GMR) and that they may also apply to
become community non-professional driver. Clarified
that recipients who are assigned to public
transportation may also use GMR when cost-effective.
1903.3A(4)(e) OUT-OF-AREA TRAVEL Reduced requirement to request NEMT to out-of-area
appointments from 21 days to 14 days in advance.
Added language for meal and lodging benefit and
removed exclusion.
1903.3A(4)(f) RURAL AREAS Language added to specify authorization and scheduling
for recipients living in rural areas will follow the
standard scheduling process and will not be considered
an out-of-area trip.
1903.3A(4)(g) ATTENDANTS TO Changed title to “Attendants to Recipients.” Changed
RECIPIENTS “escort” to “attendant.” Removed language that meal
reimbursement and lodging expenses are not a covered
benefit for attendant or recipient. Language added
clarifying attendant travel covered only when a
recipient is being transported with the exception of
family members needing to return home. Added
language clarifying meal and lodging not provided for
attendant once recipient is inpatient and that
attendants must share lodging with recipient. Removed
reference to LRI, changed to “other adult.” Language
regarding attendants for PCS recipients reworded for
clarity. Language regarding adoptive/foster parents of
foster/adopted children utilizing NEMT reworded for
improved readability.
1903.3A(4)(h) INPATIENT TREATMENT Language regarding utilizing NEMT for purpose of
FACILITIES therapeutic home passes condensed and reworded for
improved readability. Removed exclusion of
transportation costs not being covered for attendants
accompanying recipients to/from a Residential
Treatment Center (RTC) as it will now be covered.
Language added that NEMT broker must cover
transportation costs of attendant to accompany
recipient if necessary but travel costs for facility staff
not covered when not accompanying a recipient. Added
children in custody of Child Welfare as included out-of-
state residents who may obtain NEMT.
Page 3 of 4
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
1903.3A(5) NON-COVERED SERVICES Added language that oxygen tanks are allowed if
portable and self-administered. Deadheading definition
reworded for clarity. “Escort” changed to “attendant.”
1903.3B ASSESSMENT AND Removed reference to LRI and added language to specify
AUTHORIZATION that family members, friends or community partners
PROCESS may request NEMT for a recipient.
1903.3D(g-j) NEMT RECIPIENT Removed reference to LRI to instead include “individuals
RESPONSIBILITY scheduling on behalf of a recipient.” Reduced
requirement to request NEMT for local non-urgent
appointments from five days to three days and no more
than 60 days prior to travel. Added language to specify
that paratransit rides must be requested from the NEMT
vendor no more than three days in advance of the
recipient’s medical appointment. Language regarding
recipients being ready for scheduled ride reworded for
clarity.
Page 4 of 4
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
TRANSPORTATION SERVICES
1900 INTRODUCTION ............................................................................................................................ 1
1901 AUTHORITY…… ........................................................................................................................... 1
1902 DEFINITIONS….. ............................................................................................................................ 1
1903 POLICY…………. ........................................................................................................................... 1
1903.1 EMERGENCY MEDICAL TRANSPORTATION.......................................................................... 1
1903.1A COVERAGE AND LIMITATIONS ................................................................................................ 1
1903.1B AUTHORIZATION PROCESS ....................................................................................................... 4
1903.1C PROVIDER RESPONSIBILITY...................................................................................................... 4
1903.1D RECIPIENT RESPONSIBILITY ..................................................................................................... 5
1903.2 NON-EMERGENCY SECURE BEHAVIORAL HEALTH TRANSPORTS ................................. 5
1903.2A COVERAGE AND LIMITATIONS ................................................................................................ 5
1903.2B AUTHORIZATION PROCESS ....................................................................................................... 6
1903.2C PROVIDER RESPONSIBILITY...................................................................................................... 6
1903.2D RECIPIENT RESPONSIBILITY ..................................................................................................... 7
1903.3 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) SERVICES ............................. 7
1903.3A COVERAGE AND LIMITATIONS ................................................................................................ 8
1903.3B ASSESSMENT AND AUTHORIZATION PROCESS ................................................................. 17
1903.3C NET BROKER RESPONSIBILITY............................................................................................... 20
1903.3D NEMT RECIPIENT RESPONSIBILITY ....................................................................................... 26
1903.4 GEOGRAPHIC AREA ................................................................................................................... 27
1903.5 SPECIAL REQUIREMENTS FOR SELECTED COVERED NEMT SERVICES....................... 28
1903.6 ENROLLMENT AND DISENROLLMENT REQUIREMENTS AND LIMITATIONS ............. 29
1903.7 INFORMATION REQUIREMENTS ............................................................................................. 29
1904 RESERVED ...................................................................................................................................... 1
1905 NEMT GRIEVANCES, APPEALS AND PROVIDER DISPUTES ............................................... 1
1905.1 NOTICE OF DECISION .................................................................................................................. 1
1905.2 RECIPIENT GRIEVANCES AND PROVIDER DISPUTES ......................... ………………........2
MTL 10/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1900
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
1900 INTRODUCTION
Nevada Medicaid provides emergency and non-emergency medical transportation (NEMT)
services for eligible Medicaid recipients, to access medically necessary covered services. These
transportation services are provided to and from enrolled Medicaid and Managed Care
Organizations (MCOs) providers. Transportation is provided via the most appropriate and cost-
effective mode of transportation.
Emergency Medical Transportation (ground or air) is available to all eligible Nevada Medicaid
and Nevada Check Up (NCU) recipients.
NEMT services ensure that necessary non-ambulance transportation services are available to
recipients to eliminate transportation barriers for recipients to access needed medical services.
NCU recipients are not eligible for NEMT services.
July 1, 2021 TRANSPORTATION Section 1900 Page 1
MTL 13/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1901
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
1901 AUTHORITY
Statutes and Regulations:
• Social Security Act (SSA)
o Title XIX Section 1902(a)(70)
o Title XXI
• Code of Federal Regulations (CFR)
o 42 CFR 431.53 Assurance of transportation.
o 42 CFR 440.170 Any other medical care of remedial care recognized under State
law and specified by the Secretary.
o 45 CFR 92.36 (b-f) Procurement.
• Nevada Revised Statute (NRS)
o Chapter 422 Health Care Financing and Policy
o Chapter 706 Motor Carriers
• Nevada Medicaid State Plan
o Title XIX
Attachment 3.1-A Amount, duration, and scope of medical and remedial care and
services provided to the categorically needy; page 9, 9a – 9h.
Attachment 3.1-D Transportation.
o Title XXI
Section 3.1. Delivery Systems
March 25, 2020 TRANSPORTATION Section 1901 Page 1
MTL 13/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1902
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
1902 DEFINITIONS
Program definitions can be found in the Medicaid Services Manual (MSM) Addendum.
March 25, 2020 TRANSPORTATION Section 1902 Page 1
MTL 10/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1903
Subject:
MEDICAID SERVICES MANUAL POLICY
1903 POLICY
1903.1 EMERGENCY MEDICAL TRANSPORTATION
Emergency transportation is medically necessary to manage a sudden onset of a medical condition,
manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the
absence of immediate medical attention could be expected to result in placing the recipient’s health
in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily
organ or part.
These services are covered in emergent situations in which specially staffed and equipped
ambulance transportation is required to safely manage the recipient’s medical condition. Advanced
Life Support, Basic Life Support, Neonatal Emergency Transport and Air Ambulance services are
covered, depending upon the recipient’s medical needs.
1903.1A COVERAGE AND LIMITATIONS
1. PROGRAM ELIGIBILITY CRITERIA
a. Recipient must be eligible for Nevada Medicaid or NCU services.
b. Emergency medical transportation must be:
1. Medically necessary.
2. In accordance with the recipient’s medical condition and needs.
3. To the nearest, appropriate Medicaid health care provider or appropriate
medical facility.
2. COVERED SERVICES
a. GROUND EMERGENCY MEDICAL TRANSPORT
1. Recipients may be transported from any point of origin to the nearest
hospital, critical access hospital (CAH), dialysis facility or appropriate
specialty clinic (e.g. substance abuse agency, federally qualified health
center, rural health clinic, Indian health program).
2. May also transport skilled nursing facility (SNF) residents when the
required level and type of care for the recipient’s illness or injury cannot be
met by the SNF, to the nearest supplier of medically necessary services. The
hospital or CAH must have available the type of physician specialist needed
to treat the recipient’s condition. However, the utilization of emergency
transportation may not be used in lieu of non-emergency transportation.
July 1, 2021 TRANSPORTATION Section 1903 Page 1
MTL 10/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1903
Subject:
MEDICAID SERVICES MANUAL POLICY
b. AIR AMBULANCE TRANSPORT
Air ambulance transports are only covered to acute care hospitals and may be
provided via:
1. Rotary wing.
2. Fixed wing.
c. NON-IMMEDIATE MEDICALLY NECESSARY TRANSPORTS
When the recipient’s in-transit care needs exceed the capabilities of the Non-
Emergency Medical Transportation (NEMT) broker a non-immediate medically
necessary transport can be provided by an enrolled Nevada Medicaid emergency
transportation provider. Non-immediate medically necessary transports may be
arranged by a hospital, physician, emergency transportation provider or by
DHCFP’s NEMT broker. A prior authorization is not required for these types of
non-immediate medically necessary transports.
The following scenarios are examples of non-immediate medically necessary
transports that would exceed the capabilities of the NEMT broker and can be
provided by an enrolled Nevada Medicaid emergency transportation provider:
1. Transportation of a critically ill recipient to a location where an organ
transplant will occur; or
2. Hospital-to-hospital transfer of a seriously injured or ill recipient when
medically necessary tests or treatment are not available at the dispatching
hospital and the recipient’s care needs during transit requires the attendance
of medical personnel and/or the attachment to medical apparatus that would
be included in a basic life support or advanced life support vehicle
(ambulance).
d. SPECIALTY CARE TRANSPORT
Specialty care transport (SCT) is hospital-to-hospital transportation of a critically
injured or ill recipient by a ground or air ambulance, including the provision of
medically necessary supplies and services, at a level of service beyond the scope of
the emergency medical technician (EMT) - intermediate or paramedic.
3. NON-COVERED SERVICES
The following services are not covered benefits under emergency transportation and are
therefore not reimbursable.
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a. ALL EMERGENCY TRANSPORTATION
1. Response with “Non-transport”.
2. Routine or special supplies, including oxygen, defibrillation, IV’s,
intubation, ECG monitoring or air transport excise taxes (agreed upon rates
between DHCFP and specific transportation providers are all inclusive);
3. Ambulance charges for waiting time, stairs, plane loading;
4. Deadheading (an empty trip to or from a destination); or
5. Transportation of deceased persons.
b. GROUND EMERGENCY MEDICAL TRANSPORT
1. Hospital to the scene of an accident/acute event;
2. Recipient’s residence to the scene of an accident/acute event;
3. Scene of an accident/acute event to recipient’s residence;
4. Scene of an accident/acute event to the scene of an accident/acute event;
and
5. Residence to Residence.
The following types of transports are primarily covered by the NEMT broker and are
therefore considered non-covered emergency transportation services:
1. Residential, domiciliary or custodial facility to a physician’s office;
2. Physician’s office to a residential, domiciliary or custodial facility;
3. Physician’s office to recipient’s residence; and
4. Recipient’s residence to a freestanding ESRD facility (dialysis.)
c. AIR AMBULANCE TRANSPORT
1. Nursing facilities;
2. Physician’s offices; and
3. Recipient’s residence.
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1903.1B AUTHORIZATION PROCESS
Emergency medical transportation does not require prior authorization. No prior or post
authorization is required for emergency medical transportation that originates with a “911” call.
According to the Centers for Medicare and Medicaid Services (CMS), emergency response to
“911” calls normally result in a basic life support (BLS) or advanced life support level 1 (ALS-1)
service level. Emergency medical transportation providers who submit claims coded as advanced
life support level 2 (ALS-2) must present supporting documentation to verify that the transport
included the type of care described in the ALS-2 definition in the MSM chapter addendum.
DHCFP has contracts with MCOs that are contractually obligated to cover air emergency medical
transportation services for their enrollees. For MCO enrolled recipients, claims for air emergency
transportation are to be submitted to the MCO in which the recipient is enrolled. Claims submitted
to the recipient’s MCO must only be for air emergency medical transportation and not ground
emergency medical transportation. Ground emergency medical transportation claims for all
Nevada Medicaid recipients, including MCO enrolled recipients must be submitted to Nevada
Medicaid’s fiscal agent.
Providers are to submit all ground emergency medical transportation claims to Nevada Medicaid’s
fiscal agent. If the recipient is enrolled in Fee-for-Service Medicaid, air emergency transportation
claims may also be submitted to Nevada Medicaid’s fiscal agent.
Specialty care and non-immediate medically necessary transports do not require prior or post
authorization
1903.1C PROVIDER RESPONSIBILITY
Emergency medical transportation providers must submit all appropriate documentation to the
MCOs or to the Nevada Medicaid fiscal agent to enroll as an emergency medical transportation
provider.
The transportation provider is solely responsible for verifying Medicaid eligibility for each
recipient. Whenever possible, this should be done prior to rendering services. Information
concerning eligibility and enrollment verification is located in Chapter 100, of the Nevada
Medicaid Services Manual (MSM).
The provider must ensure the confidentiality of recipient medical records and other information,
such as the health, social, domestic and financial circumstances learned or obtain while providing
services to recipients.
The provider shall not release information related to a recipient without first obtaining the written
consent of the recipient or the recipient’s legally authorized representative, except as required by
law. Providers meeting the definition of a “covered entity” as defined in the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Regulations (45 CFR 160) must comply with
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the applicable Privacy Regulations contained in 45 CFR 160 and 164 for recipient health
information.
DHCFP expects that providers will be in compliance with all laws with regard to the reporting
requirements related to suspected abuse, neglect, or exploitation, as applicable.
1903.1D RECIPIENT RESPONSIBILITY
The recipient or legally authorized representative shall:
1. Provide the emergency transportation provider with a valid Medicaid/NCU Identification
card at the time the service is rendered, if possible, or as soon as possible thereafter.
a. Recipients shall provide the emergency transportation provider with accurate and
current medical information, including diagnosis, attending physician, medication
regime, etc., at the time of request, if possible;
b. Recipients shall notify the emergency transportation provider of all third-party
insurance information, including the name of other third-party insurance, such as
Medicare, Tricare, Workman’s Compensation or any changes in insurance
coverage at the time of service, if possible, or as soon as possible thereafter; and
c. Recipients shall not refuse service of a provider based solely or partly on the
provider’s race, creed, religion, sex, marital status, color, age, disability and/or
national origin.
1903.2 NON-EMERGENCY SECURE BEHAVIORAL HEALTH TRANSPORTS
Non-emergency secure behavioral health transport services means the use of a motor vehicle, other
than an ambulance or other emergency response vehicle, that is specifically designed, equipped
and staffed by an accredited agent to transport a person alleged to be in a mental health crisis or
other behavioral health condition; including individuals placed on a legal hold. Accredited agents
are licensed though the Nevada Division of Public and Behavioral Health. These types of
transports are outside the scope of services provided by the NEMT broker.
1903.2A COVERAGE AND LIMITATIONS
1. PROGRAM ELIGIBILITY AND CRITERIA
a. Recipients must be eligible for Nevada Medicaid or Nevada Check Up (NCU)
services.
b. A recipient must be experiencing a behavioral health crisis as evidenced by extreme
emotional distress that includes but is not limited to an acute episode of mental
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illness and/or suicidal thoughts and/or behavior that may co-occur with substance
use and other disorders.
2. COVERED SERVICES
a. Non-emergency secure behavioral health transport services may be used for the
following transports:
1. Facility-to-facility transport between facilities including but not limited to
hospitals, public or private mental health facilities and medical facilities.
2. Transport to and from a facility arranged by individuals authorized by NRS
433A.160 to arrange for transportation.
3. Transport of an individual seeking voluntary admission pursuant to NRS
433A.140 to a public or private mental health facility.
b. Recipients must be transported to the nearest, appropriate Medicaid health care
provider or appropriate medical facility. Long distance or out-of-state transports
are allowable when medically necessary.
3. LIMITATIONS
a. Family members or other unaccredited agents are not allowed to travel in the secure
vehicle with the recipient.
1903.2B AUTHORIZATION PROCESS
Non-emergency secure behavioral health transports do not require prior authorization. Claims
must be submitted to Nevada Medicaid’s fiscal agent.
1903.2C PROVIDER RESPONSIBILITY
Non-emergency secure behavioral health transport providers must apply to become an accredited
agent. Once accredited, providers must enroll as a Medicaid non-emergency secure behavioral
health transportation provider.
Providers are solely responsible for verifying Medicaid eligibility for each recipient. Whenever
possible, this should be done prior to rendering services. Information concerning eligibility and
enrollment verification is located in Chapter 100, of the Nevada Medicaid Services Manual
(MSM).
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The provider must ensure the confidentiality of the recipient medical records and other
information, such as the health, social, domestic and financial circumstances learned or obtained
while providing services to recipients.
The provider shall not release information related to a recipient without first obtaining the written
consent of the recipient or the recipient’s legally authorized representative, except as required by
law.
DHCFP expects that providers will be in compliance with all laws with regard to the reporting
requirements related to suspected abuse, neglect, or exploitation, as applicable.
1903.2D RECIPIENT RESPONSIBILITY
The recipient or legally authorized representative shall:
1. Provide the non-emergency secure behavioral health transport provider with a valid
Medicaid/NCU Identification card at the time the service is rendered, if possible, or as
soon as possible thereafter.
a. Recipients shall provide the non-emergency secure behavioral health transport
provider with accurate and current medical information, including diagnosis,
attending physician, medication regime, etc., at the time of request, if possible;
b. Recipients shall notify the non-emergency secure behavioral health transport
provider of all third-party insurance information, including the name of other
third-party insurance, such as Medicare, Tricare, Workman’s Compensation, or
any changes in insurance coverage at the time of service, if possible, or as soon
as possible thereafter; and
c. Recipients shall not refuse service of a provider based solely or partly on the
provider’s race, creed, religion, sex, marital status, color, age, disability and/or
national origin.
1903.3 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) SERVICES
DHCFP has contracted with a NEMT broker to provide transportation to medically necessary
Medicaid covered services including certain Waiver services. NEMT never originates from a
“911” call. NEMT is utilized by recipients whose level of care needs do not exceed the scope of
service of an EMT-Basic.
Although ride scheduling will only be accommodated during the NEMT broker’s scheduled
business hours, transportation may be scheduled for confirmed after-hours medical appointments.
After-hours and holiday rides that are not prior authorized may be reimbursed only when the
recipient requires urgent medical care. The transportation must be to an emergency care facility,
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such as an emergency room or after-hours clinic. The transportation broker provides services on a
statewide and out-of-state basis.
All NEMT services, including out-of-state and long distant transport, require prior authorization
by DHCFP’s NEMT broker with the exception of NEMT services provided by Indian Health
Programs. The NEMT broker is required to authorize the least expensive mode of transport
available consistent with the recipient’s medical condition and needs. Examples of NEMT services
may include the following:
A. Ground ambulance;
B. Stretcher accommodating vehicle.
C. Commercial air;
D. Rail service;
E. Bus, local city;
F. Bus, out of town;
G. Paratransit;
H. Private vehicle;
I. Transportation Network Company; and
J. Taxi.
1903.3A COVERAGE AND LIMITATIONS
1. PROGRAM ELIGIBILITY CRITERIA
a. The eligibility functions for Title XIX Medicaid determinations are the
responsibility of the Division of Welfare and Supportive Services (DWSS).
b. The following recipients are ineligible for NEMT services:
1. Title XXI NCU recipients;
2. Title XIX recipients who are Medicaid eligible solely for the purpose of
payment of Medicare premiums, co-insurance, deductibles, or co-pays i.e.,
Qualified Medicare Beneficiaries (QMBs), Specified Low Income
Medicare Beneficiaries (SLMBs), Qualified Individuals (QI-1s); and
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3. Not qualified” non-citizens.
c. Residents of skilled nursing facilities are entitled to NEMT services through the
facility; NEMT costs are included in the nursing facilities’ rate structures.
d. Medicaid recipients are eligible for NEMT services only from the date of
determination forward. No payment will be made for NEMT provided while a
recipient’s Medicaid application is pending. Retroactive eligibility does not apply
to NEMT services.
2. QUALIFYING CONDITIONS
NEMT for Medicaid eligible recipients to and from Medicaid medical providers for
covered medically necessary services is included but not limited to the following terms:
a. The recipient is unable to provide his/her own transportation:
b. Free Transportation: Recipients must use free transportation when it is available.
Free transportation includes, but is not limited to, when the recipient is able and
capable of providing their own transportation or when another individual or an
agency is willing to provide transportation to the recipient to obtain eligible
Medicaid services.
c. Recipients should make every reasonable effort to find day care for their minor
children when they use non-emergency transportation services; however, this may
not always be possible. When appropriate care for a minor child cannot be obtained,
the minor child may accompany the recipient. The broker must provide bus passes
for minor children unless the minor child is able to accompany the recipient at no
additional cost. More than one minor child may accompany the recipient if the
transportation provider is notified in advance.
d. The least expensive form of transportation is utilized in accordance with the
recipient’s medical condition and needs.
3. SCHEDULING TIMEFRAMES
a. SCHEDULED IN ADVANCE: Transportation should be requested from the
NEMT broker no less than three days in advance of the recipient’s medical
appointment for local, non-urgent trips. The following list includes but is not
limited to:
1. Transportation to/from a routine Medicaid-reimbursable medical or dental
appointment; and
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2. Transportation to/from regular standing medical services such as dialysis,
chemotherapy treatments, adult day care, job and day training.
b. SAME DAY SERVICES: Transportation services for a Medicaid eligible recipient
as a result of a hospital discharge must be provided as soon as possible and in any
event is not to exceed a three-hour time span. The following list includes but is not
limited to:
1. The transport from an acute general hospital to an acute psychiatric hospital;
2. Transportation to an urgent care clinic; and
3. Transportation to/from pharmacies for medical necessities.
Medicaid funds may not be used to pay for transportation services that are otherwise
available without charge to both Medicaid and non-Medicaid recipients. In
addition, Medicaid is generally the payor of last resort except for certain Federal
programs such as Title V Maternal and Child Health Block Grant funded services
or special education related health services funded under the Individuals with
Disabilities Education Act (IDEA).
4. COVERED SERVICES
a. PUBLIC TRANSPORTATION
Recipients who do not have free transportation available and live within the service
area of any public transit systems must use public transit where possible and cost-
effective.
1. Recipients are deemed to live within the public transit system service area
when they reside within 3/4 mile of a transit stop. If the recipient qualifies
for public paratransit service and this is available in the area where the
recipient resides, the recipient is deemed to live within the public transit
area, whether or not the recipient resides within 3/4 mile of the transit stop.
2. Recipients who do not have free transportation available must ride fixed-
route public transit unless they reside outside the service area or their
medical appointment is outside of the service area; they are assessed to be
medically unable to board, disembark, or ride buses; or public transit buses
cannot accommodate the recipient’s wheelchair or other medical equipment
that must accompany the recipient in transit.
3. Recipients who reside within the service area of the public transit system
and are assessed to be unable to ride fixed-route buses will be referred for
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assessment for public paratransit services. If qualified for public paratransit
services, the recipient will be required to ride only public paratransit
services, unless traveling to a destination that is outside the public transit
system service area. If traveling outside of the paratransit service area, the
recipient’s transport must be authorized by the NEMT broker.
4. A recipient who requires frequent travel on fixed route transit will be
provided with a multiple ride pass, when this is cost effective.
5. If a recipient who is qualified for public transit level of service requires
transport to a medical appointment that is not accessible by public transit,
the recipient must receive specific authorization for the transport from the
NEMT broker, who will require evidence of medical necessity for the trip
and verify that the recipient is accessing the nearest appropriate provider.
Recipients have freedom of choice when selecting medical providers but
are only eligible for NEMT to access these services if using the nearest
appropriate provider. The nearest health care provider or facility is not
always the most appropriate. The NEMT broker should consider existing
relationships between the recipient and their medical provider, or
appointment availability, when the provider is within a reasonable distance.
DHCFP will assist the NEMT broker in making these decisions. The NEMT
broker will assign the recipient to ride with the least expensive
transportation provider available.
6. Recipients are required to comply with all policy and rules of the public
transit system. Recipients who are suspended from service by public transit
agencies because of recipient misbehavior, persistent no-shows, or failure
to cancel rides in a timely manner are ineligible for other NEMT services
unless they can provide medical evidence that their inability to access
medical care during the suspension period will result in serious exacerbation
of their medical condition or pose an unacceptable risk to their general
health. Recipients who have been suspended will not be provided NEMT
for routine medical appointments. Recipients who have been suspended
must exhaust the public transit system appeal process before being assessed
for another level of service. Recipients who are suspended indefinitely from
public transit will be suspended indefinitely from access to NEMT, except
in cases where they can provide medical evidence that their inability to
access medical care will result in serious exacerbation of their medical
condition or pose an unacceptable risk to their general health.
a. SPECIAL POPULATIONS
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1. Certain Medicaid populations, such as those with an intellectual disability
can be allowed to select their preferred provider within the authorized mode
of transportation. If no specific provider is preferred, the vendor will assign
whichever mode is most appropriate.
2. The NEMT vendor may bypass the public transportation assessment
process for recipients who are considered to have a high-risk pregnancy or
are past their eighth month of pregnancy. These recipients should be
authorized a higher mode of transport.
3. Within Nevada Medicaid eligibility categories there are certain recipients
who are eligible for Emergency Medical Services only which would
typically make them ineligible for NEMT. In certain circumstances,
DHCFP authorizes dialysis services for recipients with an Emergency
Medical aid category. Those recipients with an Emergency Medical aid
category authorized for dialysis services are subsequently also eligible for
NEMT to dialysis appointments only.
c. GAS MILEAGE REIMBURSEMENT
Under certain circumstances, recipients, Legally Responsible Individuals (LRIs),
family members, friends, or community non-professional drivers may receive
mileage reimbursement for driving a recipient to medical services.
1. Recipients, LRIs, family members or friends may be authorized to receive
mileage reimbursement if the recipient is traveling to access medical
services. Compensation will be at the IRS rate for medical/moving mileage
reimbursement. Recipients must have prior authorization from the NEMT
broker for drivers to be eligible for mileage reimbursement
2. Recipients who are assigned to public fixed-route transit or paratransit may
also utilize gas mileage reimbursement if it is determined to be cost-
effective.
3. Community non-professional drivers (private citizens who contract with the
NEMT broker) who are not LRIs, nonprofit organizations, or Indian Health
Programs may receive mileage reimbursement for driving a recipient to
medical services, when this is the least expensive mode of transportation.
Friends, families, and neighbors may apply to become a community non-
professional driver. Reimbursement will be at twice the current IRS per mile
rate for business use, as found on the IRS website at http://www.irs.gov.
Mileage reimbursement is provided to the driver for the vehicle’s miles
actually driven from the point of where a recipient has been picked up and
does not exceed twice the IRS business mileage rate unless a different rate
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is negotiated by the NEMT broker due to limited transportation availability
and cost effectiveness. In cases of disputes over actual mileage, MapQuest
or other geo-mapping software will be used as the final determining factor.
Current Medicaid recipients are not allowed to enroll with the NEMT broker
as a community non-professional driver.
d. INDIAN HEALTH PROGRAMS
Several tribes and/or Indian Health Programs offer ambulance and/or van services
for both emergency and NEMT. Community health representatives (CHR) may
provide NEMT services to recipients who are eligible for NEMT services in private
vehicles to medically necessary covered services and are reimbursed at a per mile
rate that is double the IRS business mileage rate. The Indian Health Programs’
NEMT services do not require prior authorization. All claims for reimbursement by
the Indian Health Programs for non-emergency transportation services are
submitted to the NEMT broker for adjudication and payment.
e. OUT-OF-AREA TRAVEL
Recipients may be eligible to receive NEMT for out-of-area, out-of-state or airline
travel if certain conditions are met. A medical appointment is considered to be out-
of-area when the facility is located 101 or more miles from the recipient’s home.
1. Recipients must receive prior authorization for out-of-area medical services
from DHCFP’s fiscal agent or their MCO prior to requesting authorization
for transportation. The NEMT broker may also require a distance
verification form to be completed by the referring physician.
2. Recipients must request authorization for out-of-area and commercial
airline a minimum of 14 days prior to the travel date.
a. Exceptions to the 14-calendar day requirement may be granted if the
recipient has a medical necessity to travel and could not have known
14 days in advance, as in the case of a donor organ becoming
available for a transplant surgery that must occur out of the area.
b. Exceptions to the 14-day requirement will be granted for recipients
who are discharged to or from an out-of-area acute-care facility; an
out-of-state nursing facility; or otherwise detained in a juvenile
detention facility.
c. Other exceptions may be granted from time to time if they are in the
best financial interest of the State.
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d. Recipients are required to travel by the least expensive mode of
transportation available that will accommodate their medical
requirements.
e. Meal and lodging shall only be authorized for out-of-area trips when
an overnight stay is necessary due to the timing of the recipient’s
medical appointment or scheduling of the recipient’s commercial
travel such as flight, train, or bus. Recipients must utilize free
lodging when available, such as the Ronald McDonald House, or the
NEMT broker will arrange for lodging. Meal reimbursement shall
be paid in accordance with General Services Administration (GSA)
rates.
3. Recipients must submit their trip log for gas mileage or meal reimbursement
within 60 calendar days after completing the out-of-area trip.
4. Recipients who have recurring requirements to receive out-of-area trips for
a single treatment or multiple treatments for the same diagnoses, may have
multiple trips a month authorized but no more than five trips may be
authorized at one time.
f. RURAL AREAS
Authorization and scheduling requirements for trips originating in certain rural
counties will follow the standard process for scheduling and will not be considered
an out-of-area trip for recipients residing in rural areas of Nevada.
g. ATTENDANTS TO RECIPIENTS
1. The NEMT broker must allow at least one attendant, who must be a
minimum of 18 years of age (or any age if the attendant is the parent of a
minor child) to accompany a recipient or group of recipients when attendant
services are determined medically necessary or for those recipients who are
minor children. A Medicaid recipient who is physically disabled or
developmentally disabled may be authorized to be accompanied by an
attendant(s) during the assessment to access NEMT services. A person
under the age of 18 must be accompanied by one attendant unless that
person is married, legally emancipated, or obtaining family planning
services and/or family planning products. If a parent or guardian with a
physical or mental disability is taking their child to a medical appointment,
a second attendant may be authorized to assist the parent in accompanying
the child when it is deemed medically necessary.
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2. During the NEMT assessment, the assessor or a physician’s statement will
determine whether the recipient requires an attendant(s) and specify the
circumstances under which an attendant(s) may accompany the recipient
while utilizing NEMT services. Multiple attendants may be authorized to
accompany a recipient when determined medically necessary.
3. The NEMT broker will cover the transportation costs of an attendant(s) to
accompany the recipient, if medically necessary. Attendant travel is a
covered expense only when a recipient is being transported with the
exception of family members needing to return to their residence. If during
travel, a recipient requires an overnight stay, one room is reserved for the
recipient and the attendant is expected to share lodging in order to care for
the recipient. When a recipient is admitted to an inpatient facility, the
recipient would no longer be in travel status, therefore meals and lodging
would not be provided for the attendant.
4. NEMT services may not be authorized for minor children unless a parent
(regardless of the parent’s age) or another adult accompanies the child.
Exceptions include but are not limited to:
a. A minor child transported for the purpose of obtaining family
planning services and/or products.
b. If a delay of a minor child transport from one facility to another for
treatment is medically detrimental, and a parent or LRI is not
available, a Consent and Release of Liability form must always be
signed by the facility case worker prior to the transport.
c. Other specific exceptions may be made on a case-by-case basis by
DHCFP.
5. In addition, and pursuant to Nevada MSM Chapter 3500, an attendant(s)
may be authorized to accompany a recipient who requires personal care
services (PCS) in route to, or at, a destination to obtain Nevada Medicaid
covered, medically necessary services. An attendant(s) may be a parent or
legal guardian, caretaker, LRI, friend or a personal care attendant (PCA)
who accompanies the recipient.
6. Pursuant to 42 CFR 440.250 and the Nevada State Plan, an adoptive parent
under the auspices of an Adoption Assistance Program (AAP) agreement or
a foster parent of a program eligible child may utilize NEMT services for
the foster/adopted child to obtain Medicaid covered services. The agency
that maintains custody of a foster child or the adoptive/foster parents must
coordinate medical transportation services through the NEMT broker.
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h. INPATIENT TREATMENT FACILITIES
1. Transportation services for the parent(s) of a newborn less than 12 months
of age receiving treatment on an inpatient basis in a facility are covered.
2. NEMT services may be authorized for a recipient residing in an inpatient
treatment facility to allow the recipient to attend a therapeutic home visit,
in-state or out-of-state, when such visits are part of the recipient’s treatment
plan. It is the responsibility of the inpatient treatment facility to obtain
transportation for eligible recipients for all therapeutic home visits by
calling the NEMT broker. The NEMT broker covers the transportation costs
of an attendant(s) when accompanying the recipient, if medically necessary
as referenced in 1903.3A(4)(g). Attendant travel costs for facility staff are
not covered when not accompanying a recipient. NEMT services are not
available for family members to visit a recipient residing in an inpatient
treatment facility. The NEMT broker may authorize transportation for
therapeutic home visits in accordance with Nevada MSM Chapter 400 and
MSM Chapter 1600.
3. Program recipients who live out-of-state may obtain NEMT services
similarly to those eligible recipients who reside within the State of Nevada.
Such out-of-state recipients may include children in the custody of Child
Welfare, foster children, children placed in an adoptive home under the
auspices of an Adoption Assistance Program (AAP) agreement, or children
in residential treatment centers (RTC). Authorization of NETNEMT
services for eligible recipients residing out-of-state is the same as for those
eligible recipients who reside within Nevada
5. NON-COVERED SERVICES
The following are non-covered NEMT services:
a. When one or more eligible recipients make the same trip in a private vehicle or van,
reimbursement is made for only one recipient;
b. Transportation to or from any non-covered service, except for exclusion due to
Third Party Liability (TPL) coverage under the Medicaid program;
c. Travel to visit a recipient in an inpatient treatment facility, except in the case of a
parent or parents visiting a newborn that is in a facility
d. Transportation between hospitals for outpatient or inpatient care or services (e.g.,
MRI, CAT scan, etc.); exceptions may be granted when services to treat the
recipient's condition are not available at the originating hospital and/or are not part
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of the all-inclusive prospective rate or the recipient is transferring to a hospital
closer to home following an out-of-area hospital stay;
e. "Deadheading," this refers to an empty trip to or from a destination;
f. The cost of renting an automobile for private vehicle transport;
g. A non-transport charge for a recipient who did not show up for their scheduled ride;
h. Wages or salary for attendant(s);
i. Charges for waiting time, stairs, plane loading;
j. Routine or special supplies including oxygen unless oxygen tanks are portable and
self-administered. Special services such as: defibrillation; IVs; intubation or ECG
monitoring. Recipients requiring any type of medical care, medical supervision,
physical monitoring, attachment to medical intravenous therapy, EMT-
intermediate or paramedic services, etc. during transport are not eligible for non-
emergency transportation.
k. Transportation of a recipient in a personal care attendant’s private vehicle is not a
reimbursable service;
l. Transportation from a nursing facility to a medical appointment; and
m. Basic life support (BLS), and advanced life support (ALS) transports.
1903.3B ASSESSMENT AND AUTHORIZATION PROCESS
With the exception of services provided by Indian Health Programs (see Section 1903.3A(3)(c)),
the need for NEMT services must be assessed as specified in this section and authorized by the
NEMT broker.
The goal of the combined assessment and authorization processes is to determine the required level
of non-emergency transportation services.
1. Recipients wishing to use NEMT services will be assessed for the proper level of
transportation prior to being authorized access to NEMT.
a. Lower levels of ground transportation, i.e. mileage reimbursement or fixed-route
public bus, will be assessed and authorized by the NEMT broker.
b. If the request is for a greater level of ground transportation than mileage
reimbursement or fixed-route public bus, the NEMT broker uses due diligence in
questioning the recipient to see if a lower-level transport is acceptable and sufficient
for their medical condition. If the recipient agrees to the lower level, then that
transport will be authorized by the NEMT broker.
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c. If the recipient does not believe the lower level transport is appropriate or
acceptable, then they will be referred to the public paratransit services agency for a
level of service needs evaluation. If the recipient resides outside the parameter of a
paratransit agency, the NEMT broker will provide transportation to and from the
recipient’s primary care physician (PCP) at the level of service requested. The PCP
will provide documentation and/or a NEMT broker form that will identify the
correct level of transportation service based on the recipient’s medical needs.
d. If the recipient has been authorized for NEMT, and has been assessed by the public
paratransit service, the Regional Transportation Commission (RTC) has 21 days to
notify the recipient of the results of the assessment. Until the assessment has been
reviewed and submitted to the recipient, the transportation broker will continue to
provide transportation at the level of service requested by the recipient. In the event
the recipient has been denied the use of paratransit services and is now receiving a
lower level of transportation service than requested, the recipient must inform the
transportation broker of their dissatisfaction, if applicable, with the level of service
assigned. The transportation broker will then review the assessment as well as the
recipient’s medical documents and determine if the recipient is eligible for the
broker’s paratransit or curb-to-curb services. The transportation broker will notify
the recipient of their determination within 48 hours of review. If the decision
negatively impacts the recipient, the transportation broker will also provide the
recipient with a Notice of Decision (NOD).
e. If the recipient requests a hearing, until the higher level of transportation is either
approved or denied by the State Fair Hearing process, the NEMT broker will
provide rides at the requested level of service.
f. The NEMT broker will maintain a list of all assessment referrals sent to the
paratransit service agencies.
g. If the NEMT broker believes that a recipient is receiving unnecessarily expensive
transportation, then the broker is expected to conduct a reassessment to determine
the correct level of transportation needed.
h. When recipients contact the NEMT broker requesting a ride, they will be screened
for prior authorization and will be permitted to ride within the level of service
authorized.
i. If the recipient requires NEMT prior to the time of the assessment including a ride
to the paratransit service agency for an assessment, the NEMT broker will authorize
the rides at the level requested.
1. Recipients residing within the service area of a public transit systems where
paratransit services are available, who require transportation above the level
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of fixed route, must receive an assessment disqualifying them from public
paratransit prior to being authorized for a higher level of service.
2. Once a recipient has been referred to the paratransit service agency for an
assessment, the recipient has five days in which to contact the paratransit
service agency to schedule an assessment. The paratransit service agency
has up to 45 days to complete an assessment. The level of service requested
by the recipient will be provided until an assessment has been completed.
Failure to complete the paratransit assessment within 45 days will result in
the recipient being placed on a fixed route bus service for all NEMT unless
the recipient can show in writing, that paratransit service agency was unable
to complete an assessment within the 45 days.
j. Recipients may be authorized for mileage reimbursement or private commercial
transportation in addition to use of public transit if they must travel outside the
public transit system service area to access the nearest appropriate provider.
k. For authorization other than the public transit, the NEMT broker will supply the
name of the provider, the provider’s location, and the frequency of the transit that
the recipient is permitted, to the transportation company.
l. Recipients who submit evidence from an assessment showing they do not qualify
for public paratransit may be qualified for a higher level of service.
m. The NEMT broker will provide written documentation to the recipient regarding
the recipient’s authorization status and level of service.
2. If the recipient provides evidence that they are unable to ride at the level of service assigned
due to a significant change in condition or circumstance, the recipient will be re-evaluated
by the broker who may direct the recipient to the RTC for an assessment for paratransit
services.
a. Recipients contesting their assessed level of service will be authorized NEMT at
the requested level, pending an evaluation.
b. Recipients are required to ride the least expensive transport within a level of service
and will not be placed on a higher cost transport because of personal preference or
convenience.
c. Recipients may be reassessed for a greater level of service if they no longer have
access to the assigned transportation level of service.
3. Family members, friends, or community partners (hospitals, medical facilities, social
workers, case managers, tribal entities, etc.) may request transportation on behalf of an
eligible recipient, from the NEMT broker.
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4. The NEMT broker must have in effect mechanisms to ensure consistent application of
review criteria for authorization decisions and consult with the requesting provider and/or
DHCFP when appropriate.
5. The NEMT broker and DHCFP must provide standard authorization decisions within
reasonable time frames. If the broker determines, or a provider indicates, that the standard
service authorization timeframe could seriously jeopardize the recipient’s condition or
circumstance, the NEMT broker must make an expedited authorization decision and
provide notice as expeditiously as the recipient’s health condition requires.
1903.3C NEMT BROKER RESPONSIBILITY
1. The NEMT broker provides all or most services ancillary to transporting Medicaid
recipients, but provides transportation only through subcontracting or non-contract
arrangements with third parties.
a. The NEMT broker shall not hold ownership in any NEMT provider with whom the
broker sub-contracts or arranges NEMT through, as a non-contractual relationship.
b. The broker will submit all subcontracts or other documentation pertaining to the
terms and conditions for the provision of NEMT services by third parties to DHCFP
for approval.
c. The broker shall advise DHCFP in writing of all financial relationships and
transactions between itself and NEMT providers (for instance, loans, grants, etc.)
that are not included in the NEMT instrument, specifying the nature of the
relationship and the terms and conditions governing them. Such relationships and
transactions are not permitted without written approval of DHCFP administrator.
d. The NEMT broker will work cooperatively with DHCFP and the Regional
Transportation Commission for handling ride cancellations.
2. Commercial Transportation Vendors: The NEMT broker may subcontract with various
private vendors to provide transportation to Medicaid recipients.
a. The NEMT broker shall directly facilitate transportation for recipients requiring
bus passes, public paratransit and mileage reimbursement. Recipients who request
higher levels of service will need to be assessed for the level of service by the
NEMT broker, and if necessary, the appropriate paratransit services agency.
b. Recipients may not be assigned to ride with a commercial vendor if they have been
prior authorized for a lesser level of service, unless the authorized level of service
does not provide access to necessary medical care that complies fully with
Medicaid’s NEMT policy. For instance, if a recipient is authorized for fixed-route
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bus services, but the bus does not pass within 3/4 of a mile of the provider’s office,
then the NEMT broker may authorize a higher level of transportation.
c. Recipients must be assigned to the least expensive commercial vendor who
provides the level of service and geographic access required.
d. Where there is public transit available in a rural county, and that provider is capable
of offering the level of service required for the recipient, commercial vendors may
not be used for the convenience of the recipient or the NEMT broker.
3. Using monthly enrollment downloads from DHCFP or systems maintained by DHCFP’s
fiscal agent, the NEMT broker is solely responsible for verifying program eligibility for
each recipient prior to authorizing and scheduling the NEMT service. The NEMT broker
must also verify the existence of an appointment and that the appointment is a Medicaid
covered service, which may require contacting the health care provider, DHCFP’s fiscal
agent, or the contracted MCO, before authorizing transportation.
4. Neither the NEMT broker nor its providers shall release information related to a recipient
without the written consent of the recipient or the recipient’s legal or authorized
representative, except as required by law or except to verify medical appointments in
accordance with policy. The NEMT broker and any of its providers meeting the definition
of a “covered entity” as defined in the HIPAA Privacy Regulations (45 CFR 164) must
comply with the applicable Privacy Regulations contained in 45 CFR 160 and 164 for
recipient health information.
5. DHCFP expects that the NEMT broker and its provider network will be in compliance with
all laws with regard to the reporting requirements related to suspected abuse, neglect, or
exploitation, as applicable, in accordance with NRS 200.508 and 200.509.1.
Pursuant to 42 CFR 438.100(c), the NEMT broker shall ensure that each recipient is free
to exercise his or her rights and that by the exercise of those rights, no adverse effect will
result in the way the NEMT broker treats the recipient.
6. Recipients have freedom of choice when selecting medical providers but are only eligible
for NEMT to access these services if using the nearest appropriate provider (taking existing
relationships between the providers and recipients into account as well as access to care)
according to section 1903.3A(3)(a)(5)of this chapter.
1. The NEMT broker will be responsible for verifying that the recipient is using the
nearest appropriate Medicaid provider for the applicable services.
2. The NEMT broker will develop written procedures, approved by DHCFP for
verifying that the nearest appropriate Medicaid provider is being used.
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3. The procedures shall include an exception procedure that specifies the conditions
under which the recipient may access a provider other than the nearest, if exception
to the requirement might, in some cases, be appropriate.
4. DHCFP will provide the NEMT broker with a quarterly list of Medicaid providers
and their addresses, including FFS providers and providers within each MCO’s
network.
5. DHCFP will periodically review rides to verify that the NEMT broker has
transported to the nearest appropriate provider.
6. When DHCFP determines that a recipient has employed NEMT to access a provider
other than the provider located nearest to the recipient’s residence and there is no
justification documented, the NEMT broker may be required to refund the
capitation payment for that recipient for all months that the recipient accessed a
geographically inappropriate provider.
7. A transportation provider must wait at least fifteen (15) minutes after the scheduled pick-
up time before “no-showing” the recipient at the pick-up location. The NEMT broker or
contracted transportation providers shall not charge recipients for transportation services
or for no shows.
8. Recipients who are repeated no-shows or fail to cancel in a timely manner for rides
provided by its commercial vendors may be subject to suspensions of services. Recipients
who receive a suspension will have the right to a State Fair Hearing.
9. Access to transportation services shall be at least comparable to transportation resources
available to the general public. Capacity shall include all of the modes of transportation
listed in Section 1904 of this chapter.
10. The NEMT broker shall ensure all drivers of vehicles transporting program recipients meet
the following requirements:
a. All drivers, at all times during their employment, shall be at least 18 years of age
and have a current valid driver’s license from the State of Nevada to operate the
transportation vehicle to which they are assigned.
b. Drivers shall have no more than one chargeable accident and two moving violations
in the last three years. Drivers shall not have had their driver’s license, commercial
or other, suspended or revoked in the previous five years. Drivers shall not have
any prior convictions for substance abuse, sexual abuse or crime of violence.
Approval of any such driver who has been convicted of a felony shall be obtained
from DHCFP before employment by the vendor.
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c. All drivers shall be courteous, patient and helpful to all passengers and be neat and
clean in appearance.
d. No driver or attendant shall use alcohol, narcotics, illegal drugs or drugs that impair
ability to perform while on duty and no driver shall abuse alcohol or drugs at any
time. The transportation provider shall not use drivers who are known abusers of
alcohol or known consumers of narcotics or drugs/medications that would endanger
the safety of recipients.
e. All drivers and attendants shall wear or have visible, easily readable proper
organization identification.
f. At no time shall drivers or attendants smoke while in the vehicle, while involved in
recipient assistance, or in the presence of any recipient.
g. Drivers shall not wear any type of headphones or use cell phones, except for
dispatch purposes, at any time while on duty. Drivers shall not use cell phones while
operating vehicles.
h. Drivers shall assist passengers in the process of being seated and confirm that all
seat belts are fastened properly, and that wheelchairs and wheelchair passengers are
properly secured.
i. Drivers shall provide necessary assistance, support, and oral directions to
passengers. Such assistance shall include assistance with recipients of limited
mobility and movement, including the storage of mobility aids and wheelchairs.
j. The NEMT broker shall provide, or ensure that its subcontractors provide,
classroom and behind-the-wheel training for all drivers within 30 days of beginning
service under this agreement. Driver training shall, at a minimum, include defensive
driving techniques, wheelchair securement and lift operation, cultural and disability
sensitivity training, passenger assistance techniques, first aid, and general customer
service. The training curriculum is subject to DHCFP’s approval.
11. The NEMT broker shall ensure that all transportation providers maintain all vehicles
adequately to meet the requirements of the contract. Vehicles and all components shall
comply with or exceed State, Federal, and the manufacturer’s safety, mechanical, and
maintenance standards for the vehicles. Vehicles shall comply with the Americans with
Disabilities Act (ADA) regulations. All vehicles shall meet the following requirements:
a. The transportation provider shall provide and use a two-way communication
system linking all vehicles used in delivering the services under the contract with
the transportation provider’s major place of business. Pagers are not an acceptable
substitute.
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b. All vehicles shall be equipped with adequate heating and air-conditioning.
c. All vehicles shall have functioning, clean and accessible seat belts for each
passenger seat position when required by law. Each vehicle shall utilize child safety
seats when transporting children as prescribed by NRS 484B.157.
d. All vehicles shall have a functioning speedometer and odometer.
e. All vehicles shall have two exterior side view mirrors, one on each side of the
vehicle.
f. All vehicles shall be equipped with an interior mirror for monitoring the passenger
compartment.
g. The interior and exterior of the vehicle shall be clean and the exterior free of broken
mirrors or windows, excessive grime, major dents or paint damage that detract from
the overall appearance of the vehicles.
h. The vehicle shall have passenger compartments that are clean, free from torn
upholstery, floor, or ceiling covering; damaged or broken seats; protruding sharp
edges; and be free of dirt, oil, grease or litter.
i. All vehicles shall have the transportation provider’s name, vehicle number, and the
NEMT broker’s toll free and local phone number prominently placed within the
interior of each vehicle. This information and the complaint procedures shall be
available in written form in each vehicle for distribution to recipients on request.
j. Smoking is prohibited in all vehicles while transporting program recipients. All
vehicles shall have the following signs posted in all vehicle interiors, easily visible
to the passengers:
“NO SMOKING”“ALL PASSENGERS MUST USE SEAT BELTS”
k. All vehicles shall include a vehicle information packet containing vehicle
registration, insurance card and accident procedures and forms.
l. All vehicles shall be provided with a fully equipped first aid kit.
m. Each vehicle shall contain a current map of the applicable state(s) with sufficient
detail to locate recipients and medical providers.
n. All vehicles shall have a minimum of $1,500,000 combined single limit insurance
coverage for vehicles at all times during the contract period in accordance with
State regulations and contract requirements (NAC 706.191). If NAC 706.191
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minimum insurance coverage is amended, the amount that is greater of either the
Code or this Chapter will be the mandated amount of coverage.
o. Any vehicle or driver found out of compliance with the contract requirements, or
any State or Federal regulations shall be removed from service immediately until
the NEMT broker verifies correction of deficiencies. Any deficiencies and actions
taken shall be documented and become a part of the vehicle’s and the driver’s
permanent records.
p. The NEMT broker shall develop and implement an annual inspection process in
addition to the applicable State vehicle inspection requirements to verify that
vehicles used by subcontracted transportation providers meet the above
requirements and that safety and passenger comfort features are in good working
order (e.g., brakes, tire, tread, signals, horn, seat belts, air conditioning/heating,
etc.).
12. The NEMT broker shall ensure adequate oversight of subcontracted transportation
providers and ensure that providers comply with all applicable State and Federal laws,
regulations and permit requirements. This duty includes, but is not limited to verification
that each provider maintains at all times:
a. Insurance which complies with the standards at 49 CFR 387 subpart B, NAC
§191(1-3), and which provides for notice of the status of the policy to DHCFP upon
expiration, termination, or at any time requested by DHCFP;
b. An alcohol and substance abuse testing program which complies with the standards
of 49 CFR Part 382;
c. Criminal background checks conducted periodically that assure the criteria of MSM
Chapter 100 are met;
d. Signage on all vehicles identifying those operating under any exemption from
Nevada Transportation Authority (NTA) regulation;
e. Documentation in each vehicle of any exemption from NTA regulation; and
f. Current provider agreements with Nevada Medicaid.
As a contracted agent of the Director of the Department of Health and Human
Services (DHHS), subject to the requirements of NRS § 422.2705 and NRS §
706.745 the NEMT broker may utilize the services of motor carriers that are exempt
from certain certification requirements of the NTA of the Department of Business
and Industry. Prior to exercising this option, the NEMT broker shall, with the
assistance of the NTA, establish and utilize an inspection program designed to
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ensure that vehicles used by these motor carriers, and their operations, are safe. The
NEMT broker shall also require these same motor carriers to submit proof of a
liability insurance policy, certificate of insurance or surety which is substantially
equivalent in form and is in the same amount or in a greater amount than the policy,
certificate or surety required by the Department of Motor Vehicles (DMV) pursuant
to NRS 706.291 for a similar situated motor carrier. The NEMT broker shall certify
the transportation providers meet insurance requirements, vehicle safety standards,
and driver background and drug tests cited in this chapter before a letter of
exemption will be issued by DHCFP for that transportation provider.
13. The NEMT broker is encouraged and expected to use recipient vouchers and/or volunteer
programs to provide the most cost-efficient transportation service to the recipient if such
transportation is appropriate to meet the needs of the recipient. The broker shall verify and
document that vehicles and drivers used in reimbursement and volunteer programs comply
with appropriate State operating requirements, driver’s licensure, vehicle registration and
insurance coverage requirements.
14. The NEMT broker will be available as a resource to DHCFP’s fiscal agent or contracted
MCO when medically necessary covered services must be provided outside a recipient’s
community. The NEMT broker will advise the fiscal agent or contracted MCO regarding
such factors as distance and transportation availability.
15. The NEMT broker must submit claims for service outside of capitation to DHCFP utilizing
the nationally recognized International Classification of Diseases (ICD) and current
electronic data interchange (EDI) standards, as approved by the Centers of Medicare and
Medicaid Services (CMS).
1903.3D NEMT RECIPIENT RESPONSIBILITY
1. The recipient shall:
a. Use personal transportation or transportation of an LRI whenever possible;
b. Explore alternative resources first, and when such a resource exists at no cost to the
recipient, use the alternative transportation resource;
c. If free transportation is not available, use public transportation when residing within
3/4 of a mile of a bus stop (unless medical documentation is provided to support
the recipient’s or LRI’s physical or mental condition that prohibits the recipient
from utilizing public transport);
d. Participate in the assessment process to determine the appropriate level of service
needed for transportation. The recipient must follow through when referred for a
public paratransit evaluation;
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e. If eligible for paratransit services, the recipient is required to access available
paratransit programs;
f. Make and keep all appointments and travel schedules, and phone to cancel when
an unforeseen event makes it impossible to keep an appointment;
g. Recipients or individuals scheduling on behalf of the recipient are responsible to
schedule rides by contacting the NEMT broker;
h. Recipients or individuals scheduling on behalf of the recipient are urged to schedule
rides (except out-of-area travel) not less than three days and no more than 60 days
prior to travel;
i. Requests for paratransit rides from the NEMT vendor must be scheduled no more
than three days in advance of the recipient’s medical appointment;
j. Recipients must be ready and available for their scheduled ride15 minutes before
the scheduled ride and up to 30 minutes after the scheduled pick up time;
1. Recipients who are using subcontracted transportation vendors will follow
the NEMT broker policy concerning late rides.
k. Notify the NEMT broker immediately when an urgent service need for NEMT
transportation is discovered;
l. Notify the NEMT broker of all third party insurance information, including the
name of other third party insurance, or any changes in insurance coverage at the
time of service, if possible, or in a timely manner thereafter;
m. Not refuse service of a provider based solely or partly on the provider’s race, color,
national origin, sex, religion, disability or age; and
n. Provide car seats, wheelchairs, other devices or equipment, and any extra physical
assistance, not required of providers, necessary to make the trip.
1903.4 GEOGRAPHIC AREA
Nevada residents living near the state line or border may be geographically closer to out-of-state
providers than to in-state providers for both primary and specialty care. In such cases, covered
medically necessary services may be routinely provided by out-of-state providers in what DHCFP
refers to as the “primary catchment areas.” Such services are treated the same as those provided
within the state borders for purposes of authorization and transportation.
The primary catchment areas are listed in the MSM Chapter 100.
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The NEMT broker provides services statewide and in catchments areas. The NEMT broker
provides services to and from out-of-state facilities.
1903.5 SPECIAL REQUIREMENTS FOR SELECTED COVERED NEMT SERVICES
A. Out-of-Network-Providers network Providers
The NEMT broker generally uses transportation providers who have executed a contract
to be part of the NEMT broker’s network. However, occasionally it may be necessary for
enrolled recipients to obtain NEMT services from an out-of-network provider (e.g., the
recipient needs specialized transportation for which the NEMT broker has no such
specialist in its network), in which case the broker must:
1. Arrange transportation with out-of-network providers with respect to services and
payment;
2. Offer the opportunity to the out-of-network provider to become part of the network;
and
3. Negotiate a contract to determine the rate prior to services being rendered.
B. Family Planning Services
Pursuant to policies set forth in Chapter 600 of the Nevada MSM, the NEMT broker will
authorize NEMT services to family planning services for any eligible recipient to any
qualified provider.
C. Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs.
Transplant services are covered, with limitations, when medically necessary. Coverage
limitations for these services are defined in the Title XIX State Plan. When a transplant
recipient’s care needs during transit are within the scope of the NEMT broker,
transportation should be prior authorized and provided through the NEMT broker. When
the recipient’s care needs during transit exceed the capabilities of the NEMT broker and/or
the timeframe for transport is less than four hours, transportation may be treated as a non-
immediate medically necessary transport. (Refer to Section 1903.1A(2)(c) for guidance.)
D. Paratransit Transportation
Paratransit transportation may be provided based on assessed medical need. When
paratransit transportation is indicated, such transportation services shall be “curb to curb”
or “door-to-door”, whichever service is necessary for the recipient. All paratransit
providers are responsible for assisting riders into and out of their vehicles.
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1903.6 ENROLLMENT AND DISENROLLMENT REQUIREMENTS AND LIMITATIONS
The eligibility and enrollment functions are the responsibility of DHCFP and the DWSS. The
NEMT broker shall accept each recipient who is enrolled in or assigned to the NEMT broker by
DHCFP and/or its enrollment sections.
Pursuant to the State of Nevada’s Medicaid State Plan §3.1 for NEMT Services, eligible recipients
do not have the option of disenrolling from the NEMT broker, nor does the NEMT broker have
the option of disenrolling any eligible recipient. Copies of the State of Nevada Medicaid State Plan
§3.1for NEMT Services are available on DHCFP’S website at http://dhcfp.nv.gov.
“Pending” Medicaid recipients (those whose applications for assistance have been submitted but
not adjudicated) are not eligible for transportation services provided by the NEMT broker.
The NEMT broker is not financially responsible for any services rendered during a period of
retroactive eligibility.
1903.7 INFORMATION REQUIREMENTS
The NEMT broker must have written information about its services and access to services
available upon request to recipients. This written information must be available in English and
Spanish. The NEMT broker must make free, oral, Spanish interpretation services available to each
recipient, if necessary. The broker may supply telephone interpretation services for other non-
English languages. DHCFP must approve all materials distributed to recipients.
A. The NEMT broker’s written material must use an easily understood format. The NEMT
broker must also develop appropriate alternative methods for communicating with people
with vision or hearing impairments and must accommodate recipients with a physical
disability in accordance with the requirements of the ADA. All recipients must be informed
that this information is available in alternative formats and how to access those formats.
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1904 RESERVED
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1905 NEMT GRIEVANCES, APPEALS AND PROVIDER DISPUTES
1905.1 NOTICE OF DECISION
The NEMT broker may take action on a recipient’s request for transportation based on DHCFP’s
coverage policy and guidelines as set forth in the Nevada MSM. The request may be approved,
denied, or limited (i.e. denied in part, or reduced) based on these eligibility and coverage policies.
The broker shall notify each recipient in writing of the reason for any action which is taken to deny
or otherwise limit a recipient’s request, within five business days of such action; such notification
is called a Notice of Decision (NOD).
Pursuant to 42 CFR 438.10 (g), the NOD shall include information regarding the recipient’s right
to a State Fair Hearing (see Chapter 3100 of the Nevada MSM), the method for obtaining a State
Fair Hearing, and the rules that govern the recipient’s right to representation. The broker must also
provide a NOD to the requesting provider, if applicable.
The NOD must include the following information:
A. The action the broker or its network provider has taken or intends to take;
B. The reasons for the action;
C. The recipient’s right to request a State Fair Hearing;
D. The method of obtaining a State Fair Hearing;
E. The rules that govern representation at a State Fair Hearing;
F. The right of the recipient to request a State Fair Hearing and how to do so;
G. The right to request to receive benefits while the hearing is pending and how to make this
request; and
H. That the recipient may be held liable for the cost of those benefits if the hearing decision
upholds the broker’s action.
The NEMT broker shall provide any reasonable assistance to recipients in filing a State Fair
Hearing, including transportation to the hearing, if necessary.
The NEMT broker is required to maintain records of all grievances received and NODs provided,
which the State will review as part of the State’s contract monitoring and management oversight.
July 1, 2021 TRANSPORTATION Section 1905 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 1905
Subject:
MEDICAID SERVICES MANUAL HEARINGS
1905.2 RECIPIENT GRIEVANCES AND PROVIDER DISPUTES
The NEMT broker must have a process with which to address recipient grievances and provider
disputes. DHCFP will refer all recipient grievances and provider disputes to the NEMT broker for
resolution. The NEMT broker must provide information about its recipient grievance process to
all providers and subcontractors, at the time they enter into a contract.
The NEMT broker is required to dispose of each recipient grievance and provide notice as
expeditiously as the recipient’s health condition requires or no more than 90 days from the date
the grievance is received by the NEMT broker or a network provider. The NEMT broker shall
attempt to respond verbally to the recipient, authorized representative, DHCFP or provider
grievances and disputes within 24 hours of receipt of the grievance or dispute. The NEMT broker
shall issue an initial response or acknowledgement to written grievances and disputes in writing
within 72 hours.
In addition, the NEMT broker must:
A. Provide recipients any reasonable assistance in completing forms and taking other
procedural steps. This includes but is not limited to providing interpreter services and toll-
free numbers that have adequate TDD and interpreter capability;
B. Acknowledge receipt of each recipient grievance;
C. Ensure that the individuals who make decisions on recipient grievances were not involved
in any previous level of review or decision-making; and
D. Notify the recipient of the disposition of grievances in written format. The written notice
must include the results of the resolution process and the date it was completed.
July 1, 2021 TRANSPORTATION Section 1905 Page 2
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
February 23, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, HIPAA PRIVACY AND CIVIL RIGHTS
OFFICER /Jessica Kemmerer/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 2000 - AUDIOLOGY
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2000 – Audiology are being proposed for
cochlear implants to update the age for coverage to 9 months from 12 months.
.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: This proposed change affects all Medicaid-enrolled providers
delivering cochlear services. Those provider types (PT) include but are not limited to: Audiology
(PT 23), hearing aid suppliers (PT 76), Therapy (PT 34).
Financial Impact on Local Government: Unknown.
These changes are effective February 24, 2021.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 06/21 MTL 12/09
MSM 2000 – Audiology MSM 2000 – Audiology
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2003.4A (2)(b). Coverage and Updated age for coverage from 12 months to nine
Limitations months of age.
2003.4A(6) Children Updated age for coverage from 12 months to 9
months.
Page 1 of 1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
AUDIOLOGY SERVICES
2000 INTRODUCTION ...............................................................................................................................1
2001 AUTHORITY ......................................................................................................................................1
2002 RESERVED .........................................................................................................................................1
2003 AUDIOLOGY POLICY ......................................................................................................................1
2003.1 COVERAGE AND LIMITATIONS ...................................................................................................1
2003.1A PROVIDER RESPONSIBILITY.........................................................................................................1
2003.1B RECIPIENT RESPONSIBILITY ........................................................................................................1
2003.2 AUDIOLOGICAL TESTING .............................................................................................................1
2003.2A COVERAGE AND LIMITATIONS ...................................................................................................1
2003.2B PRIOR AUTHORIZATION ................................................................................................................2
2003.3 HEARING AIDS .................................................................................................................................2
2003.3A COVERAGE AND LIMITATIONS ...................................................................................................2
2003.3B PRIOR AUTHORIZATION ................................................................................................................4
2003.3C RECIPIENT RESPONSIBILITY ........................................................................................................5
2003.4 COCHLEAR AND AUDITORY BRAINSTEM IMPLANTS ...........................................................5
2003.4A COVERAGE AND LIMITATIONS ...................................................................................................5
2003.4B PRIOR AUTHORIZATION ................................................................................................................7
2003.4C RECIPIENT RESPONSIBILITY ........................................................................................................7
2003.5 AUDITORY BRAINSTEM IMPLANT (ABI) ...................................................................................7
2003.5A COVERAGE AND LIMITATIONS ...................................................................................................7
2003.5B PRIOR AUTHORIZATION ................................................................................................................8
2003.6 BONE-ANCHORED HEARING AID (BAHA) SYSTEM ................................................................8
2003.6A COVERAGE AND LIMITATIONS ...................................................................................................8
2003.6B PRIOR AUTHORIZATION ..............................................................................................................10
2003.6C RECIPIENT RESPONSIBILITY ......................................................................................................11
2004 APPEALS AND HEARINGS .............................................................................................................1
MTL 12/12
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2000
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
2000 INTRODUCTION
The Nevada Medicaid Audiology program reimburses medically necessary audiology services to
eligible Medicaid recipients under the care of the prescribing practitioner. Such services shall
maintain a high standard of quality and shall be provided within the limitations and exclusions
described in this chapter.
All providers participating in the Medicaid program must offer services in accordance with the
rules and regulations of the Medicaid program. Audiology services are an optional benefit within
the Nevada Medicaid program. All Medicaid policies and requirements (such as prior
authorization, etc.) are the same for Nevada Check Up (NCU), with the exception of three areas
where Medicaid and NCU policies differ. For further clarification, please refer to the NCU Manual,
Chapter 1000.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2001
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
2001 AUTHORITY
The citation denoting the amount, duration and scope of services are found in the Code of Federal
Regulations (CFR) Part 440.110 and the Nevada Medicaid State Plan Attachment 3.1-A.
The State Legislature grants authority to the relevant professional licensure boards to set the
standards of practice for licensed professionals in the Nevada Revised Statutes (NRS) for the
following Specialists:
• NRS – Chapter 630 – Physicians
• NRS – Chapter 637A – Hearing Aid Specialists
• NRS – Chapter 637B – Audiologists and Speech Pathlogists
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2002
Subject:
MEDICAID SERVICES MANUAL RESERVED
2002 RESERVED
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
2003 AUDIOLOGY POLICY
2003.1 COVERAGE AND LIMITATIONS
Audiology services and supplies are covered by Nevada Medicaid for eligible recipients.
Audiological services must be performed by a certified and licensed audiologist as described in
the NRS 637B. Refer to specific coverage and limitations for each service.
2003.1A PROVIDER RESPONSIBILITY
Providers must verify recipient eligibility before rendering services. The presence of a Medicaid
and NCU identification card does not guarantee eligibility. It is the provider’s responsibility to ask
the recipient if there is additional audiology coverage through third party payers.
The provider will allow, upon request of proper representatives of the Division of Health Care
Financing and Policy (DHCFP), access to all records which pertain to Medicaid or NCU recipients
for regular review, audit or utilization review. Providers must inform Nevada Medicaid of any
misuse of the Medicaid or NCU card or inappropriate utilization.
2003.1B RECIPIENT RESPONSIBILITY
Services requested by the recipient, but for which Medicaid makes no payment are the
responsibility of, and may be billed to, the recipient. Nevada Medicaid recipients are only
responsible for payment of services not covered by Medicaid. Prior to service, the recipient must
be informed in writing he/she will be responsible for payment. The recipient is responsible for:
1. presenting a valid Nevada Medicaid and NCU card to the provider at each visit;
2. presenting any form or identification necessary to utilize other health insurance coverage;
3. making and keeping appointments with the provider; and
4. notifying providers immediately of any change in eligibility status, e.g., eligibility changes
from Fee-for-Service (FFS) to managed care.
2003.2 AUDIOLOGICAL TESTING
2003.2A COVERAGE AND LIMITATIONS
1. Audiological testing is limited to once per 12 rolling months for eligible recipients and
must be referred by an M.D.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
2. A physician must examine the hearing aid beneficiary for pathology or disease no more
than six months prior to the fitting of the aid(s) and submit a statement certifying the
medical necessity of the evaluation to the audiologist.
3. One audiogram testing per 12 rolling months does not require prior authorization. The
audiogram should be no more than six months old.
4. To qualify for coverage by Medicaid, the report must show levels of hearing loss as
follows:
a. Adults: at least 30 decibels for the frequency range of 500-3000 Hz.
b. Children: at least 20 decibels for the frequency range of 500-3000 Hz.
2003.2B PRIOR AUTHORIZATION
1. A prior authorization request is needed for any hearing aid(s) exceeding the allowed
amount of $350.00 per aid. The audiologist’s testing reports must be attached and show the
following:
a. hearing levels and discrimination scores including the type of hearing loss
conductive or neuron-sensory; and
b. a copy of the audiogram which should be no older than six months; and
c. patient’s capabilities for use of the hearing aid(s), physical dexterity, mental
capabilities and motivation; and
d. type of hearing aid(s) recommended including the cost.
2. Additional hearing evaluations outside the normal program guidelines must be prior
authorized. The audiologist must keep a copy of the referral and test results in the
recipient’s medical record
2003.3 HEARING AIDS
2003.3A COVERAGE AND LIMITATIONS
Medicaid will reimburse only licensed physicians, licensed audiologists and certified hearing aid
dispensers for hearing aid fitting and dispensing.
1. Hearing aids and related supplies are covered by Nevada Medicaid for eligible recipients.
Coverage is limited to once every 24 rolling months. This may be exceeded through Early
and Periodic Screening, Diagnostic and Treatment (EPSDT) Healthy Kids if it is
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
determined to be medically necessary by the Quality Improvement Organization (QIO)-
like vendor. Refer to Chapter 1500 of the MSM for more information.
2. The manufacturer must be willing to accept the payment for the hearing aid(s) from the
Medicaid hearing aid dispensers. Such payment constitutes payment in full. Shipping and
handling for the hearing aid(s) is not a covered benefit. Recipients are not to be billed for
any additional charges.
3. Hearing Aid Batteries: Hearing aid batteries are limited to one package of four per hearing
aid per month. Requests for batteries more frequently for recipients age 21 and older
require prior authorization. Children under age 21 may exceed the limitation, when
medically necessary.
4. Ear Molds: Ear molds are to be provided with each new behind-the-ear hearing aid.
Replacement for children is covered without prior authorization through Healthy Kids
(EPSDT). Replacement for adults and children on NCU is covered when medically
necessary without prior authorization up to two in 24 months.
5. Hearing Aid Fitting and Dispensing: Hearing aid fitting and dispensing includes selecting,
ordering, fitting, evaluating of appropriate amplification and dispensing the hearing aid(s).
It also includes an initial supply of batteries. Medicaid reimburses for ear impressions and
ear molds as a separate procedure.
Non-audiology providers of hearing aids (Durable Medical Equipment (DME) providers)
may provide hearing aids and hearing aid related services and items but no professional
audiology services for which an audiologist’s academic credentials and licensing are
required.
Non-audiology providers of hearing aids are covered to provide hearing aid counseling,
hearing aid fitting and sale of the hearing aid(s) itself. Coverage also includes revision of
hearing aid accessories, replacement of parts and repairs.
The provider must allow the recipient to have a 30-day trial period with a money back
guarantee if the aid(s) does not benefit the patient. A recheck of the patient with the aid(s)
must be offered two weeks or sooner following dispensing to determine if there are
improved hearing levels and discrimination scores. The visit(s) should also include
counseling on the use and care of the hearing aid(s) and ensure proper fit of the ear molds.
6. Warranty: Hearing aids must include a minimum 12-month warranty from the
manufacturer that covers repair, damage and loss of the hearing aid(s). The provider must
maintain the warranty in the recipient’s medical record. A second-year warranty or
insurance is required. If the manufacturer does not include a second year warranty, the
provider should request a prior authorization for additional insurance.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
7. Replacement: Hearing aids may be replaced when:
a. the current aid(s) cannot be repaired as determined by the Medicaid provider;
b. the recipient’s hearing deficit requires a different type of device for maximum
benefit;
c. the manufacturer’s warranty has expired; or
d. there is no other insurance.
8. Broken or Lost Hearing Aids: If replacement of a hearing aid(s) becomes necessary after
12 rolling months or more, the recipient will have a reevaluation by the audiologist prior
to fitting of the replacement aid(s). The replacement aid(s) must be prior authorized if the
aid(s) is no longer covered by a manufacturer’s warranty or other insurance.
9. Supplies/Accessories: Hearing aid supplies/accessories (i.e. ear hooks, tubes) do not need
prior authorization.
10. Testing/Repairs: Reimbursement will not be made for repairs covered by the
manufacturer’s warranty or other insurance.
If testing/repair of the hearing aid(s) is needed after this time period, it is limited to once
every 12 rolling months per aid. The provider will need to identify which aid (right or left)
is being repaired. Repairs must be covered by a six-month warranty.
Medicaid will reimburse for repairs on hearing aids that were not purchased by Medicaid.
Medicaid does not reimburse for repairs if the hearing aid was damaged by tampering or
misuse. Recipients are not to be billed for any additional charges.
11. Non-Covered Hearing Aids: Semi-implantable middle ear hearing aids are not a covered
benefit as they are considered investigational.
2003.3B PRIOR AUTHORIZATION
1. Hearing aids exceeding the allowed amount of $350.00 per aid require prior authorization
from the QIO-like vendor and need to include medical necessity for the more expensive
aids, including cost.
2. Prior authorization with medical necessity is required for any additional aid(s) needed
during the 24-rolling month period.
3. Additional evaluations, fitting and dispensing, ear molds, testing/repair, replacement of
broken or lost hearing aid(s), supplies or insurance outside the normal program guidelines
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
will require prior authorization from the QIO-like vendor. Each request must have the
appropriate documentation attached.
2003.3C RECIPIENT RESPONSIBILITY
Along with previously mentioned responsibilities, the recipient is also responsible for:
1. routine maintenance;
2. purchase of additional batteries beyond the limitation of one package of four per hearing
aid per month when a prior authorization has been denied; however, children under age 21
may exceed the limitation, when medically necessary;
3. repairs and replacement of the hearing aid(s) if the recipient loses Medicaid eligibility; and
4. picking up the hearing aid(s) and returning for any necessary adjustments within the
hearing aid trial period established with the provider.
2003.4 COCHLEAR AND AUDITORY BRAINSTEM IMPLANTS
2003.4A COVERAGE AND LIMITATIONS
1. Bilateral and unilateral cochlear implants are a Nevada Medicaid covered benefit when
determined to be medically necessary for eligible recipients with profound hearing
impairment. Covered services include but are not limited to:
a. otologic examination.
b. audiological evaluation.
c. physical examination.
d. psychological evaluation.
e. surgical implantation of the device.
f. postoperative follow-up evaluation and rehabilitation.
2. Coverage is restricted to those recipients who meet the following audiologic/medical
criteria as determined by a physician or audiologist:
a. recipient must be referred by an M.D. or Ear, Nose and Throat specialist with
documentation to determine medical candidacy for such a device. This is to include
recent (within six months) results of a CT or MRI scan to evaluate the anatomy of
the inner ear; and
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
b. must be at least nine months of age or older; and
c. must suffer from severe to profound pre-or-post lingual hearing loss (70 decibels
or greater) confirmed by audiologic testing that obtains limited or no benefit from
appropriate hearing aids for six months or greater; and
d. must have the cognitive ability to use auditory clues and a willingness to undergo
an extended program of rehabilitation; and
e. must be free of middle ear infection; and
f. must have an accessible cochlear lumen that is structurally suited to implantation;
and
g. be free of lesions in the auditory nerve and acoustic areas of the central nervous
system; and
h. have no contraindications for the surgery.
3. Use of the device must be in accordance with the Food and Drug Administration (FDA)
approved labeling.
4. There must be good family support with self-motivation, as determined by a physician or
audiologist. Education of families/caregiver and the recipient must be conducted to ensure
understanding of the benefits and limitations of the device, appropriate expectations,
commitment to the development of auditory and verbal skills, dedication to the therapeutic
program and the ability to adequately care for the external equipment.
5. Adults
Cochlear implants may be covered for prelinguistically (before the development of
language), perilinguistically (during the development of language), and postlinguistically
(after language has fully developed) deafened adults (over age 21). Postlinguistically
deafened adults must demonstrate test scores of 40% or less on sentence recognition scores
from tape recorded tests in the recipient’s best listening condition.
6. Children
Cochlear implants may be covered for prelinguistically and postlinguistically deafened
children from 9 months through 20 years of age. Bilateral profound sensorineural deafness
must be demonstrated by the inability to improve on age appropriate closed set word
identification tasks with amplification.
7. Rehabilitation Program
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2003
Subject:
MEDICAID SERVICES MANUAL POLICY
A post-cochlear implant rehabilitation program is necessary to achieve benefit from the
cochlear implant for both children and adults. The program is performed by an audiologist
and speech-language pathologists. The rehabilitation program includes development of
skills in understanding running speech, recognition of consonants, vowels and tests of
speech perception ability. Refer to Chapter 1700 for Therapy Services of the MSM.
8. Warranty
The limited warranty must be included in the documentation from the product
manufacturer. Services beyond the warranty must be prior authorized.
9. Damage and Loss
Damage and loss insurance is required at the time of implant. Insurance must be all-
inclusive for replacement and loss, no deductibles or co-pays are allowed. There must be
continuous insurance coverage for five years. Insurance is not to exceed $250/year.
2003.4B PRIOR AUTHORIZATION
Prior authorization is required with medical documentation to substantiate the request for the
cochlear implant.
2003.4C RECIPIENT RESPONSIBILITY
Along with previously mentioned responsibilities, the recipient is also responsible for:
1. wearing a helmet while bicycling, roller blading, playing football and soccer; players must
not “head” the ball.
2. keeping equipment out of reach of animals.
3. removing the speech processor and headset before entering a room where an MRI scanner
is located.
4. wearing the special harness that secures the speech processor during active sports. For
water sports and activities that generate high levels of static electricity, such as playing on
trampoline and plastic slides, the equipment must be removed.
2003.5 AUDITORY BRAINSTEM IMPLANT (ABI)
2003.5A COVERAGE AND LIMITATIONS
1. An ABI is a covered benefit as medically necessary when all of the following criteria are
met;
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Subject:
MEDICAID SERVICES MANUAL POLICY
a. the recipient is 12 years of age or older; and
b. the recipient has been diagnosed with Neurofibromatosis Type 2 (NF2); and
c. the recipient is undergoing bilateral removal of tumors of the auditory nerves; and
d. it is anticipated that the recipient will become completely deaf as a result of surgery;
or
e. the recipient had bilateral auditory nerve tumors removed and is now bilaterally
deaf.
2. Warranty: The limited warranty must be included in the documentation from the product
manufacturer. Services beyond the warranty must be prior authorized.
3. Rehabilitation Program: The recipient must have multiple sessions with the audiologist to
test, adjust the sound processor and learn to interpret new sounds.
2003.5B PRIOR AUTHORIZATION
Prior authorization is required with medical documentation to substantiate the request for the
auditory brainstem implant.
The physician who performs the cochlear implant or auditory brainstem implant surgery must
obtain prior authorization from the QIO-like vendor before providing the service. Authorization is
determined based on medical necessity. Each request must include documentation to show the
recipient has met Medicaid guidelines for the procedure.
2003.6 BONE-ANCHORED HEARING AID (BAHA) SYSTEM
2003.6A COVERAGE AND LIMITATIONS
Bone Anchored Hearing Aid (BAHA), also called an implantable bone conduction hearing aid, is
a Nevada Medicaid covered benefit when it is determined medically necessary for eligible
recipients five years and older. The BAHA is an alternative hearing device for recipients unable
to use conventional hearing instruments.
BAHA Softbands and BAHA Headbands are a covered benefit for children of any age who have
conditions that are eligible for a BAHA implant. The BAHA system is designed to treat:
1. Conductive or Mixed Hearing Loss from possible causes of:
a. chronic otitis media.
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Subject:
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b. congenital malformations where the cochlear function is good but there are no ear
canals.
c. Cholesteatoma.
d. middle ear dysfunction/disease.
e. external otitis.
2. Unilateral Sensorineural Deafness or Single Sided Deafness (SSD) from possible causes
of:
a. acoustic neuroma tumors, other surgical intervention.
b. sudden deafness.
c. neurological degenerative disease.
d. trauma.
e. ototoxic treatments.
f. genetic.
g. Meniere’s Disease.
3. Audiologic/Medical criteria:
Recipients must be referred by an M.D. or Ear, Nose and Throat Specialist with
documentation to determine medical candidacy for such a device. This may include a
radiology report. Assessment by an audiologist to determine if the type and degree of
hearing loss meet the necessary criteria is also required.
a. Mixed and Conductive Hearing Loss with the following criteria:
1. >5 years of age.
2. <45 dB HL BC pure tone average (PTA) (measured at 0.5, 1, 2 and 3K Hz).
3. >or equal to 60% speech discrimination scores (using standardized test).
4. bilateral fitting-symmetric bone conduction thresholds are defined as no
more than 10 dB difference of the PTA or less than 15 dB individual
frequencies.
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Subject:
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b. Single Sided Deafness with the following criteria:
1. >5 years of age.
2. normal hearing in contralateral ear. (Normal hearing is defined as pure tone
average air conduction (PTAAC) threshold equal to or better than 20 dB HL
[measured at 0.5, 2 and 3 kHz]).
3. Functions by transcranial routing of the signal.
c. Additional qualifying criteria should include:
1. sufficient bone volume and bone quality present for successful implant
placement; and
2. no contraindications to anesthesia or surgery; and
3. careful consideration given to the recipient’s physical, psychological and
emotional state as determined by physician or audiologist; and
4. well informed recipients who have the right expectations of the BAHA
system and are highly motivated, as determined by physician or audiologist;
and
5. recipients who are able to maintain and clean the skin around the abutment
or with the aid of others. For children, the responsibility falls on the parents
or guardians; and
6. recipients trained in the care, use of the device and comfortable with
connecting and disconnecting the sound processor from the abutment, prior
to the fitting of the speech processor.
4. Warranty: The limited warranty must be included in the documentation from the product
manufacturer. Services beyond the warranty must be prior authorized.
5. Follow-Up: It is important the audiologist provides a follow-up program for the recipient.
2003.6B PRIOR AUTHORIZATION
Prior authorization is required with medical documentation to substantiate the request for the
BAHA implant, softband or headband.
The physician who performs the BAHA implant surgery must obtain prior authorization from the
QIO-like vendor before providing the service. Authorization is based on medical necessity. Each
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request must include documentation to show the recipient has met Medicaid criteria for the
procedure.
2003.6C RECIPIENT RESPONSIBILITY
Along with previously mentioned responsibilities, the recipient is also responsible for:
1. removing the sound processor prior to bathing, showering, swimming or engaging in any
water activities, as it is not water proof;
2. never exposing the sound processor to extreme heat or cold; and
3. avoiding the loss of the sound processor during physical activity by removing it or using
the safety line provided.
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Section:
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Subject:
MEDICAID SERVICES MANUAL APPEALS AND HEARINGS
2004 APPEALS AND HEARINGS
Please reference MSM Chapter 3100 for Medicaid Recipient Hearings.
June 9, 2009 AUDIOLOGY SERVICES Section 2004 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
January 26, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, HIPAA PRIVACY AND CIVIL RIGHTS
OFFICER
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 2100 – HOME AND COMMUNITY BASED SERVICES
WAIVER FOR INDIVIDUALS WITH INTELLECTUAL AND
DEVELOPMENTAL DISABILITIES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2100 – Home and Community Based
Services Waiver for Individuals with Intellectual and Developmental Disabilities are being
proposed to bring this chapter in line with the current waiver renewal which was approved on
October 1, 2018.
Updates to this chapter include changing the term “Home and Community Based Waiver” to
“Home and Community Based Services” throughout the chapter to adhere to CMS guidance;
changing the acronym “HCBW” to “HCBS” throughout the entire chapter; all references to
“Waiver for Individuals with Intellectual Disabilities and Related Conditions” have been removed
and replaced with “Waiver for Individuals with Intellectual and Developmental Disabilities (ID
Waiver)” as defined by Nevada Revised Statutes (NRS) 435.007; changing the form referred to as
“NMO-2734” as a “notification” throughout the entire chapter; replacing Individual Support Plan
(ISP) to Person Centered Plan (PCP) to adhere to the HCBS New Settings Rule; changing “case
manager” to “service coordinator” throughout the entire chapter; expanding the term “authorized
representative” to “designated representative/LRI” throughout the entire chapter; changing
“individuals” to “recipients” throughout the entire chapter; adding citation MSM 2103.2A to all
provider responsibilities/qualifications sections to avoid duplicative language throughout the
entire chapter; added new section - Recipient Rights and Responsibilities to each waiver services
for consistency throughout the chapter.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: None.
Financial Impact on Local Government: Unknown at this time.
These changes are effective February 1, 2021.
Page 1 of 16
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 02/21 MTL 20/15
CHAPTER 2100 – HOME AND CHAPTER 2100 – HOME AND
COMMUNITY-BASED SERVICES FOR COMMUNITY-BASED SERVICES FOR
INDIVIDUALS WITH INTELLECTUAL INDIVIDUALS WITH INTELLECTUAL
AND DEVELOPMENTAL DISABILITIES AND DEVELOPMENTAL DISABILITIES
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2100 Introduction Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
The section was reworded and updated for
consistency throughout the chapter and clarity.
Replaced 2nd paragraph with The Home and
Community Based Services (HCBS) Program for
Individuals with Intellectual and Developmental
Disabilities (ID Waiver) is an optional service
approved by the Centers for Medicare and Medicaid
Services (CMS), which authorizes the DHCFP the
flexibility to design this waiver and select the mix of
waiver services that best meet the goals of the
program. This waiver allows the provision of
services based on the identified needs and is
designed to provide eligible Medicaid waiver
recipients access to both state plan as well as certain
extended Medicaid covered services.
Some language from Authority Section was moved
to Introduction.
2101 Authority Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
The second paragraph was deleted as portions of the
wording was used in the Introduction.
The citations for CFR, NRS and NAC was updated
for consistency with all Medicaid Service Manuals.
Page 2 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Added citations NAC Chapter 632, HIPAA, MSM
100 and Section 3715 of the CARES Act.
2103.1 Waiver Eligibility Terminology and acronyms updated per the
Criteria description provided in the Background and
Explanation section above.
“Nevada” was replaced with “The HCBS ID”.
Moved eligibility criteria requirements from its
original manual section.
Removed “office staff and authorized by the
DHCFP’s Central Office Staff.”
Replaced “psychologist” with “Intake Team” and
added “assessments and/or”.
Added “This support system must be in place to
ensure the physical, environmental, and basic care
needs of the applicant/recipient are met in order to”
and clarified eligibility language.
Clarified who determines the financial eligibility and
combined two paragraphs for consistency.
2103.1A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Changed “waiver year” to “biennium.”
Language was updated for policy clarity.
Added Section 3715 of the CARES Act policy to item
4.
Added “1915(c) waiver” to item number 5.
Added “spouse,” removed “health/medical care,” and
replaced and/or updated “child” with “recipient”
Added “there is no LRI residing in the recipient’s
home” and “or the recipient’s support team has
Page 3 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
documented a need for ADL or IADL habilitative
services to be provided by direct support staff.”
Removed “Without this verification, HCBW services
will not be authorized.”
Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) was moved to the Coverage and
Limitations from the previous location.
2103.1B Provider Added new section “Providers are responsible for
Responsibilities confirming the recipient’s Medicaid eligibility each
month prior to rendering waiver services.”
2103.1C Recipient Rights Added new section “Applicants or recipients must
and Responsibilities meet and maintain all criteria to be eligible, and to
remain on the ID Waiver.”
2103.2 Waiver Services Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
Removed “and the state budget process,” “Providers
and recipients must agree to comply with the
requirements for service provision in accordance with
ADSD and the DHCFP policies.” and “for individuals
who have been assessed to be at risk for ICF/IID
placement without the provision of enhanced
supports as identified in the Individual Support Plan
(ISP).”
The list of services provided was updated according
to the Waiver Application.
2103.2A Provider Terminology and acronyms updated per the
Responsibilities description provided in the Background and
Explanation section above.
Changed “All Providers” to “Provider Requirements.”
Updated approval and certification to include NAC
435 and ADSD Policy and Procedures added in Item a.
Page 4 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Added requirement to obtain and maintain a Service
Provider Agreement with ADSD prior to providing
services to waiver recipients added in Item b.
Enrollment language was updated to add “Fee-for-
Service Nevada Medicaid” and to reference to MSM
Chapters 100 and 2100 added in Item c.
Added the requirement to follow the PCP and Service
Authorization for prior authorization of waiver
services.
Added requirement for providers to provide copy of
all renewal of professional licenses/certifications.
Added cooperation with the ADSD and/or State or
Federal reviews and/or inspections.
Removed language regarding provider enrollment that
duplicates language in MSM Chapter 100 and the
fiscal agent provider enrollment checklist.
Added “subcontractors and volunteers who have
contact with recipients or access to their financial or
personal information” to those requiring background
checks.
Added requirement to maintain background check
information on file for 5 years and references to the
appropriate NRS and NAC.
Added required training for providers that outlines the
documentation must be kept on file and available for
review, new employee orientation must be completed
within 6 months, annual training requirements,
providers must comply with established by ADSD.
2103.2B Recipient Rights Terminology and acronyms updated per the
Responsibilities description provided in the Background and
Explanation section above.
Added “Rights” to “Recipient Responsibilities”
throughout the chapter.
Page 5 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Added first paragraph, “The Recipients are entitled to
their privacy; to be treated with respect; and be free
from coercion and restraint.”
Added Item 8, “Notify the ADSD and the provider if
services are no longer requested or required.”
Added Item 16, “Cooperate with all the ADSD
meetings and contacts such as phone/face-to-face as
per the PCP.”
2103.3 Day Habilitation Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
Service Coordination has been moved to another
section of this chapter and re-arranged the section
Added language to include volunteer work in the
community, retirement activities and alternate
schedules to allow for participation with activities in
the community.
2103.3A Coverage and Terminology and acronyms updated per the
Limitation description provided in the Background and
Explanation section above.
2103.3B Provider Removed all duplicated language and added a
Responsibilities reference to MSM 2103.2A for details.
2103.3C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.4 Residential Support Terminology and acronyms updated per the
Services description provided in the Background and
Explanation section above.
Clarified policy regarding the habilitation plans and
the information addressed.
Updated the list of included supports for clarification.
Added language to allow the recipient freedom in their
residence.
Page 6 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Shared Living Arrangement was defined.
Removed reference to provider owned homes in rural
areas.
Language was updated for clarity regarding the
duplication and authorization of services.
2103.4A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Added verification of certifications must be
maintained in employee files.
Updated language and policy regarding the residential
supports and the delivery of said services.
Replaced “Host Home” with “Shared Living
Arrangement.”
2103.4B Provider Removed all duplicated language and added a
Responsibilities reference to MSM 2103.2A for details.
Added requirements specific to residential supports
that are not contained in the noted MSM.
2103.4C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.5 Prevocational Terminology and acronyms updated per the
Services description provided in the Background and
Explanation section above.
The service description was updated to align with the
CMS approved waiver application and for clarity.
2103.5A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
2103.5B Provider Removed all duplicated language and added a
Responsibilities reference to MSM 2103.2A for details.
Page 7 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2103.5C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.6 Supported Terminology and acronyms updated per the
Employment description provided in the Background and
Explanation section above.
Updated language and clarified the language and
policy regarding the two sub-categories, Individual
Supported Employment and Small Group Supported
Employment.
Individual Supported Employment was updated to add
the description of what will not qualify for payment.
Small Group Employment was updated to add similar
language from the CMS approved waiver application.
Deleted language that was duplicative within this
section.
2103.6A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Updated citation language to reflect the appropriate
sources of the policy language and coverages.
Deleted verbiage in Item 3 as it is duplicative of MSM
2103.6.
Added “Supported Employment services do not
include facility-based work settings, or other similar
types of vocational services furnished in specialized
facilities that are not a part of the general workforce.”
Added “Recipients who receive Supported
Employment services may receive two or more types
of non-residential support services; however, different
types of non-residential support services may not be
billed during the same period of the day.”
2103.6B Provider Removed all duplicated language and added a
Responsibilities reference to MSM 2103.2A for details.
Page 8 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2103.6C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.7 Behavioral Terminology and acronyms updated per the
Consultation, description provided in the Background and
Training and Explanation section above.
Intervention
2103.7A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Participation in PCP, Team meetings and medical
appointments, monthly summary of progress added to
the included services.
Added requirement that written authorization is
needed for amounts in excess of the limit.
2103.7B Provider Terminology and acronyms updated per the
Responsibilities and description provided in the Background and
Qualifications Explanation section above.
Removed all duplicated language and added a
reference to MSM 2103.2A for details.
Clarified the Professional level of licensure details.
2103.7C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.8 Counseling Services Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
Participation in PCP, Team meetings and medical
appointments, monthly summary of progress added to
the included services.
2103.8A Coverage and Removed services included for simplicity and added
Limitations requirement that written authorization is needed for
amounts in excess of the limit.
Page 9 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2103.8B Provider Terminology and acronyms updated per the
Responsibilities and description provided in the Background and
Qualifications Explanation section above.
Removed all duplicated language and added a
reference to MSM 2103.2A for details.
Clarified supervision requirements.
2103.8C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.9 Residential Support Terminology and acronyms updated per the
Management description provided in the Background and
Explanation section above.
Removed details regarding Targeted Case
Management, support managers assisting with
management of residential supports.
2103.9A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Added details regarding Targeted Case Management,
support managers assisting with management of
residential supports.
2103.9B Provider Terminology and acronyms updated per the
Responsibilities and description provided in the Background and
Qualifications Explanation section above.
Removed all duplicated language and added a
reference to MSM 2103.2A for details.
Added one year of experience meeting QIDP
qualification.
2103.9C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
Page 10 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2103.10 Non-Medical Non-Medical Transportation Terminology and
Transportation acronyms updated per the description provided in the
Background and Explanation section above.
Added “recreational” and “activities are not all
inclusive.”
2103.10A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Added a $100 fee limit per month per recipient.
2103.10B Provider Terminology and acronyms updated per the
Responsibilities description provided in the Background and
Explanation section above.
Removed all duplicated language and added a
reference to MSM 2103.2A for details.
Clarified policy regarding the verification of safe
driving record and completion and ongoing
verification of safety inspections.
2103.10C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.11 Nursing Services Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
Language was updated to the 3 components of
services to “Medial Management”, “Nursing
Assessment”, and “Direct Services”.
Sections of the policy was moved, and some portions
deleted within this section to align with the nursing
services.
Direct Service description and policy was added.
2103.11A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Page 11 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Duplicated language was deleted.
Added the requirement to include notes and summary
of Nursing services on all nursing activities.
2103.11B Provider Terminology and acronyms updated per the
Responsibilities and description provided in the Background and
Qualifications Explanation section above.
Removed all duplicated language and added a
reference to MSM 2103.2A for details.
2103.11C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.12 Nutritional Terminology and acronyms updated per the
Counseling Services description provided in the Background and
Explanation section above.
Added description of services that may be included
under Nutritional Counseling.
2103.12A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Removed all duplicated language.
2103.12B Provider Terminology and acronyms updated per the
Responsibilities and description provided in the Background and
Qualifications Explanation section above.
2103.12C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter
2103.13 Career Planning Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
Service description updated to include time limited
and focus on career direction and development,
activities to assist in the identification of employment
Page 12 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
goals, providers to collaborate with the development
of career goals and set forth guidelines for the
services.
2103.13A Coverage and Terminology and acronyms updated per the
Limitations description provided in the Background and
Explanation section above.
Updated time limit from 40 days to 216 hours within
a 6-month time period per year.
Added limitation of services under programs funded
by section 110 of the Rehabilitation Act of 1973.
2103.13B Provider Terminology and acronyms updated per the
Responsibilities description provided in the Background and
Explanation section above.
Added policy regarding the verification of safe driving
record and completion and ongoing verification of
safety inspections.
Deleted duplicated language.
2103.13C Recipient Rights Added this section and reference MSM 2103.2B for
and Responsibilities details to be consistent with other sections in this
chapter.
2103.14 Intake Procedures Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
Removed “Coverage and Limitations” section for
consistency with other sections of this chapter.
Removed Waiver Slot Provision and under this
heading, language was moved to another area of this
section and some were deleted due to duplicated
language.
Re-arranged this section for clarity and consistency.
Language was added and reworded throughout this
section for clarity and consistency.
Page 13 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Deleted language on Item 2d.5 as it is not applicable.
Deleted language Item 4 under Effective Date for
Waiver Services for simplicity and clarity.
Support Plan Development was added to provide more
specifics on how to develop appropriate support plan
in accordance with the PCP.
2103.15 Permanent Case Terminology and acronyms updated per the
File description provided in the Background and
Explanation section above.
Reworded language for clarity and consistency.
2103.16 Service Coordinator Terminology and acronyms updated per the
Recipient Contacts description provided in the Background and
Explanation section above.
Reworded language for clarity and consistency.
Added language on Items A2a and 2b.
Added language on Item B3 and removed and
reworded language.
2103.17 Billing Procedures Terminology and acronyms updated per the
description provided in the Background and
Explanation section above.
Deleted Coverage and Limitations for consistency
with other sections in this chapter.
2103.18 DHCFP Annual Terminology and acronyms updated per the
Review description provided in the Background and
Explanation section above.
Removed Coverage and Limitations to be consistent
with other sections in this chapter.
Under this section added Assurances and Sub-
Assurances to align with the currently approved ID
Waiver application.
Page 14 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2104 Hearings Added “REQUEST DUE TO ADVERSE ACTIONS”
and introduction to Hearings, “An adverse action
refers to denials, terminations, reductions or
suspensions of a recipient’s eligibility determination
or an applicant’s request for services. The DHCFP
must grant an opportunity for a hearing to an
applicant/recipient/designated representative/LRI in
the event an adverse action is taken by the DHCFP.”
2104.1 Suspended Waiver This section has been added as recipients are entitled
Services to a fair hearing during suspension status.
2104.2 Release from The entire section has been added.
Suspended Waiver
Services
2104.3 Denial of Waiver Terminology and acronyms updated per the
Application description provided in the Background and
Explanation section above.
Removed Item l, as it is not applicable.
2104.4 Termination of Terminology and acronyms updated per the
Waiver Services description provided in the Background and
Explanation section above.
Added “Death of recipient.”
Added at the end of this section, “When a recipient has
a reduction of waiver services, the Service
Coordinator will send a notification to the DHCFP
LTSS Unit identifying the reason for the reduction and
what the service is being reduced to. The LTSS Unit
will send a NOD to the recipient or the recipient’s
designated representative/LRI. The form must be
mailed by the DHCFP to the recipient at least 13
calendar days before the DOA on the NOD” and
“When a recipient is denied waiver services, the
Service Coordinator will send a notification to the
DHCFP LTSS Unit identifying the reason for the
denial. The LTSS Unit will send a NOD to the
recipient or the recipient’s designated
representative/LRI within five days, identifying the
reason for denial. The DOA is the same day of the
NOD.”
Page 15 of 16
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2104.5 Reduction or Denial Terminology and acronyms updated per the
of Waiver Services description provided in the Background and
Explanation section above.
2104.6 Reauthorization Coverage and Limitations has been deleted for
within 90 Days consistency with other sections of this chapter.
Added from a previous section, “When a recipient is
placed in an institutional setting such as nursing
facility, ICF/IID, or hospital, they must be sent a NOD
terminating them from the waiver 60 days from admit
date. Their waiver slot must be held for 90 days from
the NOD date. A recipient may be placed back in that
slot if they are released within 90 days of the NOD
date, and request reinstatement, but must continue to
meet waiver eligibility criteria. After 90 days, their
slot may be given to the next individual on the wait
list.”
Provider Responsibilities has been omitted for
consistency with other sections of this chapter.
Page 16 of 16
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
HOME AND COMMUNITY BASED WAIVER
2100 INTRODUCTION ...........................................................................................................................1
2101 AUTHORITY ..................................................................................................................................1
2102 RESERVED .....................................................................................................................................1
2103 POLICY ...........................................................................................................................................1
2103.1 WAIVER ELIGIBILITY CRITERIA..............................................................................................1
2103.1A COVERAGE AND LIMITATIONS ...............................................................................................2
2103.1B PROVIDER RESPONSIBLITIES ...................................................................................................4
2103.1C RECIPIENT RESPONSIBLITIES ..................................................................................................4
2103.2 WAIVER SERVICES ......................................................................................................................4
2103.2A PROVIDER RESPONSIBILITY.....................................................................................................5
2103.2B RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................10
2103.3 DAY HABILITATION .................................................................................................................11
2103.3A COVERAGE AND LIMITATIONS .............................................................................................12
2103.3B DAY HABILITATION PROVIDER RESPONSIBILITIES ........................................................12
2103.3C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................12
2103.4 RESIDENTIAL SUPPORT SERVICES .......................................................................................12
2103.4A COVERAGE AND LIMITATIONS .............................................................................................14
2103.4B PROVIDER RESPONSIBILITIES ...............................................................................................15
2103.4C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................16
2103.5 PREVOCATIONAL SERVICES ..................................................................................................16
2103.5A COVERAGE AND LIMITATIONS .............................................................................................16
2103.5B PROVIDER RESPONSIBILITIES ...............................................................................................17
2103.5C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................17
2103.6 SUPPORTED EMPLOYMENT ....................................................................................................17
2103.6A COVERAGE AND LIMITATIONS .............................................................................................18
2103.6B PROVIDER RESPONSIBILITIES ...............................................................................................19
2103.6C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................19
2103.7 BEHAVIORAL CONSULTATION, TRAINING AND INTERVENTION ................................19
2103.7A COVERAGE AND LIMITATIONS .............................................................................................19
2103.7B PROVIDER RESPONSIBILITIES AND QUALIFICATIONS ...................................................20
2103.7C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................21
2103.8 COUNSELING SERVICES ..........................................................................................................21
2103.8A COVERAGE AND LIMITATIONS .............................................................................................22
2103.8B PROVIDER RESPONSIBILITIES AND QUALIFICATIONS ...................................................22
2103.8C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................22
2103.9 RESIDENTIAL SUPPORT MANAGEMENT .............................................................................22
2103.9A COVERAGE AND LIMITATIONS .............................................................................................22
2103.9B PROVIDER RESPONSIBILITIES AND QUALIFICATIONS ...................................................24
2103.9C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................24
1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
2103.10 NON-MEDICAL TRANSPORTATION.......................................................................................24
2103.10A COVERAGE AND LIMITATIONS .............................................................................................24
2103.10B PROVIDER RESPONSIBILITIES ...............................................................................................24
2103.10C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................25
2103.11 NURSING SERVICES ..................................................................................................................25
2103.11A COVERAGE AND LIMITATIONS .............................................................................................26
2103.11B PROVIDER RESPONSIBILITIES AND QUALIFICATIONS ...................................................27
2103.11C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................27
2103.12 NUTRITION COUNSELING SERVICES ...................................................................................27
2103.12A COVERAGE AND LIMITATIONS .............................................................................................28
2103.12B PROVIDER ADDITIONAL RESPONSIBILITIES AND QUALIFICATIONS .........................28
2103.12C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................28
2103.13 CAREER PLANNING ..................................................................................................................28
2103.13A COVERAGE AND LIMITATIONS .............................................................................................29
2103.13B PROVIDER RESPONSIBILITIES ...............................................................................................29
2103.13C RECIPIENT RIGHTS AND RESPONSIBILITIES ......................................................................30
2103.14 INTAKE PROCEDURES ..............................................................................................................30
2103.15 PERMANENT CASE FILE ..........................................................................................................34
2103.16 SERVICE COORDINATOR RECIPIENT CONTACTS .............................................................34
2103.17 BILLING PROCEDURES ............................................................................................................36
2103.18 DHCFP ANNUAL REVIEW ........................................................................................................36
2103.19 MEDICAID PROVIDER ENROLLMENT PROCESS ................................................................38
2104 HEARINGS REQUEST DUE TO ADVERSE ACTIONS .............................................................1
2104.1 SUSPENDED WAIVER SERVICES..............................................................................................1
2104.2 RELEASE FROM SUSPENDED WAIVER SERVICES ...............................................................1
2104.3 DENIAL OF WAIVER APPLICATION ........................................................................................2
2104.4 TERMINATION OF WAIVER SERVICES ...................................................................................2
2104.5 REDUCTION OR DENIAL OF WAIVER SERVICES .................................................................3
2104.6 REAUTHORIZATION WITHIN 90 DAYS ...................................................................................4
2104.7 HEARINGS PROCEDURES ..........................................................................................................5
2
MTL 02/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2100
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
2100 INTRODUCTION
The Division of Health Care Financing and Policy (DHCFP) and the Aging and Disability Services
Division (ADSD) recognizes that many individuals at risk of being placed in Intermediate Care
Facilities (ICFs) can be cared for in their homes and communities, preserving their independence
and ties to family and friends at a cost no higher than that of institutional care.
The Home and Community Based Services (HCBS) Program for Individuals with Intellectual and
Developmental Disabilities (ID Waiver) is an optional service approved by the Centers for
Medicare and Medicaid Services (CMS), which authorizes the DHCFP the flexibility to design
this waiver and select the mix of waiver services that best meet the goals of the program. This
waiver allows the provision of services based on the identified needs and is designed to provide
eligible Medicaid waiver recipients access to both state plan as well as certain extended Medicaid
covered services.
Nevada acknowledges that people who have intellectual and developmental disabilities are able to
lead satisfying and productive lives when they are provided the needed services and supports to
do so. The DHCFP is committed to the goal of providing individuals with intellectual and
developmental disabilities with the opportunity to remain in a community setting in lieu of
institutionalization.
HOME AND COMMUNITY-BASED SERVICES
(HCBS) WAIVER FOR INDIVIDUALS WITH
INTELLECTUAL DISABILITIES AND
February 1, 2021 DEVELOPMENTAL DISABILITIES Section 2100 Page 1
MTL 02/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2101
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
2101 AUTHORITY
Section 1915(c) of the Social Security Act permits states the option to waive certain Medicaid
statutory requirements in order to offer an array of HCBS to eligible individuals who may require
such services in order to remain in their communities and avoid institutionalization. The DHCFP’s
HCBS for Individuals with Intellectual and Developmental Disabilities is approved by the CMS.
This waiver is designed to provide eligible Medicaid waiver recipients access to both 1905(a) State
Plan services as well as certain extended Medicaid covered services unique to this waiver. The
goal is to allow recipients to live in their own homes or community settings.
Statutes and Regulations:
• Social Security Act: 1915 (c)
• Title 42 Code of Federal Regulations (CFR) Section 441, Subpart I (Community Supported
Living Arrangements Services)
• Title 42 CFR Section 483.430(a) (Qualified Intellectual Disabilities Professional (QIDP))
• Nevada Revised Statute (NRS) Chapter 435 (Individuals with Intellectual Disabilities and
Developmental Disabilities)
• Nevada Administrative Code (NAC) Chapter 435 (Individuals with Intellectual Disabilities
and Developmental Disabilities)
• NAC Chapter 632 (Nursing)
• Health Insurance Portability and Accountability Act (HIPAA)
• Medicaid Service Manual (MSM) Chapter 100
• Section 3715 of the CARES Act
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2103 POLICY
2103.1 WAIVER ELIGIBILITY CRITERIA
The HCBS ID Waiver waives certain statutory requirements and offers waiver services to eligible
recipients to assist them to remain in the community. The target population for this waiver includes
all individuals who are diagnosed with intellectual disabilities or developmental disabilities and
who have been found eligible and have an open case with an ADSD Regional Center. Individuals
are eligible if they meet Medicaid's eligibility requirements and are either in an Intermediate Care
Facility for Individuals with Intellectual Disabilities (ICF/IID) or are at risk for ICF/IID placement
without the provision of HCBS and supports.
Eligibility for the ID Waiver is determined by the combined efforts of ADSD, the DHCFP and the
Division of Welfare and Social Services (DWSS). Two separate determinations must be made to
be eligible for and receive services under the ID Waiver:
a. Service eligibility for the ID Waiver is determined by an ADSD's Regional Center.
1. An ADSD Regional Center Intake Team, based on assessments and/or supporting
documentation, establishes the existence of an intellectual disability or
developmental disability.
2. Each applicant/recipient must meet and maintain Level of Care (LOC) for
admission into an ICF/IID. Specifically, the individual would require imminent
placement in an ICF/IID facility (within 30 to 60 days) if HCBS Waiver services
or other supports were not available.
3. Each applicant/recipient must demonstrate a continued need for a waiver service(s)
to prevent placement in an ICF/IID. Sole utilization of Medicaid State Plan Services
does not support the qualifications to be covered by the waiver.
4. The applicant/recipient must have a support system in place to ensure the physical,
environmental, and basic care needs of the applicant/recipient are met in order to
provide a safe environment during the hours when services are not being provided.
HCBS Waiver services are not a substitute for available natural and informal
supports provided by family, friends or other available community resources.
b. The financial eligibility determination for Medicaid benefits is made by the DWSS. Waiver
applicants/recipients must meet and maintain Medicaid eligibility coverage for all months
in which waiver services are provided.
c. Services from the ID Waiver cannot be provided until and unless the applicant is found
eligible in both determination areas.
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2103.1A COVERAGE AND LIMITATIONS
1. Waiver recipients must meet and maintain Medicaid’s eligibility coverage through the
DWSS for all months waiver services are being provided.
2. The ID Waiver is limited by legislative mandate and available matching state funding to a
specific number of recipients who can be served throughout the biennium. A waitlist is
utilized to prioritize applicants who have been presumed to be eligible for the waiver as
defined below.
a. First priority is individuals residing in an ICF/IID or other institutional settings.
b. Second priority is individuals who are at risk of institutionalization due to loss of
their current support system or crisis situation.
c. Third priority is all individuals, deemed appropriate for waiver services, who do
not fall under priority one or two, based on the date of request for a waiver service.
3. The DHCFP must assure the CMS that Medicaid’s total expenditures for waiver and
Medicaid State Plan services will not, in any waiver year, exceed 100% of the amount that
would be incurred by Medicaid for these individuals in an institutional setting in the
absence of the waiver. The DHCFP must also document that there are safeguards in place
to protect the health and welfare of recipients.
4. Waiver services must not be billed when an individual is admitted to an institutional setting,
such as a hospital, ICF/IID or nursing facility (NF) for the duration of the stay. Residential
settings that bill per diem may bill the per diem rate for admit and discharge days only
when services were provided and documented for some part of the days in question.
Residential settings that bill by the unit or hour may bill for services provided and
documented on admit and discharge days.
Section 3715 of the CARES Act may be utilized where HCBS can be provided in an acute
care hospital setting as long as those services are:
a. identified in an individual’s person-centered support plan (or comparable Plan of
Care (POC));
b. provided to meet needs of the individual that are not met through the provision of
hospital services;
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c. not a substitute for services that the hospital is obligated to provide through its
conditions of participation or under Federal or State law, or under another
applicable requirement; and
d. designed to ensure smooth transitions between acute care settings and home and
community-based settings, and to preserve the individual’s functional abilities.
5. If an applicant/recipient is determined eligible for more than one HCBS Waiver, the
individual cannot receive services under two or more such 1915(c) waivers at the same
time. The applicant/recipient must choose one HCBS Waiver and receive services provided
by that waiver.
6. Recipients of the ID Waiver who are enrolled or elect to enroll in a hospice program may
be eligible to remain on the waiver if they require waiver services to remain in the
community. Collaborative case coordination between the hospice agency and the waiver
Service Coordinator is required to prevent any duplication of services. Refer to MSM
Chapter 3200 for additional information on hospice services.
7. An able and/or capable parent, spouse or Legally Responsible Individual (LRI) of a
recipient has a duty/obligation to provide the necessary maintenance, education,
supervision and support. Necessary maintenance includes but is not limited to, the
provision of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living
(IADLs). Payment will not be made for the routine care, supervision or services normally
provided for the recipient without charge as a matter of course in the usual relationship
among members of the nuclear family. Waiver services are not a substitute for available
natural and informal supports provided by family, friends or other available community
resources; however, they are available to supplement those support systems, so the
recipient is able to remain in their home.
Allowance may be given in individual circumstances when:
a. there is no LRI residing in the recipient’s home;
b. or there is no other LRI residing in the home and an able and/or capable
spouse/parent’s employment requirements result in prolonged or unexpected
absences from the home;
c. or when such employment requirements require the able and/or capable
spouse/parent or LRI to work uninterrupted at home in order to meet the
requirement of his or her employer;
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d. or when employment requirements include unconventional work weeks or work
hours;
e. or the recipient’s support team has documented a need for ADL or IADL
habilitative services to be provided by direct support staff.
The LRI may be asked to provide verification from a physician, place of employment, or
school that they are not capable, due to illness or injury, or unavailable, due to hours of
employment and school attendance, to provide services. Additional verification may be
required on a case by case basis.
8. LRIs may not be reimbursed for HCBS Waiver services.
9. Legal guardians of individuals age 18 and over are considered LRIs.
10. The children made eligible for Medicaid through their enrollment in the Waiver for
Individuals with Intellectual and Developmental Disabilities receive all the medically
necessary Medicaid coverable services available under Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT). A child’s enrollment in the waiver will not be used
to deny, delay, or limit access to medically necessary services that are required to be
available to Medicaid-eligible children under federal EPSDT rules. The waiver service
package is a supplement to EPSDT services.
2103.1B PROVIDER RESPONSIBLITIES
Providers are responsible for confirming the recipient’s Medicaid eligibility each month prior to
rendering waiver services.
2103.1C RECIPIENT RESPONSIBLITIES
Applicants or recipients must meet and maintain all criteria to be eligible, and to remain on the ID
Waiver.
2103.2 WAIVER SERVICES
The ADSD, the operating agency for the ID waiver, in conjunction with the DHCFP, the
administrating agency determines which services will be offered under the ID Waiver.
Under this waiver, the following services are available:
A. Day Habilitation.
B. Residential Support Services.
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C. Prevocational Services.
D. Supported Employment.
E. Behavioral Consultation, Training and Intervention
F. Counseling Services.
G. Residential Support Management.
H. Non-Medical Transportation.
I. Nursing Services.
J. Nutrition Counseling Services.
K. Career Planning.
2103.2A PROVIDER RESPONSIBILITIES
1. Provider Requirements:
a. Must obtain approval or certification, as applicable, from ADSD/Developmental
Services (DS) pursuant to Nevada Revised Statute (NRS) 435, Nevada
Administrative Code (NAC) 435 and the ADSD Policy and Procedures.
b. Must obtain a Master Service Agreement through Department of Administration
Purchasing Division and a Provider Service Agreement through the ADSD.
c. Must enroll as a Provider Type 38 with Fee-for-Service Nevada Medicaid, meet
and maintain all the requirements to be enrolled as a Medicaid provider pursuant to
MSM Chapter 100 and 2100.
d. May not bill for services provided by an LRI.
e. May only provide and bill for services that have been authorized in the PCP. Prior
authorization for waiver services is made through the recipient’s PCP and Service
Authorization.
f. Must verify the Medicaid eligibility status of each HCBS Waiver recipient each
month.
g. Upon renewal of professional licenses/certifications, providers must submit copies
of renewals to the ADSD as applicable.
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h. Each provider must cooperate with the ADSD, the DHCFP and/or State or Federal
reviews or inspections.
i. Must have the ability to communicate with the recipient, understand the recipient
and implement the recipient’s PCP.
2. Criminal Background Checks:
A criminal background check is required for all owners, administrators, subcontractors,
volunteers and employees who have contact with recipients or access to their financial or
personal information.
Refer to MSM Chapter 100 for provider requirements.
All background check information must be maintained on file and available for review,
including the initial check and a recheck for each five (5) year period. Refer to NRS
435.220, 435.333, 435.537 and 435.893, NAC 435.515, 435.518, 435.520, 435.537,
435.845, 435.855, 435.860 and 435.893.
3. Required Training for Providers:
a. Employees must have Cardio Pulmonary Resuscitation (CPR) and First Aid
training within 30 days of hire and prior to working alone with recipients, if
providing direct service. Documentation of training must be kept on file and
available for review.
b. Must complete required training and new employee orientation, per ADSD policy,
within six months of beginning employment. Documentation of training to be kept
on file and available for review.
c. All providers are required to provide annual training to employees on recipient
rights; confidentiality; abuse, neglect, exploitation, isolation and abandonment
including definitions, signs, symptoms, and prevention; as well as incident and
serious occurrence reporting requirements. Providers will also complete established
training requirements as directed by the ADSD. Documentation of training must be
kept on file and available for review.
d. Supported Living provider employees who administer medication must maintain
current certification for Medication Administration pursuant to NAC 435.675.
Documentation of training must be kept on file and available for review.
e. Any employee who is likely to utilize restraint procedures in accordance with NRS
433 must maintain current certification in a Crisis Prevention/Intervention training
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program approved by the ADSD. Approved training programs require national
recognition and evidence of annual review and update of curriculum based on the
best legal, behavioral and ethical practices of standards of care. Documentation of
training must be kept on file and available for review.
4. Exemptions from Training
a. The ADSD, may exempt a prospective service provider from those parts of the
required training where the agency judges the person to possess adequate
knowledge or experience, or where the provider’s duties will not require the
particular skills.
b. The exemption and its rationale must be provided in writing and a copy of the
exemption must be placed in the recipient’s case record. Where the recipient or
other private third party functions as the employer, such individuals may exercise
the exemption authority identified above.
5. Documentation:
Providers must maintain relevant documentation of services provided on one or more
documents, including documents that may be created or maintained in electronic format.
This documentation must be kept in a manner as to fully disclose the nature and extent of
services delivered and must be readily available for review.
The documentation must include:
a. Type of service.
b. Date of service.
c. Name of recipient receiving service.
d. Recipient record number.
e. Name of provider.
f. Full written or electronic signature or initials of the person delivering the service if
a signature and corresponding initials are on file with the provider. For electronic
signatures, systems and software products must include protections against
modification, with administrative safeguards that correspond to policies and
procedures of the operating agency. The individual whose name is on the alternate
signature method and the provider bear the responsibility for the authenticity of the
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information being attested to. For example, an attendance record must have daily
initials and documentation of time in and time out.
g. Number of units of the delivered service during which time the service was
provided.
h. Signatures or initials of the recipient must be included on the Jobs and Day Training
(JDT) and Residential Support Services logs. If the recipient is unable to provide
initials due to a cognitive and/or physical limitation, this will be clearly documented
in the Person Centered Plan (PCP).
i. Recipient’s living in 24 hour Residential Support settings must have individualized
service logs, even if they have shared support hours with roommates living in the
home.
j. Providers are required to have copies of side effect information sheets for all
medications taken by the recipient on-hand and available for staff.
6. Incidents and Serious Occurrences:
Each Providers must report any recipient incidents to the ADSD. Serious occurrences are
to be reported to the ADSD within 24 hours. All other reportable incidents are to be
reported to the ADSD within two business days. All Serious Occurrence Reports must be
maintained on file by the provider. The ADSD will submit quarterly data to the DHCFP
for serious occurrence reports.
Serious occurrences involving either the provider/employee or recipient may include, but
are not limited to the following:
a. Unplanned hospitalization or ER visit;
b. Injury or fall requiring medical intervention;
c. Physical, verbal, emotional, sexual abuse or sexual harassment;
d. Assault, violence, or threat;
e. Suicide threat or attempt;
f. Criminal activity or legal involvement;
g. Theft or exploitation;
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h. Medication error per the ADSD policy;
i. Loss of contact with the recipient;
j. Elopement of a recipient residing in a 24-hour setting;
k. Death of the recipient; or
l. HIPAA violation;
m. Major property damage;
n. Auto accident (involving the recipient);
o. Staff injury/illness/accident requiring medical attention;
p. Environmental incident requiring emergency assistance
q. Death of unpaid caregiver.
7. Notification of Suspected Abuse, Neglect, Exploitation, Isolation, or Abandonment:
State law requires that individuals employed in certain capacities must make a report to the
appropriate law enforcement or applicable reporting agency immediately, but in no event
later than 24 hours after there is reason to suspect the abuse, neglect, exploitation, isolation,
or abandonment of a minor child, vulnerable adult or older individual. The DHCFP requires
that all providers be in compliance with the intent of all applicable laws.
For recipients under the age of 18, the Division of Child and Family Services (DCFS) or
the appropriate county agency accepts reports of suspected child abuse and neglect. For
vulnerable adults’ age 18 and over, or any adult 60 or over, Adult Protective Services
within the ADSD accepts reports of suspected abuse, neglect or self-neglect, exploitation
or isolation.
a. Child Abuse - Refer to NRS 432B regarding child abuse or neglect.
b. Abuse of a Vulnerable Adult or Oder Person- Refer to NRS 200.5091 to 200.50995
regarding elder abuse, exploitation, isolation neglect or abandonment.
c. Vulnerable adult (NRS 200.5091 to 200.50995) is defined as “a person 18 years of
age or older who:”
1. suffers from a condition of physical or mental incapacitation because of a
developmental disability, organic brain damage or mental illness; or
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2. has one or more physical or mental limitations that restrict the ability of the
person to perform the normal ADLs.
8. Complaint Procedure
The Provider must respond to all complaints in a reasonable and prompt manner. The
Provider must maintain records that identify the complaint, the date received and the
response, outcome and resolution of the incident.
The Provider must investigate and respond in writing to all written complaints within ten
calendar days of receipt.
The Provider will provide the recipient written notification of the complaint and its
outcome. As appropriate, written notification must also be provided to the Regional Center
Service Coordinator.
9. HIPAA, Privacy, and Confidentiality
Refer to MSM Chapter 100 for information on HIPAA, privacy, and confidentiality of
recipient records and other Protected Health Information (PHI).
10. The ADSD:
An Interlocal Agreement between the ADSD and the DHCFP is maintained to outline
responsibilities of both agencies in the operation and administration of the HCBS for the
ID Waiver.
11. Provider Agencies:
a. All employees must have a file which includes reference checks, CPR/First Aid
certification and documentation of new employee orientation and ongoing training.
All background check information must be maintained in a separate individual
employee file.
2103.2B RECIPIENT RIGHTS AND RESPONSIBILITIES
The Recipients are entitled to their privacy; to be treated with respect; and be free from coercion
and restraint.
Additionally applicants or recipients must meet and maintain all criteria to be eligible and to
remain on the ID Waiver.
The recipient or the recipient’s designated representative/LRI will:
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1. Notify the provider(s) and Service Coordinator of a change in Medicaid eligibility.
2. Notify the provider(s) and Service Coordinator of current insurance information, including
the name of other insurance coverage, such as Medicare.
3. Notify the provider(s) and Service Coordinator of changes in medical status, service needs,
address, and location, or changes of designated representative/LRI.
4. Treat all staff and providers appropriately with respect and in a safe manner.
5. Initial and/or sign the provider service documentation logs as applicable, verifying services
were rendered unless otherwise unable to perform this task due to intellectual and/or
physical limitations.
6. Notify the provider when scheduled visits cannot be kept.
7. Notify the provider and Service Coordinator of missed visits by provider staff.
8. Notify the ADSD and the provider if services are no longer requested or required.
9. Notify the provider and the ADSD Service Coordinator of unusual occurrences, complaints
regarding delivery of services or specific staff, or to request a change in caregiver.
10. If applicable, furnish the provider with a copy of their Advance Directives (AD).
11. Not request a provider to work more than the hours authorized in the PCP.
12. Not request a provider to provide service for a non-recipient, family, or household
members.
13. Not request a provider to perform services not included in the PCP.
14. Contact the Service Coordinator to request a change of provider.
15. Sign all required forms unless otherwise unable to perform this task due to intellectual
and/or physical limitations.
16. Cooperate with all the ADSD meetings and contacts such as phone/face-to-face as per the
PCP.
2103.3 DAY HABILITATION
Day Habilitation Services are regularly scheduled activities in a non-residential setting, separate
from the recipient’s private residence or other residential living arrangement. Services include
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assistance with the acquisition, retention, or improvement in self-help, socialization and adaptive
skills that include performing ADL’s and community living.
Activities and environments are designed to foster the acquisition of skill, building positive social
behavior and interpersonal competence, greater independence, and personal choice. Services will
include opportunities for volunteer work in community settings and opportunities for community
integration through participation in social, recreational, and cultural activities. Services furnished
are identified in the recipient’s PCP.
Day Habilitation services focus on enabling the recipient to attain or maintain his or her maximum
potential and shall be coordinated with any needed therapies in the recipient’s person-centered
services and support plans, such as physical, occupational, or speech therapy.
Day Habilitation services may also be used to provide supported retirement activities. This may
involve alternating schedules to allow for more time throughout the day or supports to participate
in hobbies, clubs, and/or activities in the community.
2103.3A COVERAGE AND LIMITATIONS
1. Recipients who receive Day Habilitation services and supports may have two or more types
of non-residential services. However, different types of non-residential habilitation
services may not be billed during the same time period of the day.
2. Day Habilitation may not provide for the payment of services that are vocational in nature
(i.e. for the primary purpose of producing goods or performing services).
3. Documentation is maintained in the file of each recipient receiving Day Habilitation that
the service is not available under a program funded by Section 110 of the Rehabilitation
Act of 1973 or Individuals with Disabilities Education Improvement Act (IDEA) (20
U.S.C. 1401 et seq.).
2103.3B DAY HABILITATION PROVIDER RESPONSIBILITIES
Refer to MSM Section 2103.2A.
2103.3C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.4 RESIDENTIAL SUPPORT SERVICES
Residential Support Services are designed to ensure the health and welfare of the recipient, as well
as the welfare of the community at large, through protective oversight and supervision activities
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in addition to support to assist in the acquisition, improvement, retention, and maintenance of the
skills necessary for recipients to successfully, safely, and responsibly reside in their community.
Residential Support Services are provided throughout the course of normal ADLs, as well as in
specialized training opportunities outlined in the recipient’s PCP. These services are individually
planned and coordinated, assuring the non-duplication of services with other Medicaid State Plan
Services. PCP teams may identify priority areas to address through habilitation plans, however
that does not limit additional supports that a person may need to live in the community. These
additional supports do not require habilitation plans.
Residential Support Services staff are trained and responsible for implementing the Individual
Habilitation Plans, goals and objectives, and other service supports related to residential and
community living. These supports include but are not limited to:
A. the facilitation of personal care;
B. ADLs and IADLs;
C. supports for health and welfare needs;
D. effective communication skills;
E. community inclusion
F. the development of natural support networks;
G. mobility training;
H. survival and safety skills;
I. support and teaching of interpersonal and relationship skills;
J. making choices and problem-solving skills;
K. community living skills;
L. social and leisure skills;
M. money management skills;
N. support and skill training related to health care needs, to include medication management.
Residential Support Services emphasize positive behavioral strategies, including interventions and
supervision designed to maximize community inclusion while safeguarding the recipient and
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general public. The Service Coordinator will ensure the recipient has freedom in their residential
setting. Services also support exercising recipient’s rights and protect against rights violations and
infringements without due process.
Intermittent Supported Living Services are services provided by an individual or organizational
provider to recipients residing in their own homes who do not require one-on-one supervision
and/or 24-hour care.
A Shared Living Arrangement is an arrangement in which an individual with a disability, and a
person, couple or family choose to live together in an integrated community neighborhood which
provides Residential Support Services through an intermittent Supported Living Arrangement
(SLA).
Twenty-four hour Supported Living Services are Residential Support Services provided up to 24
hours per day by an organizational provider. These services are delivered within homes in
integrated neighborhood settings.
Residential Support Services cannot duplicate the scope and nature of Medicaid State Plan
Personal Care Services (PCS). Services must be coordinated to ensure there is no duplication.
Waiver services must be authorized in the recipient’s PCP.
2103.4A COVERAGE AND LIMITATIONS
1. Residential Support Services staff receives training and are responsible for implementing
PCPs, goals, objectives, and service supports related to residential living and community
life.
These services include but are not limited to:
a. the participation in the development of the PCP.
b. adaptive skill development.
c. facilitation of personal care and ADLs.
d. facilitation of community inclusion.
e. facilitation of IADLs to include teaching community life skills; interpersonal and
relationship skills; building of natural support networks; choice making skills;
social and leisure skills; budgeting and money management skills.
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f. providing assistance with medication administration by a staff certified in an ADSD
approved Medication Program. Verification of certification must be maintained in
the employee files.
g. providing assistance with support and skill training in health care needs.
h. facilitation of mobility training, survival and safety skills.
2. Residential Support Services may be provided on a continuum of service delivery model
ranging from intermittent up to 24-hour SLA, as determined by the PCP team. Residential
Support Services are provided in either the service recipient's natural family home or in a
non-provider owned home or apartment; owned or leased in the service recipient’s name
or on behalf of the service recipient, with the exception of approved Shared Living services
and provider owned homes that have been approved by the Regional Center. The provider
is required to have a lease with each service recipient living in a provider owned home.
Residential Support Services are provided in integrated settings within community
residential neighborhoods. In 24-hour SLA, protective oversight hours must be shared with
other recipients in the home unless clear documentation exists that shows a need for one-
on-one supervision due to health and safety needs of the recipient which are supported in
the PCP and approved by the Regional Center Program Manager.
3. Under this service category, the responsibility for the living environment rests with the
service agency and encompasses a variety of SLAs:
a. Residential Support Services in a 24-hour setting are limited to four recipients
unless otherwise authorized by the Regional Center Program Manager.
b. SLAs are limited to two service recipients residing in one home, unless otherwise
authorized by the Regional Center Program Manager.
Individual SLA homes do not require state licensure; however, individual providers and
provider agencies must be certified by the ADSD in order to render services to ID Waiver
recipients.
2103.4B PROVIDER RESPONSIBILITIES
Refer to MSM 2103.2A, in addition to the provider responsibilities listed:
1. Providers must ensure the recipient has the freedom to furnish and decorate their living
area to their liking within the lease or other agreement.
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2. The Provider will ensure the setting is physically accessible to the recipient. The Provider
will ensure the units have entrance doors lockable by the individual, with only appropriate
staff having keys to doors.
3. Settings where landlord/tenant laws do not apply, the provider must ensure that a written
residential agreement is in place for the HCBS Waiver recipient and that it provides
comparable protections as those under the jurisdiction's landlord/tenant law.
4. Exceptions to the above must be supported by assessed need and clearly justified and
documented in the PCP.
2103.4C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM 2103.2B.
2103.5 PREVOCATIONAL SERVICES
Prevocational Services should enable recipients to attain the highest level of vocation in the most
integrated setting and by matching the recipient’s interests, strengths, priorities, abilities, and
capabilities to the job while following applicable Federal wage guidelines. The services are
intended to develop and teach general skills. Examples include but are not limited to: ability to
communicate with supervisors, co-workers and customers in the workplace setting; generally
accepted workplace conduct and dress; an ability to follow directions; an ability to complete tasks;
workplace problem solving skills and strategies; and workplace safety and mobility training.
Prevocational Services provides for learning and work experience, which may include volunteer
work, where a recipient can develop general, non-job or task-specific strengths and skills that
contribute to employability in paid employment within integrated community settings. Services
are expected to occur over a defined period of time and with specific outcomes to be achieved, as
identified in the recipient PCP. The services are designed to create a path to integrated, community-
based employment for which a recipient is compensated at or above the minimum wage, but not
less than the customary wage and level of benefits paid by the employer for the same or similar
work performed by individuals without disabilities.
Recipients receiving Prevocational Services must have employment-related goals in their PCP; the
general habilitative activities must be designed to support such employment goals Competitive,
integrated employment in the community for which a recipient is compensated at or above the
minimum wage, but not less than the customary wage and level of benefits paid by the employer
for the same or similar work performed by individuals without disabilities, considered to be the
optimal outcome for Prevocational Services.
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2103.5A COVERAGE AND LIMITATIONS
The Prevocational Services provided under this waiver are not available under a program funded
under Section 110 of the Rehabilitation Act of 1973 or Section 602(16) and (17) of the IDEA (20
U.S.C. 1401(16 and 17)). Documentation will be maintained in the file of each recipient receiving
Prevocational Services that the service is not otherwise available under a program funded under
the Rehabilitation Act of 1973, or P.L. 94-142.
1. Recipients who receive Prevocational Services may include two or more types of non-
residential support services; however, different types of non-residential support services
may not be billed during the same time period of the day.
2103.5B PROVIDER RESPONSIBILITIES
Refer to MSM Section 2103.2A.
2103.5C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.6 SUPPORTED EMPLOYMENT
Supported Employment Services are individualized and may include any combination of the
following services: Vocational job related discovery or assessment, person-centered employment
planning, job placement, job development, negotiation with prospective employers, job analysis,
job carving, training and systematic instruction, job coaching, benefit supports, training and
planning, transportation training, asset development and career advancement services and other
workplace support services including services not specifically related to job skill training that
enable the recipient to be successful in integrating into the job setting.
There are two sub-categories of Supported Employment – Individual Supported Employment and
Small Group Supported Employment.
A. Individual Supported Employment
Individual Supported Employment is for recipients who need intensive ongoing supports
to obtain and maintain a job that meets their personal and career goals in competitive,
customized employment, or self-employment, in an integrated work setting within the
general workforce for which an individual is compensated at or above the minimum wage,
but not less than the customary wage and level of benefits paid by the employer for the
same or similar work performed by individuals without disabilities. Individual Supported
Employment services do not include payment for supervision, training, support, or
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adaptations typically available to other workers without disabilities in similar positions in
the business. Individual Supported Employment services also do not include supports
needed for unpaid, volunteer opportunities.
One approach to individual supported employment is Customized Employment.
Customized Employment means individualizing the employment relationship between
employees and employers in ways that meet the needs of both. It is based on an
individualized determination of the strengths, needs and interest of the recipient, and is also
designed to meet the specific needs of the employer. Customized Employment assumes the
provision of reasonable accommodations and support necessary to perform the function of
a job that is individually negotiated and developed.
B. Small Group Supported Employment
Small Group Employment Supports are services and training activities provided in regular
business, industry, and community settings of two to eight workers with disabilities.
Examples include mobile crews which employ small groups of recipients in integrated
employment in the community with the goals of sustained paid employment and work
experience leading to further career development and individual integrated community-
based employment for which the recipient is compensated at or above the minimum wage,
but not less than the customary wage and level of benefits paid by the employer for the
same or similar work performed by individuals without disabilities. Small Group
Supported employment services do not include payment for supervision, training, support,
or adaptations typically available to other workers without disabilities in similar positions
in the business. Small Group Employment services also do not include supports needed for
unpaid, volunteer opportunities.
The desired outcome of Supported Employment services is sustained paid employment and work
experience leading to further career development and individual integrated community-based
employment for which the recipient is compensated at or above the minimum wage, but not less
than the customary wage and level benefits paid by the employer of the same or similar work
performed by individuals without disabilities.
2103.6A COVERAGE AND LIMITATIONS
1. When Supported Employment services are provided at a work site in which individuals
without disabilities are employed, payment will be made only for the adaptations,
supervision and training required by recipients as a result of their disabilities, and will not
include payment for the supervisory activities rendered as a normal part of the business
setting.
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2. Supported Employment furnished under the ID Waiver may not include services available
under a program funded under Section 110 of the Rehabilitation Act of 1973 or section
602(16) and (17), of the Individuals with Disabilities Education Act (IDEA) (20 U.S.C
1401 (16 and 17).
3. Supported Employment services do not include supports needed for unpaid, volunteer.
4. Federal Financial Participation (FFP) will not be claimed for incentive payments, subsidies,
or unrelated vocational training expenses such as the following:
a. Incentive payments made to an employer to encourage or subsidize the employer’s
participation in a Supported Employment services;
b. Payments that are passed through to users of Supported Employment services; or
c. Payments for vocational training that is not directly related to a recipient’s
Supported Employment services.
5. Supported Employment services do not include facility-based work settings, or other
similar types of vocational services furnished in specialized facilities that are not a part of
the general workforce.
6. Recipients who receive Supported Employment services may receive two or more types of
non-residential support services; however, different types of non-residential support
services may not be billed during the same period of the day.
2103.6B PROVIDER RESPONSIBILITIES
Refer to MSM Section 2103.2A.
2103.6C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.7 BEHAVIORAL CONSULTATION, TRAINING AND INTERVENTION
Behavioral Consultation, Training and Intervention Services provide behaviorally based
assessment and intervention for recipients, as well as support, training, and consultation to family
members, caregivers, paid residential support staff, or jobs and day training staff. This service also
includes participation in the development and implementation of the PCP and/or Positive Behavior
Support Plans, necessary to improve a recipient’s independence and inclusion in their community,
increase positive alternative behaviors, and/or address challenging behavior. These services are
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not covered under the State Plan and are provided by professionals in Psychology, Behavior
Analysis and related fields.
2103.7A COVERAGE AND LIMITATIONS
1. Behavioral Consultation, Training and Intervention may be provided in the recipient’s
home, school, workplace, and in the community. The services include:
a. functional behavioral assessment and an assessment of the environmental factors
that are precipitating a problem behavior;
b. development of Behavior Support Plan in coordination with the team members;
c. consultation and/or training on how to implement positive behavior support
strategies and/or Behavior Support Plan;
d. consultation or training on data collection strategies to monitor progress.;
e. monitoring of recipient and the provider(s) in the implementation and modification
of the support plan, as necessary;
f. Participation in the PCP;
g. Team meeting and medical appointments to provide resources information and
recommendations, as necessary; and
h. Providing a monthly summary of progress.
Behavioral Consultation, Training and Intervention may not exceed $5,200.00 per year per
recipient. Written authorization by the Regional Center is required for amounts in excess of the
limit.
2103.7B PROVIDER RESPONSIBILITIES AND QUALIFICATIONS
1. In addition to the provider responsibilities listed in MSM Section 2103.2A:
a. Employees of behavioral provider agencies and individual providers have:
1. Professional holding Bachelor’s level licensure and/or certification per NRS
437; or has a Bachelor’s degree in psychology, special education or closely
related field plus at least one year professional clinical experience using
behavior intervention and functional assessment procedures as well as
developing, implementing and monitoring of behavior support plans in
applied setting; or
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2. Professional holding Master’s level licensure and/or certification per NRS
437; or has a Master’s degree in psychology, special education or closely
related field with expertise in functional assessment and the provision of
positive behavioral supports.
b. Experience working with individuals with intellectual disabilities or developmental
disabilities is preferred.
2103.7C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.8 COUNSELING SERVICES
Counseling Services provide assessment/evaluation, consultation, therapeutic interventions,
support and guidance for recipients and/or family members, caregivers, and team members, which
are not covered by the Medicaid State Plan and which improve the recipient’s personal adaptation
and inclusion in the community. This service is available to recipients who have intellectual and/or
developmental disabilities and provides problem identification and resolution in areas of
interpersonal relationships, community participation, independence, and attaining personal
outcomes, as identified in the recipient’s PCP.
Counseling Services are specialized and adapted in order to accommodate the unique complexities
of enrolled recipients and may include;
A. consultation with team members, including family members, support staff, service
coordinators and other professionals comprising the participant's support team;
B. individual and group counseling services;
C. assessment/evaluation services;
D. therapeutic interventions strategies;
E. risk assessment;
F. skill development;
G. psycho educational activities;
H. participating in PCP Team meetings and appointments to provide resource information and
recommendations, as necessary; and
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I. providing a monthly summary of progress.
Counseling services are provided based on the recipient’s need to assure his or her health and
welfare in the community and enhance success in community living.
2103.8A COVERAGE AND LIMITATIONS
Counseling services may not exceed $1,500.00 per year per recipient. Written authorization by the
Regional Center is required for amounts in excess of the limit.
2103.8B PROVIDER RESPONSIBILITIES AND QUALIFICATIONS
1. In addition to the provider responsibilities listed in MSM Section 2103.2A:
a. Providers must have graduated from an accredited college or university with a
Master’s degree in a two year curriculum in counseling, marriage and family
therapy, psychology, social work or a closely related academic field. A closely
related field is licensed by the State of Nevada by appropriate categories; or
b. A graduate level intern who is enrolled in a Master’s level program at an accredited
college or university that provides at least two year curriculum in counseling,
marriage and family therapy, psychology, social work or a closely related
academic field or doctor level program in a clinical field; and are supervised by a
licensed clinician or mental health counselor.
c. Professional experience in a setting serving individuals with intellectual
disabilities is preferred.
2103.8C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.9 RESIDENTIAL SUPPORT MANAGEMENT
Residential Support Management is designed to ensure the health and welfare of recipients
receiving Residential Support Services from agencies. This service is intended to ensure the
supports are planned, scheduled, monitored, and implemented according to the recipient’s
preferences and needs depending on the frequency and duration of approved services.
2103.9A COVERAGE AND LIMITATIONS
1. Residential Support Management staff will assist the recipient in managing their supports
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within the home and community settings. This service includes:
a. assisting the recipient to develop one’s goal(s);
b. scheduling and attending interdisciplinary meetings;
c. develop habilitation plans specific to Residential Support Services, as determined
in the recipient’s PCP and training residential support staff in implementation and
data collection;
d. assisting the recipient to apply for and obtain community resources and benefits
such as Medicaid, Supplemental Security Income (SSI), Social Security Disability
Insurance (SSDI), Housing and Urban Development (HUD), Supplemental
Nutrition Assistance Program (SNAP), housing, etc.;
e. assisting the recipient in locating residences;
f. assisting the recipient in arranging for and effectively managing community
resources and informal supports;
g. assisting the recipient to identify and sustain a personal support network of family,
friends, and associates;
h. providing problem solving and support with crisis management;
i. supporting the recipient with budgeting, bill paying, and with scheduling and
keeping appointments;
j. observing, coaching, training and providing feedback to direct service staff to
ensure they have the necessary and adequate training to carry out the supports and
services identified in the PCP;
k. following up with health and welfare concerns and remediation of deficiencies;
l. completing required paperwork on behalf of the recipient (as needed);
m. making home visits to observe the recipient’s living environment to assure health
and welfare; and
n. providing information to the Service Coordinator (Targeted Case Manager) and
support team members to allow evaluation and assurance that support services
provided are those defined in the PCP and are effective in assisting the recipient to
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reach his or her goals.
Residential Support Managers must work collaboratively with the recipient’s Service Coordinator
as well as other support team members. Residential Support Management services are different
from Targeted Case Management as the Service Coordinator is responsible for the development
of the PCP, which is the overall HCBS support plan, in consultation with the PCP Team.
2103.9B PROVIDER RESPONSIBILITIES AND QUALIFICATIONS
In addition to provider listed in 2103.2A, Residential Support Managers must have:
1. A High School Diploma or equivalent and two years’ experience providing direct
service in a human services field and remain under the direct supervision/oversight
of a Qualified Intellectual Disabilities Professional (QIDP) or its equivalent; or
2. Completion of a Bachelor’s degree from an accredited college or university in
psychology, special education, counseling, social work, or closely related field and
one year of experience meeting the qualification of a QIDP.
2103.9C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.10 NON-MEDICAL TRANSPORTATION
Non-Medical Transportation service are offered to enable recipients to gain access to community
activities. Non-Medical Transportation service allows recipients to engage in normal day-to-day
non-medical activities such as going to the grocery store or bank, participating in social and
recreational events or attending a worship service; activities are not all inclusive. Whenever
possible, family, neighbors, friends, or community agencies should provide this service without
charge.
2103.10A COVERAGE AND LIMITATIONS
1. This service will not duplicate or impact the amount, duration and scope of the Medical
Transportation benefit provided under the Medicaid State Plan. Refer to MSM Chapter
1900 for more information regarding the coverage and limitations of State Plan Medical
Transportation.
2. Non-Medical Transportation services under this waiver must be described or identified in
the recipient’s PCP before the service is utilized. The use of Non-Medical Transportation
must be summarized in the provider’s quarterly progress report.
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3. Non-Medical Transportation fees cannot exceed $100.00 per month per recipient.
2103.10B PROVIDER RESPONSIBILITIES
In addition to provider responsibilities listed in 2103.2A, providers must have:
1. A valid Nevada Driver’s License and provide verification of safe driving record and proof
of driver’s liability insurance.
2. Evidence of vehicle safety inspection completed prior to transporting recipient’s and
completion of ongoing periodic vehicle safety inspections. Providers are responsible for
obtaining vehicle safety inspections and providing them to the ADSD upon request.
2103.10C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.11 NURSING SERVICES
There are three components of Nursing Services: Medical Management, Nursing Assessment, and
Direct Services, (over and above State Plan).
1. Medical Management
These services will be provided by a Registered Nurse (RN) or Licensed Practical Nurse
(LPN) licensed in the state. Services are geared toward the development of health services
support plans; training of direct support staff or family members to carry out treatment;
monitoring of staff knowledge and competence to improve health outcomes; assistance
with revision of health support plans in response to new or revised treatment orders or lack
of positive outcomes of current supports by staff; monitoring/ assessment of the recipient’s
condition in response to current health supports provided; and as needed assistance with
referrals to other medical providers. This service includes professional observation and
assessment, individualized program design and implementation, training of recipients and
family members, consultation with caregivers and other agencies, and monitoring and
evaluation of planning and service outcomes. The functions outlined for this service differs
from case management in that this service relates directly to the medical needs of the
individual.
In addition, nurses may attend PCP team meetings and physician visits as needed to provide
advocacy, resource information and recommendations to team and treating physicians in
order to facilitate health supports.
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2. Nursing Assessment
This service will be completed by a RN to identify the needs, preferences, and abilities of
the recipient. The assessment includes: an interview with the recipient; and/or their
designated representative/LRI, an observation by the nurse to consider the symptoms and
signs of condition, verbal and nonverbal communication skills, medical and social history,
medication and any other information available.
The nurse will assess vital signs, skin color and condition, motor and sensory nerve
function, reproduction, dentition, height, nutrition, rest, sleep patterns, physical activities,
elimination, and level of consciousness. Additionally, the following social and emotional
factors will be assessed which include religion, occupation, attitudes on health care, mood,
emotional tones, family ties and responsibility. The assessment is extremely important
because it provides recommendations for medical and mental health care and follow-up
which are shared with the recipient’s team for review and inclusion in the PCP. Nursing
assessments may be performed and completed upon approved referral and authorization of
the service coordinator. Assessments are completed by a RN and provide the basis for
recommendations for medical and mental health care and follow-up, which are shared with
the person’s team for review and inclusion in the individual’s support plan.
3. Direct Services
This service provides routine medical and health care services that are integral to meeting
the daily needs of participants. This includes the routine administration of medication by
nurses tending to the needs of participants who are ill and providing care to participants who
have ongoing medical needs. Direct skilled nursing services are intended to be provided by
an RN or LPN in a community setting, including home or work, as described and approved
in the recipient’s PCP. LPNs must be under the supervision of a RN licensed in the state.
Services include skilled medical care that is integral to meeting the daily medical needs of
recipient. These services are intended to allow individuals under this waiver to live safely
within an integrated community setting.
Services are limited to those that only a licensed professional can provide versus non-skilled
care that unlicensed staff can provide such as, activities of daily living.
Skilled services include, but are not limited to: medication administration, wound care,
nasogastric or gastronomy tube feeding, ostomy care, tracheotomy aspiration care, and
catheter care, only when the procedure can be performed safely by a RN or LPN.
2103.11A COVERAGE AND LIMITATIONS
1. Nursing Services must be provided within the Scope of the Nevada Nurse Practice Act.
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2. Nursing Services must be provided by an RN or LPN under the supervision of an RN who
is licensed to practice as a nurse in the State of Nevada.
3. Nursing Services under the ID Waiver must include nursing progress notes and summaries
on all nursing activities.
4. Nursing Services may be provided in the recipient’s home, work site, or in other
community settings as described in the PCP.
5. Nursing Services provided in this waiver will not duplicate the Nursing Services covered
under the Medicaid State Plan.
2103.11B PROVIDER RESPONSIBILITIES AND QUALIFICATIONS
In addition to provider responsibilities listed in 2103.2A providers must be:
1. An RN in accordance with NRS 632 licensing requirements; or
2. An LPN under the supervision of an RN in accordance with NRS 632 licensing
requirement.
2103.11C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.12 NUTRITION COUNSELING SERVICES
Nutrition Counseling Services include assessment of the recipient’s nutritional needs,
development and/or revision of recipient’s nutritional plan, nutritional counseling and nutritional
intervention, observation and technical assistance related to successful implementation of the
nutritional plan. These services include:
a. Nutritional training, education and consultation for recipients and their families or support
staff involved in the day-to-day support of the recipient;
b. Completing comprehensive assessment of nutritional needs;
c. Developing, implementing and monitoring of nutritional plan incorporated in the PCP,
including updating and making changes in the PCP as needed;
d. Assisting in menu planning and healthy menu options; and
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e. Providing monthly case notes on nutritional activities and summaries of progress on the
nutritional plan.
These waiver-covered nutritional duties are above and beyond those approved and covered under
Medicaid State Plan Services.
2103.12A COVERAGE AND LIMITATIONS
This service is limited to $1,300.00 per year, per recipient. This service does not include the cost
of meals or food items.
2103.12B PROVIDER ADDITIONAL RESPONSIBILITIES AND QUALIFICATIONS
In addition to the provider responsibilities/qualifications listed in MSM Section 2103.2A,
providers must be:
1. A registered Dietician as certified by the American Dietetic Association.
2. Licensed to practice in the State of Nevada.
2103.12C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.13 CAREER PLANNING
Career Planning is a person-centered, comprehensive employment planning and support service
that provide assistance for recipients to obtain, maintain, or advance in competitive employment
or self-employment. It is time limited and focuses on engaging a recipient in identifying a career
direction and developing a plan for achieving integrated employment at or above minimum wage.
Career Planning includes activities that are primarily directed at assisting a recipient with
identification of an employment goal and creating a plan to achieve this goal that are associated
with performing competitive work in community integrated employment. This can be achieved by
job exploration, job shadowing, informational interviewing, assessment of interests and labor
market research.
The providers coordinate, evaluate and collaborate with recipients, designated representative/LRI,
support team, employers and others who can assist with discovering recipients’ skills, abilities,
interests, preferences, conditions and needs. This support and evaluation should be provided to the
maximum extent possible in the presence of the recipient and should be conducted in the
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community, but completion of activities in the home or without the presence of the recipient should
not be precluded.
A. If a waiver recipient is employed, career planning may be used to explore other competitive
employment career objectives which are more consistent with the person’s skills and
interests, or to explore advancement opportunities in his or her chosen career.
B. Career Planning should be reviewed and considered as a component of a recipient’s person-
centered services and support plan, no less than annually, more frequently as necessary, or
as requested by the recipient.
C. These services should be designed to support successful employment outcomes consistent
with the recipient’s goals.
D. Career Planning may include social security benefits support, training, consultation and
planning as well as assessments for the use of assistive technology in the workplace to
increase independence.
E. The setting for the delivery of services must be aligned with the individualized need and
that which is most conducive in developing a career objective and a career plan.
The outcome of this service is documentation of the individual's stated career objective and career
plan used to guide individual employment support. Services include planning for sufficient time
and experiential learning opportunities to allow for appropriate exploration, assessment and
discovery processes for learning about career options, as well as the participant’s skills and
interests. Career Planning may include informational interviewing, job tours, job shadowing,
community exploration, community and business research, benefit supports, job preference
inventories, situational and community-based assessments, job sampling, training and planning, as
well as assessments for the use of assistive technology in the workplace to increase independence.
2103.13A COVERAGE AND LIMITATIONS
1. The PCP may include two or more types of non-residential habilitation services. However,
different types of non-residential habilitation services may not be billed simultaneously. If
a waiver recipient is receiving Pre-Vocational Services or Day Habilitation Services,
Career Planning may be used to develop additional learning opportunities and career
options consistent with the recipient’s skills and interest.
2. Career Planning will be limited to 216 hours within a six-month time period each year per
recipient. The six-month periods may not be provided consecutively.
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3. Career Planning furnished under the waiver may not include services available under a
program funded under section 110 of the Rehabilitation Act of 1973 or section 602(16) and
(17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401 (16 and 17).
2103.13B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in MSM Section 2103.2A, providers of Career
Planning must have:
1. Experience in working with individuals with intellectual and developmental disabilities
providing employment service and job development.
2. Knowledge of person-centered career planning, job analysis, supported employment
services, situational and community-based assessments, best practices in customized
employment, and knowledge of the business needs of an employer.
3. A Valid Nevada Driver’s License. Must also have access to an operational and insured
vehicle and be willing to use it to transport recipients. (Providers will bill Career Planning
unit rate for time spent transporting, this is not a separate rate); And
4. Evidence of vehicle safety inspection completed prior to transporting recipient’s and
completion of ongoing periodic vehicle safety inspections. Providers are responsible for
obtaining safety inspections and providing them to the ADSD upon request.
2103.13C RECIPIENT RIGHTS AND RESPONSIBILITIES
Refer to MSM Section 2103.2B.
2103.14 INTAKE PROCEDURES
A. WAIVER REFERRAL AND PLACEMENT ON THE WAIT LIST
1. A referral or inquiry for the waiver may be made by a potential applicant or by
another party on behalf of the potential applicant by contacting the local ADSD
Regional Center. The Regional Center staff will discuss waiver services, including
eligibility requirements with the referring party or potential applicant.
2. The Service Coordinator must conduct a LOC screening to verify eligibility for the
wait list.
NOTE: If the applicant does not meet an LOC, they will receive a Notice of
Decision (NOD) which includes the right to a fair hearing.
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3. All applicants who meet waiver criteria must be placed on the statewide waiver
wait list by priority and referral date. The following must be completed before
placement on the wait list:
A. The applicant must meet LOC criteria for placement in an ICF/IID.
B. The applicant must require at least one ongoing waiver service.
C. The applicant must meet criteria for an intellectual or developmental
disability.
Applicants will be sent a NOD indicating “no slot available. The ADSD will notify the
DHCFP LTSS Unit when no slot is available. The applicant will remain on the waiting list
until a waiver slot is available.
The allocation of waiver slots is maintained with the ADSD. As waiver slots become
available, ADSD determines how many slots may be allocated.
B. WAIVER SLOT ALLOCATION
Once a waiver slot is allocated by the ADSD, the applicant will be processed for the waiver.
The procedure used for processing an applicant will be as follows:
1. The ADSD Service Coordinator will schedule a face-to-face visit with the applicant
to complete the full waiver assessment to include diagnostic data, LOC
determination, and will obtain all applicable forms, including but not limited to the
Authorization for Release of Information.
The applicant and/or designated representative/LRI must understand and agree that
personal information may be shared with providers of services and others as
specified on the form.
The ADSD Service Coordinator will inform the applicant and/or designated
representative/LRI that, pursuant to NRS 232.357, the Divisions within the Nevada
Department of Health and Human Services (DHHS) may share confidential
information between themselves without a signed authorization for release of
information.
The Service Coordinator will provide an application to apply for Medicaid benefits
through DWSS if the applicant does not have these benefits already in place. The
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applicant is responsible for completing the application and submitting all requested
information to DWSS. The Service Coordinator will assist upon request.
2. The applicant/recipient will be given the right to choose waiver services in lieu of
placement in an ICF/IID. If the applicant/recipient and/or designated
representative/LRI prefers placement in an ICF/IID, the service coordinator will
assist the applicant/recipient in arranging for facility placement.
3. The applicant/recipient will be given the right to request a hearing if not given a
choice between HCBS Waiver and ICF/IID placement.
4. When the applicant/recipient is approved by the ADSD for the ID Waiver services,
the following will occur:
a. A team meeting is held, and a written PCP is developed in conjunction with
the recipient and the PCP Team to determine specific service needs and to
ensure the health and welfare of the recipient. The applicant/recipient and/or
designated representative/LRI and provider(s) must sign and date the PCP.
Interim PCP’s, unsigned by the applicant/recipient and/or designated
representative/LRI and the provider(s), may be authorized for up to 60 days
from the PCP development meeting.
Note: Applicant/recipients already receiving services via the ADSD State
General Funds will already have a PCP in place.
b. The applicant/recipient, the applicant/recipient’s family, or the designated
representative/LRI, providers, and participants of the applicant/recipient’s
choice are included in the development of the PCP.
c. Applicants/recipients will be given the free choice of all qualified available
Medicaid providers of each Medicaid covered service included in the
written individual support plan. Current PCP must be given to all service
providers and kept in the recipient’s record.
d. All forms must be complete with signatures and/or initials and dates by the
applicant/recipient and/or designated representative/LRI and provider(s),
where required. Electronic signatures are acceptable, as pursuant to NRS
719, on forms that require a signature.
e. The ADSD will forward a completed waiver packet requesting to add a
benefit plan to the DHCFP LTSS Unit.
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1. The HCBS Waiver Eligibility Status form will be sent by the
DHCFP Central Office Waiver Unit to the ADSD Service
Coordinator.
2. The ADSD is responsible for notifying the DWSS of approval to
coordinate waiver slot allocation.
3. The DWSS is responsible for notifying the ADSD of the applicants’
status, to initiated. waiver services.
C. SUPPORT PLAN DEVELOPMENT
Developmental Services uses a person-directed planning process. Assessment information
assists the team with identifying barriers to reaching the person’s vision, desired outcomes,
and support needs. Goals related to reaching the vision are developed based on the person’s
desired life outcomes, as well as any needs for maintaining appropriate health and welfare.
This information is provided to the person-centered team for plan development at the PCP
meeting. This process provides direction for the identification of goals and assures that the
meeting focuses on the participant and his or her priorities, preferences, and perspective.
The PCP is developed utilizing applicable assessments that may include a social
assessment, health assessment, risk assessment, or self-medication administration
assessment tool.
The support plan is inclusive of the services and supports that are provided to meet the
assessed needs of the participant. The service coordinator is responsible for understanding
all services provided to the service recipient, gathering assessment, information,
developing the PCP based on team recommendations, facilitating plans for any necessary
referrals, and monitoring all services, as part of the support plan implementation. The
support plan also identifies the priority areas to be addressed based upon the person-
centered planning process. The PCP will identify which priority areas of support require
habilitation plans. Additional supports, including general supervision, can be provided as
needed to assist the individual with their daily life living in the community without the
need for habilitation plans.
D. EFFECTIVE DATE FOR WAIVER SERVICES
The effective date for waiver services approval is the completion date of all the intake
forms, or the waiver eligibility determination date by the DWSS, whichever is later. If the
applicant is in an institution, the effective date cannot be prior to the date of discharge from
the institution.
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Waiver services will not be backdated beyond the first of the month in which the waiver
eligibility determination is made by the DWSS.
E. SERVICE COORDINATION
Service Coordination is provided under the Medicaid State Plan Targeted Case
Management service. This is an integral part of the management of the ID Waiver.
Refer to MSM Chapter 2500 for allowable activities under Targeted Case Management.
F. WAIVER COST
The DHCFP must assure CMS that the average per capita expenditures under the waiver
will not exceed 100% of the average per capita expenditures for the institutional LOC under
the Medicaid State Plan that would have been made in that fiscal year, had the waiver not
been granted.
2103.15 PERMANENT CASE FILE
A. For each approved ID Waiver recipient, the Service Coordinator must maintain a
permanent record that documents services provided under the ID Waiver. The service
provider is also required to maintain their billing documents and service records.
B. These records must be retained for six years from the date the last claim is paid.
2103.16 SERVICE COORDINATOR RECIPIENT CONTACTS
A. Recipient Contact
1. The Service Coordinator must have monthly contact with each waiver recipient, or
a recipient’s designated representative/LRI, or the recipient’s Supported Living or
Jobs and Day Training provider. The contact must be sufficient to address health
and safety needs of the recipient, needed support plan changes, recipients’ goals
and satisfaction with services and supports. At a minimum, there must be a face-to-
face visit with each recipient quarterly.
2. During quarterly contacts, the Service Coordinator will monitor whether the
habilitation plans are meeting identified goals and provide any necessary follow up
on needs or concerns.
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a. The Service Coordinator must show due diligence to hold the established
contacts as outlined in the PCP and every attempt to contact the recipient
must be documented. At least three attempts must be completed on separate
days within the quarter, if no response is received after the 3rd attempt, a
letter must be sent to the recipient requesting a return contact. If the
recipient fails to respond by the date indicated in the letter, the recipient
may be terminated.
b. When DHCFP is conducting a review of a recipient and the Service
Coordinator has clearly documented the above steps were attempted during
any given quarter wherein a quarterly contact was required, DHCFP shall
waive that quarterly contact requirement.
B. Reassessment
1. Recipients must be reassessed at least annually within the same month. The
recipient and provider(s) must sign and date the PCP. Interim PCP’s, unsigned by
the recipient and provider(s), may be authorized for up to 60 days.
2. The recipient must also be reassessed when there is a significant change in his/her
condition.
3. The number of hours specified on each recipient’s Service Authorization for each
specific service, are considered the maximum number of hours allowed to be
provided by the provider and paid by the ADSD and the DHCFP, unless the Service
Coordinator has approved additional hours due to a temporary condition or
circumstances. Providers are allowed to provide fewer services than stated on the
Service Authorization if the reason for providing less service is adequately
documented.
4. When the recipient’s service needs increase, due to a temporary condition or
circumstance, the Service Coordinator must thoroughly document the increased
service needs in their case notes. The PCP does not need to be revised for temporary
conditions or circumstances. A temporary condition or circumstance is defined as
an increase or decrease in service needs for a period not to exceed 30 days.
5. Residential Support Management hours are defined in the PCP. A temporary
increase in the residential support management hours for the recipient must receive
prior authorization from the ADSD, within the month of the temporary increase,
and be justified based on health, safety and welfare concerns. If an increase is
warranted to exceed a 30-day period, there must be a reassessment based on
thorough documentation in the Residential Support Managers case notes reflecting
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the health, safety and welfare concerns and the Service Authorization must be
revised.
a. Reassessment Procedures
During the reassessment process, the Service Coordinator must:
1. Re-affirm the recipient meets the waiver criteria outlined in Section
2103.1.
2. Re-assess the recipient’s ability to perform ADLs and IADLs,
his/her medical and mental status and support systems.
3. Re-evaluate the services being provided and progress made toward
the goal(s) stated in the PCP.
4. Develop a revised PCP.
5. Re-assess the recipient’s LOC.
6. Inform recipients about their rights, including the right to be free
from abuse, neglect, exploitation, isolation and abandonment.
2103.17 BILLING PROCEDURES
The State assures that claims for payment of ID Waiver services are made only when a recipient
is Medicaid eligible and only when the service is included in the approved PCP plan.
Refer to the fiscal agent’s website at: www.medicaid.nv.gov for the Provider Billing Guide
Manual.
2103.18 DHCFP ANNUAL REVIEW
The DHCFP (administrative authority) conducts an annual program review of the ID Waiver
operated by the ADSD to assess policy adherence, recipient quality of life, and the health and
welfare of recipients receiving waiver services. The State must operate this waiver in accordance
with certain “assurances” identified in Federal regulations. CMS has designated waiver assurances
and sub assurances that states must include as part of an overall quality improvement strategy,
which are:
1. The State demonstrates that it implements the processes and instrument(s) specified in its
approved waiver for evaluating/reevaluating a recipient’s LOC consistent with care
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provided in a hospital, NF or ICF/IID.
a. An evaluation for LOC is provided to all recipients for whom there is reasonable
indication that services may be needed in the future.
b. The processes and instruments described in the approved waiver are applied
appropriately and according to the approved description to determine initial
recipient LOC.
2. Support Plan: The State demonstrates it has designed and implemented an effective system
for reviewing the adequacy of supportive service plans for waiver recipients.
a. Support Plans address recipients assessed needs (including health and safety risk
factors) and personal goals, either by the provision of waiver services or through
other means as determined by the PCP team through the person-centered planning
process.
b. Support Plans are updated/revised at least annually or when warranted by changes
in the waiver recipient’s needs.
c. Services are delivered in accordance with the support plan, including the type,
scope, duration, and frequency specified in the support plan.
3. Qualified Providers: The State demonstrates that it has designed and implemented an
adequate system for assuring that all waiver services are provided by qualified providers.
a. The State verifies that providers initially and continually meet required licensure
and /or certification standards and adhere to other standards prior to their furnishing
waiver services.
b. The State implements its policies and procedures for verifying that training is
provided in accordance with State requirements and the approved waiver.
4. Health and Welfare: The State demonstrates it has designed and implemented an effective
system for assuring wavier recipient health and welfare.
a. The State demonstrates on an ongoing basis that it identifies, addresses and seeks
to prevent instances of abuse, neglect, exploitation, isolation and unexplained
death.
b. The State demonstrates that an incident management system is in place that
effectively resolves those incidents and prevents further similar incidents to the
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extent possible.
c. The State policies and procedures for the use or prohibition of restrictive
interventions (including restraints and seclusion) are followed.
d. The State assures overall health and safety and monitors these assurances based on
the responsibility of the service provider as stated in the approved waiver.
5. Financial Accountability: The State must demonstrate that it has designed and implemented
an adequate system for ensuring financial accountability of the waiver.
a. The State provides evidence that claims are coded and paid for in accordance with
the reimbursement methodology specified in the approved waiver and only for
services rendered.
b. The State provides evidence that rates remain consistent with the approved rate
methodology through the five-year waiver cycle.
6. Administrative Authority: The DHCFP retains ultimate administrative authority and
responsibility for the operation of the waiver by exercising oversight of the performance
of waiver functions by other state and local/regional non-state agencies (if appropriate) and
contracted entities.
The annual review is conducted using the above assurances and sub assurances as well as
state specified performance measures identified in the approved ID waiver in order to
evaluate the operation of the waiver.
Providers must cooperate with the DHCFP’s annual review process.
2103.19 MEDICAID PROVIDER ENROLLMENT PROCESS
1. All providers should refer to the MSM Chapter 100 for enrollment procedures.
2. All providers must comply with all the DHCFP and ADSD enrollment requirements,
provider responsibilities/qualifications, the DHCFP and ADSD provider agreement and
limitations set forth in this chapter.
3. Provider non-compliance with all or any of these stipulations may result in the DHCFP’s
decision to exercise its right to terminate the provider’s contract.
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2104 HEARINGS REQUEST DUE TO ADVERSE ACTIONS
An adverse action refers to denials, terminations, reductions or suspensions of a recipient’s
eligibility determination or an applicant’s request for services. The DHCFP must grant an
opportunity for a hearing to an applicant/recipient/designated representative/LRI in the event an
adverse action is taken by the DHCFP.
2104.1 SUSPENDED WAIVER SERVICES
A. A recipient’s case must be suspended, instead of closed, if it is likely the recipient will be
eligible again for waiver services within the next 60 days (for example if a recipient is
admitted to an institutional setting, such as a hospital, a NF, or ICF/IID).
B. After receiving written notification from the Service Coordinator with the admission date
and the request for suspension of waiver services, a NOD identifying the effective date and
the reason for suspension will be provided to the recipient by the DHCFP LTSS unit.
C. If at the end of 60 days the recipient has not been removed from suspension status, the
waiver must be terminated.
D. The DHCFP LTSS unit sends a NOD to the recipient and/or designated representative/LRI
advising them of the date and reason for the waiver closure/termination.
E. Waiver services will not be paid for the days that a recipient’s eligibility is in suspension
status.
2104.2 RELEASE FROM SUSPENDED WAIVER SERVICES
When a recipient has been released from the hospital, NF or an ICF/IID before 60 days from the
admit date, the Service Coordinator must do the following within five working days:
A. Notify the DHCFP LTSS Unit of the release of suspension.
B. Complete a new PCP if there has been a significant change in the recipient’s condition
needs. If a change in services is expected to resolve in less than 30 days, a new PCP is not
necessary. Documentation of the temporary change must be made in the Service
Coordinator’s notes. The date of the resolution must also be documented in the Service
Coordinator’s notes.
C. Complete a new Service Authorization, if necessary.
D. Contact the service providers(s) to re-establish services.
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2104.3 DENIAL OF WAIVER APPLICATION
Reasons an applicant will be denied for waiver services:
a. The applicant does not meet the criteria of being diagnosed with intellectual or
developmental disability.
b. The applicant does not meet the LOC criteria for placement in an ICF/IID).
c. The applicant has withdrawn their request for waiver services.
d. The applicant fails to cooperate with the Service Coordinator or the HCBS providers in
establishing and/or implementing the PCP implementing waiver services or verifying
eligibility for waiver services.
e. The applicant’s support system is not adequate to provide a safe environment during the
time when HCBS are not being provided. HCBS services are not a substitute for natural
and informal supports provided by family, friends or other available community resources.
f. The applicant fails to show a need for HCBS.
g. The applicant would not require imminent placement in an ICF/IID if HCBS were not
available. (Imminent placement means within 30 to 60 days.)
h. Another agency or program will provide the services.
i. The ADSD has filled the number of slots allocated to the ID Waiver. The applicant has
been approved for the waiver waitlist and will be contacted when a slot is available.
When the application for waiver services is denied the DHCFP LTSS Unit will issue a NOD,
within five business days, to the recipient or designated representative/LRI identifying the reason
for denial. The Date of Action (DOA) is the same date as the NOD date.
2104.4 TERMINATION OF WAIVER SERVICES
Reasons to terminate a recipient from the waiver:
A. The recipient no longer meets the criteria of an intellectual or developmental disability.
B. The recipient no longer meets the LOC criteria for placement in an ICF/IID.
C. The recipient has requested termination of waiver services.
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D. The recipient has failed to cooperate with the Service Coordinator or HCBS providers in
establishing and/or implementing the support plan, implementing waiver services, or
verifying eligibility for waiver services.
E. The recipient’s support system is not adequate to provide a safe environment during the
time when HCBS are not being provided. HCBS Waiver services are not a substitute for
natural and informal supports provided by family, friends or other available community
resources.
F. The recipient fails to show a continued need for HCBS.
G. The recipient no longer requires imminent ICF/IID placement if HCBS Waiver services
were not available. (Imminent placement means within 30 to 60 days.)
H. The recipient has moved out of state.
I. Another agency or program will provide the services.
J. The recipient has been, or is expected to be, institutionalized over 60 days (in a hospital,
nursing facility, ICF/IID, or incarcerated) ****See below.
K. The ADSD has lost contact with the recipient.
L. Death of the recipient.
When a recipient is scheduled to be terminated from the ID Waiver, the Service Coordinator will
send a notification to the DHCFP LTSS Unit identifying the reason for termination. The DHCFP
LTSS Unit will send a NOD to the recipient or the recipient’s designated representative/LRI. The
form must be mailed by the DHCFP to the recipient at least 13 calendar days before the DOA on
the NOD. Refer to MSM Chapter 3100 for exceptions to the advance notice.
****Service Coordinators must track recipient stays in an institutional setting. Five days prior to
the 45th day, the Service Coordinator will send a notification to the DHCFP LTSS Unit identifying
the 60th day of inpatient status, which is the termination date for waiver services.
Waiver slots must be held for 90 days, from the date the NOD is sent to the recipient indicating
termination or institutional placement, in case they are released and need waiver services upon
release.
2104.5 REDUCTION OR DENIAL OF WAIVER SERVICES
Reasons to reduce or deny waiver services:
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a. The recipient no longer needs the number of service/support hours/days which were
previously provided.
b. The recipient no longer needs the service/supports previously provided.
c. The recipient’s parent and/or designated representative/LRI is responsible for the
maintenance, health care, education and support of their minor child or ward.
d. The recipient’s support system is providing the service.
e. The recipient has failed to cooperate with the Service Coordinator or HCBS providers in
establishing and/or implementing the support plan, implementing waiver services, or
verifying eligibility for waiver services.
f. The recipient has requested the reduction of supports/services.
g. The recipient’s ability to perform tasks has improved.
h. Another agency or program will provide the service.
i. Another service will be substituted for the existing service.
j. The recipient has reached the authorized unit or annual service limit.
When a recipient has a reduction of waiver services, the Service Coordinator will send a
notification to the DHCFP LTSS Unit identifying the reason for the reduction and what the service
is being reduced to. The LTSS Unit will send a NOD to the recipient or the recipient’s designated
representative/LRI. The form must be mailed by the DHCFP to the recipient at least 13 calendar
days before the DOA on the NOD.
When a recipient is denied waiver services, the Service Coordinator will send a notification to the
DHCFP LTSS Unit identifying the reason for the denial. The LTSS Unit will send a NOD to the
recipient or the recipient’s designated representative/LRI within five days, identifying the reason
for denial. The DOA is the same date of the NOD date.
2104.6 REAUTHORIZATION WITHIN 90 DAYS
When a recipient is placed in an institutional setting such as nursing facility, ICF/IID, or hospital,
they must be sent a NOD terminating them from the waiver 60 days from admit date. Their waiver
slot must be held for 90 days from the NOD date. A recipient may be placed back in that slot if
they are released within 90 days of the NOD date, and request reinstatement, but must continue to
meet waiver eligibility criteria. After 90 days, their slot may be given to the next individual on the
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wait list. If a recipient requests reinstatement after the 90 days expired, they are treated as a new
referral.
The Service Coordinator will send a notification to the DHCFP LTSS Unit identifying the
reinstatement date.
2104.7 HEARINGS PROCEDURES
Please reference MSM Chapter 3100, Hearings, for hearings procedures.
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TRANSMITTAL LETTER
January 26, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, RECIPIENT HIPAA PRIVACY & CIVIL RIGHTS OFFICER
/Jessica Kemmerer/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 2200 – HOME AND COMMUNITY BASED SERVICES (HCBS) WAIVER FOR
THE FRAIL ELDERLY
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2200 – are being proposed to bring this chapter in
line with the current waiver renewal which was approved on July 1, 2020.
Changes to this chapter include: updating the term “Home and Community-Based Waiver” (HCBW) to
“Home and Community-Based Services” (HCBS) throughout the chapter to adhere to CMS guidance;
changing the form referred as “NMO-2734” to “Waiver Eligibility Status Form” throughout the chapter;
expanding the term “goals” to “personalized goals” throughout the chapter (as applicable); updated the
term ‘working day’ to ‘business day’ throughout the chapter; updated the term “authorized
representative” to designated representative,” deleted the term “QIO-like vendor” throughout the
chapter and identified the vendor as “fiscal agent” where applicable; added the term Legally Responsible
Individual (LRI) throughout the chapter; and corrected the term from ‘Waiver Unit’ to ‘LTSS Unit’
throughout the chapter; deleting the term “program” from “waiver program” and replaced with waiver
for clarity; added the titles to the Statues and Regulations throughout the chapter.
The policy was revised under Intake, Referral Prescreening process, Placement on the Waitlist and Waiver
slot Allocation as the process has been updated and streamlined. Policy was revised in Suspended Waiver
Services and reorganized.
The Assisted Living Waiver expired 6/30/14 and was combined with the Frail Elderly (FE) Waiver effective
7/1/2014. Some of the policy from the Assisted Living Waiver Chapter was added to the FE Waiver. Some
sections within the FE Waiver were moved to organize the content, and to improve and clarify policies
throughout the chapter.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and re-
arranging of sections was necessary.
Entities Financially Affected: None.
Financial Impact on Local Government: Unknown at this time.
These changes are effective February 01, 2021.
Page 1 of 12
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 03/21 MTL 31/10, 38/11, 18/19, 22/12, 23/11
CHAPTER 2200 – HOME AND COMMUNITY CHAPTER 2200 – HOME AND COMMUNITY BASED
BASED SERVICES (HCBS) WAIVER FOR THE FRAIL SERVICES (HCBS) WAIVER FOR THE FRAIL ELDERLY
ELDERLY
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2200 Introduction Terminology and acronyms were updated per the
description provided in the Background and
Explanation section above.
The second paragraph was deleted and replaced with a
reworded version that better reflects an overview of
the waiver.
Several sentences were moved from sections 2201 and
modified for clarity.
2201 Authority Terminology and acronyms were updated per the
description provided in the Background and
Explanation section above.
Added the acronym for the Social Security Act – SSA.
Updated the CFR to the appropriate citation style.
Added “Section 3715 of the Care’s Act, removed CFR
418; 431; 440; 441; 489; State Medicaid Manual Section
4440; Nevada’s Home and Community Based Waiver
for the Frail Elderly Control Number; and H.R. 6042
115th Congress.
2203.1 Waiver Eligibility Terminology and acronyms were updated per the
Criteria description provided in the Background and
Explanation section above.
This section was moved from 2203.2 to 2203.1. The
language in this section was reworded for clarity.
Added details of existing waiver eligibility
requirements: must meet DWSS eligibility; additional
requirements for Residential Group Homes for Seniors
and Assisted Living Facility; added NAC 449 citation.
Page 2 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
The DHCFP approval and intake requirements have
been removed as well as Administrative Case
Management Activities.
2203.1A Coverage and This section was moved from 2203.2A to 2203.1A.
Limitations
Added clarifications regarding providing and
reimbursement of services provided outside eligibility
period; clarification in case the recipient is eligible for
more than one waiver; criteria for participants in a
hospice program; CARES Act guidelines.
Deleted a sentence related to Wait List Priority, no
policy was changed with the deletion.
Clarification regarding changes of placement on the
waitlist based on changes in condition/circumstances.
2203.1B Provider A portion of this section was moved from 2203.1B to
Responsibilities 2203.11B.
2203.1C Recipients A portion of this section was moved from 2203.1C to
Responsibilities 2203.11C.
2203.2 Waiver Services This section was moved from 2203.3 to 2203.2.
2203.2A Coverage and This section was moved from 2203.3A to 2203.2A.
Limitations Added language to clarify “remain in the community”.
2203.2B Provider This section was moved from 2203.3B to 2203.2B.
Responsibilities Terminology and acronyms were updated per the
description provided in the Background and
Explanation section above. Sections have been
reworded for clarity.
Added Waivers for Adults in a facility based assisted
living Provider Type (PT 59); clarified all providers must
meet federal, state and local statutes, rules and
regulations; added the right to terminate provider
contracts for failure to comply with any or all
stipulations; providers are responsible for claims
submitted; clarified providers capacity and guidelines
to provide services;
The section regarding Criminal Background checks was
updated and portion removed as it is outlined in MSM
100 and is duplicative.
Page 3 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
Created new section #3 titled “Recipient Records”;
removed paragraphs one to four; added PERS; deleted
“Services for waiver recipients residing in a residential;
expanded on the requirements of record keeping for
the provider’s documentation on claims, employees
and recipients’ files. Added 21st Century Cures Act.
Updated NRS # from 449.037 to NRS # 449.0302,
original NRS # has been changed, and added the title to
the regulations listed within this section.
Added information regarding the web based SOR Form
available at the fiscal agent’s website. Added 3 new
reportable events under Incidents and Serious
Occurrences.
Deleted the “ADSD: in addition to” section an additional
responsibilities remaining criteria regarding Criminal
Background checks (this is duplicative, it is outlined in
MSM 100).
The Qualification and Training section added “abuse,
neglect, and exploitation, including signs, symptoms,
and prevention;” to subsection #5.
Created sub-section under # 5: b. “Additional training
requirements for Residential Group Homes for Seniors
and Assisted Living Facilities” to list the training and
qualifications applicable to residential facilities under
this section.
2203.2C Recipients This section was moved from 2203.3 to 2203.2C.
Responsibilities Terminology and acronyms were updated per the
description provided in the Background and
Explanation section above. The content was
reorganized, and the language was updated/reworded
for clarity.
Added criteria of required environment for providers
and staff.
Added requirement to work with Case Manager and
provider to create a back-up plan in case caregiver is
unavailable to work.
Added regarding annual face-to-face visit.
Page 4 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
Added guidelines if case management is the only
service provided, monthly contact is required.
Added recipient is not eligible for EPSDT.
Early and Periodic Screening, Diagnostic and
Treatment section 2203.2D was removed.
2203.3 Case Management This section was renumbered from 2203.4 to 2203.3
and subsequent sections numbered accordingly.
Renamed from “Direct Service Case Management” to
“Case Management”.
The language was updated/reworded for clarity.
2203.3A Coverage and Terminology and acronyms were updated per the
Limitations description provided in the Background and
Explanation section above. The content was
reorganized, and the language was updated/reworded
for clarity.
Added language to #5 requiring inquiries and narration
of recipient’s choice to continue waiver services.
The last sentence was moved down to create #11 and
language was expanded for clarity.
Added to detail due diligence regarding ongoing
contacts with recipients as outlined in the POC.
2203.3B Providers Terminology and acronyms were updated per the
Responsibilities description provided in the Background and
Explanation section above.
2203.3C Recipients Terminology and acronyms were updated per the
Responsibilities description provided in the Background and
Explanation section above.
2203.4 Homemaker Services This section was renumbered from 2203.5 to 2203.4,
and all subsequent sections renumbered accordingly.
The first sentence of #2 was moved up from Coverage
and Limitations, language was added for clarity.
2203.4A Coverage and The following language was added “at the recipient’s
Limitations home, or place of residence (community setting)” and
removed “by agencies enrolled as a Medicaid provider."
Page 5 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2203.4B Provider Requirements Terminology and acronyms were updated per the
description provided in the Background and
Explanation section above.
2203.4C Recipients Expanded the acronym IVR, Interactive Voice
Responsibilities Response.
2203.5 Chore Services This section was renumbered from 2203.6 to 2203.5
and all subsequent sections renumbered accordingly.
The beginning of #2 was moved up from 2203.5A
Coverage and Limitations, language was added for
clarity.
2203.5A Coverage and Minor deletions made for clarity and in accordance
Limitations with the description provided in the Background and
Explanation section above.
2203.5B Provider Replaced “Section” with “MSM.
Responsibilities
2203.6 Respite Care This section was renumbered from 2203.7 to 2203.6
and all subsequent sections renumbered accordingly.
A portion was moved up from 2203.6A Coverage and
Limitations, language was added to describe the
services provided.
2203.6A Coverage and Language was added to clarify the period of services,
Limitations the services are provided for the duration of the POC,
and services must be prior authorized by ADSD.
2203.6B Provider Terminology and acronyms were updated per the
Responsibilities description provided in the Background and
Explanation section above.
Replaced “Section” with “MSM.
Deleted “perform general assistance with ADLs and
IADLs and provide supervision to functionally impaired
recipients in their private home;”.
2203.7 Personal Emergency This section was renumbered from 2203.8 to 2203.7
Response System and all subsequent sections renumbered accordingly.
Page 6 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
The first item was moved up from 2203.7A Coverage
and Limitations’ Language was added to describe the
services provided.
2203.7A Coverage and Added “The service component includes both, the
Limitations installation of the device and monthly monitoring. Two
separate authorizations are required for payment, the
initial installation fee for the device and a monthly fee
for ongoing monitoring; both are covered under the
waiver.”
2203.7B Provider Replaced “Section” with “MSM.
Responsibilities
Added monthly monitoring of the PERS device.
Removed reference to Better Business Bureau as this is
not a requirement for enrollment.
Language was updated for clarity.
2203.7C Recipients This section was renumbered from 2203.9 to 2203.8
Responsibilities and all subsequent sections renumbered accordingly.
2203.8 Adult Day Care A portion of #1 and all of #2 and #3 where moved up
Services from 2203.8A Coverage and Limitations, language was
added to describe the services provided.
2203.8A Coverage and Terminology and acronyms were updated per the
Limitations description provided in the Background and
Explanation section above. Added language to clarify
timeframe of service.
Added “Meals must be served in a manner suitable for
the recipient and prepared with regard for individual
preferences. Special diets and nourishments must be
provided as ordered by the client’s physician.”
Deleted “Reference MSM Chapter 1900 for
transportation policies.”
2203.8B Adult Companion This section was renumbered from 2203.10 to 2203.9
Services and all subsequent sections renumbered accordingly.
Item 1 was moved up from 2203.9A Coverage and
Limitations. Language was added to describe the
services provided.
Page 7 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2203.9A Coverage and Language was updated for clarity.
Limitations
Added “Reference MSM Chapter 1900 Transportation
Services for transportation policies.”
2203.9B Provider Replaced “Section” with “MSM.
Responsibilities
Language was added for clarity.
2203.10 Augmented Personal This section was renumbered from 2203.11 to 2203.10
Care and all subsequent sections renumbered accordingly.
Terminology and acronyms were updated per the
description provided in the Background and
Explanation section above.
2203.10A Coverage and Deletion of the first item listed due to duplication.
Limitations
Added language and details regarding the recipient’s
placement on the waiver based on the recipient needs.
Service Level definitions clarified and added definition
for new SL4 approved at the 2017 legislative session
for recipients with critical behaviors. Added
clarification on reassessment due to changes and the
need for providers to keep daily log documentation.
Expanded on the definition of personalized care as
established by CMS’s new HCBS waivers rule.
Added language from the Assisted Living chapter
regarding core principles for residential facilities
providing personalized care.
2203.10B Provider Replaced “Section” with “MSM.
Responsibilities
Terminology and acronyms were updated per the
description provided in the Background and
Explanation section above.
Added language regarding the recipient’s choice and
satisfaction with services provided. Clarifying verbiage
was added in accordance with CMS’s new HCBS
Waiver rules.
Section regarding Recipient Records was added.
Page 8 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2203.10C Recipient Terminology and acronyms were updated per the
Responsibilities description provided in the Background and
Explanation section above.
2203.11 Administrative Case This was moved from original section 2203.1 to
Management Activities 2203.11. Subsequent sections (2203.1A Coverage and
Limitations, 2203.1B Provider Responsibilities and
2203.1C Recipient Responsibilities) moved and
renumbered accordingly.
“Intake Procedures” was deleted.
2203.11A Coverage and Service activities updated for language clarity through
Limitation section. Deleting repetitive wording. Terminology and
acronyms were updated per the description provided
in the Background and Explanation section above.
Added screening for LOC determination of level of
services offered and development of the POC details.
2203.11B Provider Added “In addition to the provider responsibilities
Responsibilities listed in MSM 2203.3B Case Manager:
Language was streamlined for clarity.
2203.11C Recipient Terminology and acronyms were updated per the
Responsibilities description provided in the Background and
Explanation section above.
2203.12 Intake Procedures Terminology and acronyms were updated per the
description provided in the Background and
Explanation section above.
2203.12A Coverage and Terminology and acronyms were updated per the
Limitations description provided in the Background and
Explanation section above.
Replaced ‘intake worker’ with “ADSD Intake Specialist”
to identify the person that will contact the applicant.
Updated the requirement for the initial contact for a
new referral from 7 days to 15 working days per FE
Waiver.
Added information regarding time frame requirement
to complete face-to- face assessment of 45days
(previously 28 days and not included in FE chapter).
Page 9 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
Updated sub-section title from “No Waiver Slots
Available” to “Placement on the Wait List”; the section
was reworded for clarity.
Added language to clarify applicant’s placement on the
waitlist while financial eligibility is determined and for a
slot to become available.
Updated sub-section title to “Waiver Slot Allocation”.
Added language to clarify that once a waiver slot
becomes available a second face-to-face visit is
required to complete the initial assessment.
Added language regarding the procedure for the initial
assessment process and requirements to complete the
Comprehensive Social Health Assessment (CSHA),
forms given to the applicant during assessment. Added
time frame to indicate the CSHA is valid for 90 days for
applicants on the waitlist.
Updated the information the ADSD includes in the
initial assessment packet and clarification of the
approval/denial process between DHCFP and ADSD.
2203.13 Annual Waiver Review This section was moved, now in section 2203.13.
2203.13A Coverage and This section was moved, now in section 2203.13A.
Limitations
2203.13B Provider This section was moved, now in section 2203.13B.
Responsibilities
Updated verbiage to in accordance with Background
and Explanation section above.
2203.15 Provider Enrollment This section was moved, now in section 2203.12.
Added PT numbers and location information of the
enrollment checklist.
Section title “2203.12A Coverage and Limitations” was
deleted.
2203.16 Billing Procedures This section was renumbered and is now 2203.16.
Added link of the fiscal agent’s website for Provider
Billing Guide Manual information.
Page 10 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
Deleted Coverage and Limitations and Provider
Responsibilities sections, the information is duplicative
of the Provider Billing Guide Manual.
2203.17 Advance Directive This section was renumbered from 2203.15 to
2203.17.
This section was moved, now in section 2203.16.
2204 Hearings Requested The title of the section was updated from “Hearings” to
Due to Adverse “Hearings Requested Due to Adverse Actions”.
Actions
Added explanation of the hearings process due to
adverse action taken on the waiver eligibility.
2204.1 Suspended Waiver Terminology and acronyms were updated per the
Services description provided in the Background and
Explanation section above.
The language was updated / reworded for clarity
throughout section.
Added new suspension reason due to an extended
absence
2204.2 Release from The language was updated / reworded for clarity
suspended waiver throughout section.
services
2204.3 Denial of waiver Language was updated/reworded for clarity
application throughout the section.
Added note under letter ‘m’ to explain the Case
Manager’s responsibility to provide information on how
to become a provider and assist as needed before
terminating the recipient from waiver services.
2204.4 Termination of waiver Terminology and acronyms were updated per the
services description provided in the Background and
Explanation section above.
Deleted the first reason as the DHCFP or the ADSD do
not terminate waiver services for that reason.
Added note under letter ‘o’ to explain the Case
Manager’s responsibility to provide information on how
Page 11 of 12
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
to become a provider and assist as needed before
terminating the recipient from waiver services.
Deleted the “ADSD” on the paragraph at the end of the
section, as the Case Manager can be private or from the
ADSD.
Reworded the last paragraph of this section for
clarification that one DWSS receives notification of the
recipient’s death, the DWSS need to notify ADSD and
DHCFP.
Added “Death of the recipient.”
2204.5 Reduction of waiver Terminology and acronyms were updated per the
services description provided in the Background and Explanation
section above.
2204.6 Reauthorization within Introduction was moved from 2204.6A with updates to
90 days of waiver terminology, and acronyms were updated per the
termination description provided in the Background and
Explanation section above.
2204.6A Coverage and Terminology and acronyms were updated per the
Limitations description provided in the Background and
Explanation section above.
Clarified process for slot allocation for what to do with
the slot when someone enters a nursing facility (NF) or
hospital. The slot is held 90 days from the date on the
notice termination.
2204.6B Provider This was reworded for clarity.
Responsibilities
2204.6C Recipients This was reworded for clarity.
Responsibilities
2205 Appeals and Hearings Added language to clarify the need to inform the
applicants and recipients of the opportunity to request
a Fair Hearing.
Page 12 of 12
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
HOME AND COMMUNITY BASED WAIVER (HCBW) FOR THE FRAIL ELDERLY
2200 INTRODUCTION ...........................................................................................................................1
2201 AUTHORITY ..................................................................................................................................1
2202 RESERVED .....................................................................................................................................1
2203 POLICY…….. .................................................................................................................................1
2203.1 WAIVER ELIGIBILITY CRITERIA..............................................................................................1
2203.1A COVERAGE AND LIMITATIONS ...............................................................................................2
2203.1B PROVIDER RESPONSIBILITIES .................................................................................................3
2203.2 WAIVER SERVICES ......................................................................................................................3
2203.2A COVERAGE AND LIMITATIONS ...............................................................................................3
2203.2B PROVIDER RESPONSIBILITIES .................................................................................................4
2203.2C RECIPIENT RESPONSIBILITIES .................................................................................................9
2203.3 CASE MANAGEMENT ...............................................................................................................10
2203.3A COVERAGE AND LIMITATIONS .............................................................................................10
2203.3B PROVIDER RESPONSIBILITIES ...............................................................................................12
2203.3C RECIPIENT RESPONSIBILITIES ...............................................................................................12
2203.4 HOMEMAKER SERVICES .........................................................................................................13
2203.4A COVERAGE AND LIMITATIONS .............................................................................................13
2203.4B PROVIDER RESPONSIBILITIES ...............................................................................................14
2203.4C RECIPIENT RESPONSIBILITIES ...............................................................................................14
2203.5 CHORE SERVICES ......................................................................................................................15
2203.5A COVERAGE AND LIMITATIONS .............................................................................................15
2203.5B PROVIDER RESPONSIBILITIES ...............................................................................................15
2203.5C RECIPIENTS RESPONSIBILITIES .............................................................................................16
2203.6 RESPITE CARE ............................................................................................................................16
2203.6A COVERAGE AND LIMITATIONS .............................................................................................16
2203.6B PROVIDER RESPONSIBILITES .................................................................................................16
2203.6C RECIPIENTS RESPONSIBILITIES .............................................................................................17
2203.7 PERSONAL EMERGENCY RESPONSE SYSTEM (PERS) ......................................................17
2203.7A COVERAGE AND LIMITATIONS .............................................................................................17
2203.7B PROVIDER RESPONSIBILITIES ...............................................................................................17
2203.7C RECIPIENTS RESPONSIBILITIES .............................................................................................18
2203.8 ADULT DAY CARE SERVICES .................................................................................................18
2203.8A COVERAGE AND LIMITATIONS .............................................................................................18
2203.8B PROVIDER RESPONSIBILITIES ...............................................................................................19
2203.9 ADULT COMPANION SERVICES .............................................................................................19
2203.9A COVERAGE AND LIMITATIONS .............................................................................................19
2203.9B PROVIDER RESPONSIBILITIES ...............................................................................................19
2203.9C RECIPIENTS RESPONSIBILITIES .............................................................................................20
2203.10 AUGMENTED PERSONAL CARE .............................................................................................20
Page 1 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
2203.10A COVERAGE AND LIMITATIONS .............................................................................................20
2203.10B AUGMENTED PERSONAL CARE PROVIDER RESPONSIBILITIES ....................................23
2203.10C RECIPIENT RESPONSIBILITIES ...............................................................................................25
2203.11 ADMINISTRATIVE CASE MANAGEMENT ACTIVITIES .....................................................26
2203.11A COVERAGE AND LIMITATIONS .............................................................................................26
2203.11B PROVIDER RESPONSIBILITIES ...............................................................................................27
2203.11C RECIPIENT RESPONSIBILITIES ...............................................................................................27
2203.12 INTAKE PROCEDURES ..............................................................................................................27
2203.12A COVERAGE AND LIMITATIONS .............................................................................................27
2203.13 ANNUAL WAIVER REVIEW .....................................................................................................30
2203.13A COVERAGE AND LIMITATIONS .............................................................................................30
2203.13B PROVIDER RESPONSIBILITIES ...............................................................................................31
2203.14 ELECTRONIC VISIT VERIFICATION (EVV)...........................................................................31
2203.15 PROVIDER ENROLLMENT .......................................................................................................32
2203.16 BILLING PROCEDURES ............................................................................................................32
2203.17 ADVANCE DIRECTIVES............................................................................................................33
2204 HEARINGS REQUESTS DUE TO ADVERSE ACTIONS ...........................................................1
2204.1 SUSPENDED WAIVER SERVICES..............................................................................................1
2204.2 RELEASE FROM SUSPENDED WAIVER SERVICES ...............................................................1
2204.3 DENIAL OF WAIVER APPLICATION ........................................................................................2
2204.4 TERMINATION OF WAIVER SERVICES ...................................................................................3
2204.5 REDUCTION OF WAIVER SERVICES .......................................................................................4
2204.6 REAUTHORIZATION WITHIN 90 DAYS OF WAIVER TERMINATION ...............................5
2204.6A COVERAGE AND LIMITATIONS ...............................................................................................5
2204.6B PROVIDER RESPONSIBILITIES .................................................................................................5
2204.6C RECIPIENT RESPONSIBILITIES .................................................................................................5
2205 APPEALS AND HEARINGS .........................................................................................................1
Page 2 of 2
MTL 03/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2200
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
2200 INTRODUCTION
The Home and Community-Based Services (HCBS) Waiver for the Frail Elderly (FE Waiver)
recognizes that many individuals at risk of being placed in hospitals or Nursing Facilities (NF) can
be cared for in their homes and communities, preserving their independence and ties to family and
friends at an average cost no higher than that of an institutional care.
The FE Waiver is an optional service approved by the Centers for Medicare and Medicaid Services
(CMS), which authorizes the Division of Health Care Financing and Policy (DHCFP) the
flexibility to design this waiver and select the mix of waiver services that best meet the goals of
the program. This waiver allows the provision of services based on the identified needs and is
designed to provide eligible Medicaid waiver recipients access to both state plan services as well
as certain extended Medicaid covered services.
Nevada acknowledges that people who are elderly are able to lead satisfying and productive lives
when they are provided the needed services and supports to do so. The DHCFP is committed to
the goal of providing the elderly with the opportunity to remain in a community setting in lieu of
institutionalization when appropriate.
HOME AND COMMUNITY- BASED SERVICES
February 1, 2021 (HCBS) WAIVER FOR THE FRAIL ELDERLY Section 2200 Page 1
MTL 03/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2201
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
2201 AUTHORITY
Section 1915(c) of the Social Security Act (SSA) permits states the option to waive certain
Medicaid statutory requirements in order to offer an array of home and community-based services
to eligible individuals who may require such services in order to remain in their communities and
avoid institutionalization.
Statutes and Regulations:
• Social Security Act: 1915(c) (HCBW)
• Health Insurance Portability and Accountability Act of 1996 (HIPAA)
• Nevada Revised Statutes (NRS) Chapters 200 (Crimes Against the Person), 426 (Persons
with Disabilities), 427A (Services to Aging Persons and Persons with Disabilities), 422
(Health Care Financing and Policy), 449 (Medical and Other Related Facilities), 616
(Industrial Insurance), 629 (Healing and Arts Generally)
• Nevada Administrative Code (NAC) Chapters 427A (Services to Aging Persons), 441A
(Communicable Diseases), 449 (Medical and Other Related Facilities)
• 21st Century Cures Act, H.R. 34, Sec. 12006 – 114th Congress
• Section 3715 of the Care’s Act
HOME AND COMMUNITY-BASED SERVICES
February 1, 2021 (HCBS) WAIVER FOR THE FRAIL ELDERLY Section 2201 Page 1
MTL 03/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2202
Subject:
MEDICAID SERVICES MANUAL RESERVED
2202 RESERVED
HOME AND COMMUNITY-BASED SERVICES
February 1, 2021 (HCBS) WAIVERFOR THE FRAIL ELDERLY Section 2202 Page 1
MTL 03/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2203
Subject:
MEDICAID SERVICES MANUAL POLICY
2203 POLICY
2203.1 WAIVER ELIGIBILITY CRITERIA
The DHCFP’s Home and Community-Based Services (HCBS) for the Frail Elderly waives certain
statutory requirements and offers waiver services to eligible recipients to assist them to remain in
their own homes or community.
Eligibility for Medicaid’s HCBS Waiver is determined by the Aging and Disability Services
Division (ADSD) and the Division of Welfare and Supportive Services (DWSS). These State
agencies collaboratively determine eligibility for the Waiver as follows:
A. Waiver benefit plan eligibility is determined by ADSD by confirming the following
criteria:
1. Applicants must be 65 years of age or older;
2. Each applicant/recipient must meet and maintain a Level of Care (LOC) for
admission into a NF and would require imminent placement in a NF (within 30
days or less) if HCBS services or other supports were not available;
3. Each applicant/recipient must demonstrate a continued need for the services offered
under the FE Waiver to prevent placement in a NF or hospital. Utilization of State
Plan Services only does not support the qualifications to be covered by the waiver;
4. The applicant/recipient must require the provision of one waiver service at least
monthly;
5. The applicant/recipient must have an adequate support system. This support system
must be in place to ensure the physical, environmental and basic care needs of the
applicant/recipient are met in order to provide a safe environment during the hours
when home and community-based services are not being provided; and
6. Applicants may be placed from a NF, an acute care facility, another HCBS
program, or the community.
B. Applicant must meet institutional income and resource guidelines for Medicaid as
determined by the Division of Welfare and Supportive Services (DWSS).
C. Additional requirements for Residential Group Homes for Seniors and Assisted Living
Facility:
1. Applicant/recipient must meet the criteria for placement in a Category 1 or 2
Residential Facility as defined by NAC 449.1591 and 449.1595.
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2. Residential Group Homes for Seniors and Assisted Living Facility must have the
appropriate endorsement for the admission from Health Care Quality and
Compliance (HCQC).
2203.1A COVERAGE AND LIMITATIONS
1. Services are offered to eligible recipients who, without the waiver services, would require
institutional care (provided in a hospital or NF) within 30 days or less.
2. Recipients on this waiver must meet and maintain Medicaid’s eligibility requirements for
the waiver. Recipients must be waiver eligible for each month in which waiver services are
provided.
3. Services shall not be provided and will not be reimbursed until the applicant/recipient is
found eligible for waiver services and must be prior authorized.
4. If an applicant is determined eligible for more than one HCBS Waiver, the individual
cannot receive services under two or more such programs at the same time. The applicant
must choose one HCBS Waiver and receive services provided by that program.
5. Recipients of the HCBS Waiver who are enrolled or elect to enroll in a hospice program
may be eligible to remain on the waiver if they require waiver services to remain in the
community. Close coordination between the hospice agency and the waiver case manager
is required to prevent any duplication of services. Refer to Medicaid Services Manual
(MSM) Chapter 3200 for additional information on hospice services.
6. Waiver services may not be provided while a recipient is an inpatient of an institution.
Section 3715 of the CARES Act may be utilized where HCBS can be provided in an acute
care hospital setting as long as those services are:
a. identified in an individual’s person-centered service plan (or comparable Plan of
Care (POC);
b. provided to meet needs of the individual that are not met through the provision of
hospital services;
c. not a substitute for services that the hospital is obligated to provide through its
conditions of participation or under Federal or State law, or under another
applicable requirement; and
d. designed to ensure smooth transitions between acute care settings and home and
community-based settings, and to preserve the individual’s functional abilities.
7. The Waiver is limited by legislative mandate to a specific number of recipients who can be
served through the waiver per year (slots). When no waiver slots are available, the ADSD
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utilizes a wait list to prioritize applicants who have been presumed to be eligible for the
waiver.
Wait List Priority:
a. Applicants currently in an acute care or NF and desiring discharge;
b. Applicants who require maximum assistance and/or are dependent in all three areas
of eating, bathing, and toileting;
c. Applicants requiring services due to a crisis or emergency such as a significant
change in support system;
d. Applicants transitioning from another waiver;
e. Applicants with a terminal illness; or
f. Applicants who do not meet the criteria for priority levels 1-5.
Applicants may be considered for an adjusted placement on the wait list based on significant
change of condition/circumstances.
2203.1B PROVIDER RESPONSIBILITIES
Providers are responsible for confirming the recipient’s Medicaid eligibility each month prior to
rendering waiver services.
Applicants/recipients must meet and maintain all eligibility criteria to become eligible and to
remain on the HCBW for the Frail Elderly.
2203.2 WAIVER SERVICES
The DHCFP determines which services will be offered under the HCBS Waiver. Providers and
recipients must agree to comply with all waiver requirements for service provision.
2203.2A COVERAGE AND LIMITATIONS
Under this waiver, the following services are covered if identified in the POC as necessary to
remain in the community and to avoid institutionalization.
1. Case Management.
2. Homemaker Services.
3. Chore Services.
4. Respite Care Services.
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5. Personal Emergency Response System (PERS).
6. Adult Day Care Services.
7. Adult Companion Services.
8. Augmented Personal Care (provided in a residential facility for groups).
2203.2B PROVIDER RESPONSIBILITIES
1. All Service Providers:
a. Must obtain and maintain a provider number (Provider Type 48, 57 or 59 as
appropriate) through the DHCFP’s Fiscal Agent.
b. All providers must meet all federal, state, and local statutes, rules and regulations
relating to the services being provided.
c. In addition to this Chapter, the provider must also comply with rules and regulations
for providers as set forth in the MSM Chapter 100 Medicaid Program. Failure to
comply with any or all these stipulations may result in the DHCFP’s decision to
exercise its right to terminate the provider’s contract.
d. Must understand the authorized service specification on the POC, record keeping
responsibilities and billing procedures for provided waiver services.
e. Be responsible for any claims submitted or payment received on the recipient’s
behalf; such claims should be made under penalties of perjury. Any false claims,
statement or documents, or concealment of material facts may be prosecuted under
applicable federal or state laws.
f. Must understand that payment for services will be based on the level of service or
specific tasks identified on the POC and will not be made to legally responsible
individuals for furnishing waiver services.
g. All providers may only provide services that have been identified in the POC and
that, if required, have a Prior Authorization (PA).
h. Providers must verify the Medicaid eligibility status of each FE Waiver recipient
each month.
i. Providers must be able to: perform the duties of the job; demonstrate maturity of
attitude toward work assignments; communicate effectively; work under
intermittent supervision; deal with minor emergencies arising in connection with
the assignment and act accordingly, reporting these to the proper supervisor;
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demonstrate ability to understand, respect and maintain confidentiality in regards
to the details of case circumstances.
2. Criminal Background Checks
The DHCFP policy requires all waiver providers and it’s personnel, including owners,
officers, administrators, managers, employees and consultants must undergo State and FBI
background checks upon licensure and then at a minimum of every five years thereafter to
ensure no convictions of applicable offenses have been incurred (ADSD personnel must
follow State of Nevada policy regarding required background checks) and the safety of
recipients is not compromised. For complete instructions, refer to the Division of Public
and Behavioral Health (DPBH) website at http://dpbh.nv.gov.
The DHCFP’s fiscal agent will not enroll any provider agency whose owner or operator
has been convicted of a felony under State or Federal law for any offense which the DHCFP
determines is inconsistent with the best interest of recipients. Additional information may
be found in MSM Chapter 100 – Medicaid Program.
3. Recipient Records
a. The number of hours specified on each recipient’s POC, for each specific service
listed except Case Management and PERS, will be considered the maximum
number of hours allowed to be provided by the caregiver and paid by the DHCFP’s
fiscal agent, unless the case manager has approved additional hours due to a
temporary condition or circumstance.
b. Cooperate with ADSD and/or State or Federal reviews or inspections of the records.
c. Provider agencies who are providing waiver services in the home must comply with
the 21st Century Cures Act. Refer to Section 2203.14 of this chapter for detailed
instructions.
4. Serious Occurrence Report (SOR):
Providers must report any recipient incidents, or issues regarding the provider/employee’s
ability to deliver services to the ADSD within 24 hours of discovery. Providers must
complete the web-based Nevada DHCFP SOR Form, available at the fiscal agent’s website
at www.medicaid.nv.gov, under Providers Forms. A completed SOR form report must be
made within five business working days and maintained in the agency’s recipient record.
Serious occurrences involving either the provider/employee or recipient may include, but
are not limited to the following:
a. Suspected physical or verbal abuse;
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b. Unplanned hospitalization;
c. Abuse, neglect, exploitation, isolation, abandonment, or unexpected death of the
recipient;
d. Theft;
e. Sexual harassment or sexual abuse;
f. Injuries requiring medical intervention;
g. An unsafe working environment;
h. Any event which is reported to Adult Protective Services (ages 18 years old and
above) or law enforcement agencies;
i. Death of the recipient during the provision of waiver services; or
j. Loss of contact with the recipient for three consecutive scheduled days.
k. Medication errors resulting in injury, hospitalization, medical treatment or death.
l. Elopement of a recipient residing in a Residential Group Homes for Seniors or
Assisted Living Facility.
The State of Nevada has established mandatory reporting requirements of suspected
incidents of Elder Abuse, Neglect, Isolation Abandonment, and Exploitation. The ADSD
and local law enforcement are the receivers of such reports. Suspected elder abuse must be
reported as soon as possible, but no later than 24 hours after the person knows or has
reasonable cause to believe that an elder person has been abused, neglected, isolated,
abandoned or exploited. Refer to NRS 200.5091 to 200.50995 “Abuse, neglect,
exploitation, isolation, abandonment, or isolation of older and vulnerable persons.”
5. Adhere to HIPAA requirements.
Refer to MSM Chapter 100 for information on HIPAA, privacy and confidentiality of
recipient records, and other protected health information.
6. Obtain and maintain a business license as required by city, county, or state government, if
applicable.
7. Providers for Residential Group Homes for Seniors and Assisted Living Facility must
obtain and maintain required HCQC licensure.
8. Qualification and Training:
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a. All service providers must arrange training for employees who have direct contact
with recipients of the FE Waiver and must have service specific training prior to
performing a waiver service. Training at a minimum must include, but not limited
to:
1. policies, procedures, and expectations of the agency relevant to the
provider, including recipient’s and provider’s rights and responsibilities;
2. procedures for billing and payment;
3. record keeping and reporting including daily records and SORs;
4. information about the specific needs and goals of the recipients to be served;
and
5. interpersonal and communication skills and appropriate attitudes for
working effectively with recipients including: understanding care goals;
respecting recipient rights and needs; respect for age, cultural and ethnic
differences; recognizing family relationships; confidentiality; abuse,
neglect, and exploitation, including signs, symptoms, and prevention;
respecting personal property; ethics in dealing with the recipient, family and
other providers; handling conflict and complaints; and other topics as
relevant.
b. Additional training requirements for Residential Group Homes for Seniors and
Assisted Living Facilities:
In addition to the requirements listed above under Section 2203.2B(8)(a):
1. Caregivers of a residential facility for groups must be at least 18 years of
age; be responsible and mature and have the personal qualities which will
enable him or her to understand the problems of the aged and disabled;
demonstrate the ability to read, write, speak and understand the English
language; must possess the appropriate knowledge, skills and abilities to
meet the needs of the residents of the facility and annually receive no less
than eight hours of training related to providing for the needs of the residents
of a residential facility for groups as outlined in the NAC 449.3975
“Attendants, Qualifications; annual training,” must be knowledgeable in the
use of any prosthetic devices or dental, vision or hearing aids that the
residents use and must understand the provisions of NAC 449.156 to NAC
449.27706, “Residential Facilities for Groups” inclusive, and Sections 2 and
3 of the regulation, and sign a statement that he/she has read those
provisions as outlined in NAC 449.196 “Qualifications and training of
caregivers."
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2. If a caregiver assists a resident of a Residential Group Home for Seniors
and Assisted Living Facility in the administration of any medication,
including, without limitation, an over-the-counter medication or dietary
supplement, the caregiver must: before assisting a resident in the
administration of a medication, receive the training required pursuant to
paragraph (e) of Subsection 6 of NRS 449.032 “Medical and other Related
Facilities,” which must include, at least 16 hours of training in the
management of medication consisting of not less than 12 hours of classroom
training and not less than four hours of practical training, and obtain a
certificate acknowledging the completion of such training; receive annually
at least eight hours of training in the management of medication and provide
the Residential Group Homes for Seniors and Assisted Living Facility with
satisfactory evidence of the content of the training and his or her attendance
at the training; complete the training program developed by the
administrator of the Residential Group Homes for Seniors and Assisted
Living Facility pursuant to paragraph (e) of Subsection 1 of NAC 449.2742
“Administration of Medication: Responsibilities of administrator,
caregivers and employees of facility,” and annually pass an examination
related to the management of medication approved by the HCQC as outlined
in NAC 449.196 “Qualifications and trainings of caregivers.”
3. Within 30 calendar days after a caregiver is employed at the Residential
Group Homes for Seniors and Assisted Living facility, a caregiver must be
trained in First Aid and Cardiopulmonary Resuscitation (CPR) as described
in NAC 449.231 “First Aid and Cardiopulmonary resuscitation” and be able
to recognize and appropriately respond to medical and safety emergencies.
4. Caregivers staff providing direct care and support to residents must have
training specific to the waiver population being cared for at the Residential
Group Homes for Seniors and Assisted Living Facility, including the skills
needed to care for recipients with increasing functional, cognitive and
behavioral needs. Training will include, but not limited to, techniques such
as transfers, mobility, positioning, use of special equipment, identification
of signs of distress, First Aid and CPR.
Must have a separate file for each employee. Records of all employee’s
training required health certificates, first aid and CPR certifications, and
documents which are evidence that the employee has been tested for
tuberculosis must be in the file. Please refer to NAC 449.200 for additional
requirements.
c. Exemptions from Training for Provider Agencies:
1. The provider agency may exempt a prospective service provider from those
parts of the required training where the agency judges the person to possess
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adequate knowledge or experience, or where the provider’s duties will not
require the particular skills.
2. The exemption and its rationale must be provided in writing and a copy of
the exemption must be placed in the employee’s file.
3. ADSD/DHCFP may review exemptions for appropriateness.
2203.2C RECIPIENT RESPONSIBILITIES
The recipient or, if applicable, the recipient’s designated representative/Legally Responsible
Individual (LRI) will:
1. Notify the provider(s) and the Case Manager of any change in Medicaid eligibility;
2. Notify the provider(s) and the Case Manager of current insurance information, including
the name of the insurance coverage, such as Medicare;
3. Notify the provider(s) and the Case Manager of changes in medical status, support systems,
service needs, address or location changes, and/or any change in status of designated
representative/LRI;
4. Treat all providers and their staff members appropriately. Provide a safe, non-threatening
and healthy environment for caregiver(s) and the Case Manager(s);
5. Sign the provider’s daily/weekly record(s) to verify services were provided (except for
Case Management and PERS). If the recipient is unable to provide a signature due to
cognitive and/or physical limitations, this will be clearly documented on the SOU and/or
the case narrative;
6. Notify the provider or the Case Manager when scheduled visits cannot be kept or services
are no longer required;
7. Notify the provider agency or the Case Manager of any missed appointments by the
provider agency staff;
8. Notify the provider agency or the Case Manager of any unusual occurrences, complaints
regarding delivery of services, specific staff or to request a change in caregiver or provider
agency;
9. Furnish the provider agency with a copy of his or her Advance Directive;
10. Work with the Case Manager and/or provider agency to establish a back-up plan in case
the caregiver is unable to work at the scheduled time;
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11. Understand that a provider may not perform services or work more hours than authorized
in the POC;
12. Understand that a provider may not work or clean for a -recipient’s, family household
members or other person(s) living in the home with the recipient;
13. Understand that at least one annual face-to-face visit is required;
14. Understand that if case management is the only HCBS Waiver service, a monthly contact
with the Case Manager is required;
15. Not request a provider to perform services not included in the POC;
16. Contact the Case Manager to request a change of provider agency;
17. Complete, sign and submit all required forms on a timely basis; and
18. Be physically available for authorized waiver services, face-to-face visits, and assessments.
19. Recipients of this waiver are not eligible for EPSDT.
2203.3 CASE MANAGEMENT
Case management service is provided to eligible recipients in the HCBS Waivers when case
management is identified as a service on the POC. The recipient has a choice of case management
provided by ADSD or a private case management agency (must be enrolled as a Medicaid provider
agency).
2203.3A COVERAGE AND LIMITATIONS
These services include (not all inclusive):
1. Identification of resources and assisting recipients in locating and gaining access to waiver
services and other State Plan services, as well as needed medical, social, educational and
other services regardless of the funding source;
2. Coordination of multiple services and/or providers when applicable;
3. Monitoring the overall provision of waiver services, to protect the safety and health of the
recipient and to determine that the POC personalized goals are being met;
4. Monitoring and documenting the quality of care through contact with recipients:
a. The case manager must have ongoing contact with each waiver recipient and/or the
recipient’s designated representative/LRI; this may be a telephone contact. At a
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minimum, there must be one face-to-face visit with each recipient annually. All
other ongoing contacts may be by telephone, fax, e-mail, or face-to-face.
b. When recipient service needs increase, due to a temporary condition or
circumstance, the case manager must thoroughly document the increased service
needs in their case narrative. The POC does not need to be revised for temporary
conditions or circumstances. A temporary condition or circumstance is defined as
an increase or decrease in service needs for a period not to exceed 30 calendar days.
If the recipient is utilizing a private case management agency, this information must
be communicated to the ADSD for PA adjustment.
c. During the ongoing contact or face-to-face visit, the case manager monitors and
documents the quality of care of the recipient. Quality of care includes the
identification, remediation and follow-up of health and safety, risk factors, needs
and concerns of the recipient, waiver service satisfaction and whether the services
are promoting personalized goals stated in the POC. The case manager also assesses
the need for any change in services or providers. If the recipient is utilizing a private
case management agency, this information must be communicated to the ADSD for
PA adjustment.
d. During scheduled visits to a Residential Group Homes for Seniors and Assisted
Living Facility, the case manager is responsible for reviewing the POC and daily
logs as applicable for feedback from the recipient to help ensure services are
delivered as authorized in the POC. In addition, the case manager is responsible for
reviewing the medication log to ensure appropriate administration and
documentation is completed timely.
5. Ensure the recipient retains freedom of choice in the provision of services. During the
contacts with the recipient, the case manager must inquire and narrate the recipient’s choice
to continue receiving waiver service;
6. Notifying all affected providers of changes in the recipient’s medical status, service needs,
address, or of changes of the status of designated representative/LRI;
7. Notifying all affected providers of any unusual occurrence or change in status of a waiver
recipient;
8. Notifying all affected providers of any recipient complaints regarding delivery of service
or specific provider staff;
9. Notifying all affected providers if a recipient requests a change in the provider staff or
provider agency;
10. The Case Managers must provide recipients with appropriate amount of case management
services necessary to ensure the recipient is safe and receives sufficient services. Case
management will be considered an “as needed” service.
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11. When case management is the only waiver service identified in the POC, the Case
Managers shall continue to have monthly contact with recipients and/or the recipient’s
designated representative/LRI of at least 15 minutes (equal to one unit), per month. The
duration, scope, and frequency of case management services billed to the DHCFP must be
adequately documented and substantiated by the Case Manager’s narratives.
12. Case Managers must show due diligence to hold ongoing contacts as outlined in the POC
(frequency and method). Ongoing contacts are required, every attempt to contact the
recipient should be documented. At least three telephone calls must be completed on
separate days, if no response is received after the 3rd attempt, a letter must be sent to
recipient requesting a return contact. If the recipient fails to respond by the date indicated
in the letter, the recipient may be terminated.
13. Monitoring to assure providers of Residential Group Homes for Seniors and Assisted
Living Facility meet required program standards.
14. Arranging for the relocation of the recipient, if necessary, when an alternative placement
is requested or needed.
2203.3B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in Section 2203.2B, Case Managers must:
1. Be currently licensed as Social Worker by the State of Nevada Board of Examiners for
Social Workers or licensure as a Registered Nurse by the Nevada State Board of Nursing.
2. Have a valid driver’s license and means of transportation to enable face-to face visits.
In addition, private Case Managers must:
a. Have one- year experience of working with seniors in a home- based environment.
b. Provide evidence of taxpayer ID number, Workman’s Compensation Insurance,
Unemployment Insurance Account, Commercial General Liability, Business
Automobile Liability Coverage and Commercial Crime Insurance.
c. Be employed by a private case management provider agency.
2203.3C RECIPIENT RESPONSIBILITIES
1. Each recipient and/or designated representative/LRI must cooperate with the
implementation of services and the implementation of the POC.
2. Each recipient is to comply with the rules and regulations of the DHCFP, ADSD, DWSS
and the FE Waiver.
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2203.4 HOMEMAKER SERVICES
Homemaker services consist of light housekeeping, meal preparation, shopping, and laundry.
These services are provided when the individual regularly responsible for these activities is
temporarily absent or unable to manage their private residence and is necessary to avoid placement
in an institution.
2203.4A COVERAGE AND LIMITATIONS
1. Homemaker services are provided at the recipient’s home, or place of residence
(community setting).
2. Services must be directed to the individual recipient and related to their health and welfare.
3. The DHCFP/ADSD is not responsible for replacing goods which are or become damaged
in the provision of service.
4. Homemaker services include:
a. Meal preparation: menu planning, storing, preparing, serving of food, cutting up
food, buttering bread and plating food;
b. Laundry services: washing, drying, and folding the recipient’s personal laundry and
linens (sheets, towels, etc.) excludes ironing. Recipient is responsible for all
laundromat and/or cleaning fees;
c. Light housekeeping: changing the recipient’s bed linens, dusting, vacuuming the
recipient’s living area, cleaning kitchen and bathroom areas;
d. Essential shopping to obtain: prescribed drugs, medical supplies, groceries, and
other household items required specifically for the health and maintenance of the
recipient; or
e. Assisting the recipient and family members or caregivers in learning homemaker
routine and skills so the recipient may carry on normal living when the homemaker
is not present.
5. Activities the homemaker shall not perform and for which Medicaid will not pay include
the following:
a. transporting the recipient in a private car;
b. cooking and cleaning for the recipient’s guests, other household members or for the
purposes of entertaining;
c. repairing electrical equipment;
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d. ironing and mending;
e. giving permanents, dyeing or cutting hair;
f. accompanying the recipient to appointments, social events or in-home
socialization;
g. washing walls and windows;
h. moving heavy furniture, climbing on chairs or ladders;
i. purchasing alcoholic beverages that were not prescribed by the recipient’s
physician;
j. doing yard work such as weeding or mowing lawns, trimming trees, shoveling non-
essential snow-covered areas, and vehicle maintenance; or
k. care of pets except in cases where the animal is a certified service animal.
2203.4B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in Section 2203.2B, Homemaker Providers must:
1. Arrange and receive training related to household care, including good nutrition, special
diets, meal planning and preparation, shopping information, housekeeping techniques, and
maintenance of a clean, safe and healthy environment; and
2. Inform recipients that the ADSD, the DHCFP or its fiscal agent is not responsible for
replacement of goods damaged in the provision of service.
Providers are responsible to ensure that Electronic Visit Verification (EVV) requirements and
expectations are met, including the documentation of all services in approved EVV System.
Service must be prior authorized and documented in an approved EVV System.
2203.4C RECIPIENTS RESPONSIBILITIES
1. Agree to utilize an approved EVV system for the waiver services being received from the
provider agency.
2. Confirm services were provided by electronically signing or initialing, as appropriate per
service plan, the EVV record that reflects the service rendered. If Interactive Voice
Response (IVR) is utilized, a vocal confirmation is required.
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2203.5 CHORE SERVICES
Chore services are intermittent in nature and may be authorized as a need arises for the completion
of a specific task which otherwise left undone poses a home safety issue. Services needed to
maintain a clean, sanitary, and safe home environment. The service must be identified on the POC,
is approved by the ADSD CM, authorization must be in place and must be clearly documented on
the Comprehensive Social Health Assessment (CSHA) the need for Chore service. These services
are provided only in cases where neither the recipient, nor anyone else in the household, is capable
of performing or financially providing for them, and where no other relative, caretaker, landlord,
community volunteer/agency or third party payer is capable of, or responsible for, their provision
and without these services the recipient would be at risk of institutionalization.
2203.5A COVERAGE AND LIMITATIONS
1. This service includes heavy household chores in the private residence such as:
a. cleaning windows and walls;
b. shampooing carpets; tacking down loose rugs and tiles;
c. moving heavy items of furniture to provide safe access;
d. packing and unpacking for the purpose of relocation;
e. minor home repairs; or
f. removing trash and debris from the yard.
2. This is not a skilled, professional service.
3. In the case of rental property, the responsibility of the landlord pursuant to the lease
agreement, must be examined and confirmed prior to any authorization of service. The
legal responsibility of the landlord to maintain and ensure safety on the rental property
shall supersede any waiver covered services.
2203.5B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in Section 2203.2B, individuals performing chore
services must:
1. be able to read, write and follow written or oral instructions;
2. have experience and/or training in performing heavy household activities and minor home
repair; and
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3. maintain the home in a clean, sanitary and safe environment if performing heavy household
chores and minor home repair services.
Providers are responsible to ensure that EVV requirements and expectations are met, including the
documentation of all services in approved EVV System.
Service must be prior authorized and documented in an approved EVV System.
2203.5C RECIPIENTS RESPONSIBILITIES
1. Agree to utilize an approved EVV system for the waiver services being received from the
provider agency.
2. Confirm services were provided by electronically signing or initialing, as appropriate per
service plan, the EVV record that reflects the service rendered. If IVR is utilized, a vocal
confirmation is required.
2203.6 RESPITE CARE
Services provided to recipients unable to care for themselves. Respite care is provided on a short-
term basis because of the absence or need for relief of those persons normally providing the care.
Respite providers perform general assistance with Activities of Daily Living (ADLs) and
Instrumental Activities of Daily Living (IADLs) as well as provide supervision to functionally
impaired recipients in their private home or place of residence (community setting).
2203.6A COVERAGE AND LIMITATIONS
1. Respite services may be for 24-hour periods.
2. Respite care is limited to 336 hours for the duration of the POC.
3. Services must be prior authorized by ADSD.
2203.6B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in Section 2203.2B, Respite Providers must:
1. Have the ability to read and write and to follow written or oral instructions;
2. Have had experience in providing for the personal care needs of people with functional
impairments;
3. Demonstrate the ability to perform the care tasks as prescribed;
4. Be tolerant of the varied lifestyles of the people served; and
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5. Provide training in personal hygiene needs and techniques for assisting with ADLs, such
as bathing, grooming, skin care, transferring, ambulating, feeding, dressing and use of
adaptive aids and equipment, homemaking and household care.
Providers are responsible to ensure that EVV requirements and expectations are met, including the
documentation of all services in approved EVV System.
Service must be prior authorized and documented in an approved EVV System.
2203.6C RECIPIENTS RESPONSIBILITIES
1. Agree to utilize an approved EVV system for the waiver services being received from the
provider agency.
2. Confirm services were provided by electronically signing or initialing, as appropriate per
service plan, the EVV record that reflects the service rendered. If IVR is utilized, a vocal
confirmation is required.
2203.7 PERSONAL EMERGENCY RESPONSE SYSTEM (PERS)
PERS is an electronic device, which enables certain recipients at high risk of institutionalization
to secure help in an emergency. The recipient may also wear a portable “help” button to allow for
mobility. The system is connected to the recipient’s phone and programmed to signal a response
center once a “help” button is activated.
2203.7A COVERAGE AND LIMITATIONS
1. PERS services are limited to those recipients who live alone in a private residence, or who
are alone for significant parts of the day in that residence, have no regular caregiver for
extended periods of time, and who would otherwise require extensive routine supervision.
The recipient must be physically and cognitively capable of using the device in an
appropriate and proper manner.
2. The service component includes both, the installation of the device and monthly
monitoring. Two separate authorizations are required for payment, the initial installation
fee for the device and a monthly fee for ongoing monitoring; both are covered under the
waiver.
3. The necessity for this type of emergency safety measure to prevent institutionalization will
be identified in the assessment and included in the POC.
2203.7B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in Section 2203.2B, PERS Providers must:
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1. Be responsible for ensuring that the response center is staffed by trained professionals at
all times;
2. Be responsible for any replacement or repair needs that may occur and monthly monitoring
of the device to ensure is working properly;
3. Utilize devices that meet Federal Communication Commission standards, Underwriter’s
Laboratory, Inc. (UL) standards or equivalent standards;
4. Inform recipients of any liability the recipient may incur as a result of the recipient’s
disposal of provider property.
2203.7C RECIPIENT RESPONSIBILITIES
1. The recipient is responsible to utilize the leased PERS equipment with care and caution
and to notify the PERS provider and Case Manager if the equipment is no longer working.
2. The recipient must return the equipment to the provider when the recipient no longer needs
or utilizes the equipment, when the recipient terminates from the waiver program or when
the recipient moves from the area.
3. The recipient must not dispose or damage the PERS equipment. This is leased equipment
and belongs to the PERS provider.
2203.8 ADULT DAY CARE SERVICES
Adult Day Care services are provided in a non-institutional community-based setting, including
outpatient settings. It encompasses social service needs to ensure the optimal functioning of the
recipient.
It is provided on a regularly scheduled basis, in accordance with the goals in the recipient’s POC.
2203.8A COVERAGE AND LIMITATIONS
1. The emphasis is on social interaction in a safe environment. The POC must indicate the
number of days per week the recipient will attend.
2. Meals provided are furnished as part of the FE Waiver but must not constitute a “full
nutritional regime” (i.e., three meals per day). Meals must be served in a manner suitable
for the recipient and prepared with regard for individual preferences. Special diets and
nourishments must be provided as ordered by the client’s physician.
3. Service utilization and billing method (per diem/unit rate) will be prior authorized as
indicated in the recipient’s POC. The per diem rate is authorized when the recipient is in
attendance for six or more hours per day, and the unit rate is authorized for attendance of
a minimum of four hours and up to six hours per day. Providers must bill in accordance
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with the approved PA, even if the recipient occasionally attends less than six hours. If the
recipient’s overall pattern changes and consistently attends less than six hours a day, a
change to the POC and PA will be required to update the service utilization and billing
method.
4. Providers must not bill for days a recipient is not in attendance, even if it is a regularly
scheduled day. Providers must keep attendance records for each recipient. Claims must
reflect dates and times of service as indicated on the attendance records.
2203.8B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in Section 2203.2B, Adult Day Care Providers
must:
Meet and maintain the service specifications as an adult day care provider as outlined in NAC 449
“Medical Facilities and other Related Entities.”
2203.9 ADULT COMPANION SERVICES
Adult Companion Services provides non-medical care, supervision and socialization to a
functionally impaired recipient in his or her home or place of residence, which are furnished on a
short-term basis or to meet the need for relief for the primary caregiver.
2203.9A COVERAGE AND LIMITATIONS
1. Adult companions may assist or supervise the recipient with tasks as meal preparation and
clean up, light housekeeping, shopping and facilitate transportation/escort as needed. These
services are provided as an adjunct to the Adult Day Care Services and must be incidental
to the care and supervision of the recipient.
2. The provision of Adult Companion Services does not entail hands-on medical care.
3. This service is provided in accordance with the personalized goal in the POC and is not
purely diversional in nature.
4. Transportation is not a covered service. Reference MSM Chapter 1900 Transportation
Services for transportation policies.
2203.9B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in Section 2203.2B, Adult Companion Providers
must:
1. Be able to read, write and follow written or oral instructions; and
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2. Have experience or training in how to interact with recipients with disabling and various
health conditions.
Providers are responsible to ensure that EVV requirements and expectations are met, including the
documentation of all services in approved EVV system.
Service must be prior authorized and documented in an approved EVV System.
2203.9C RECIPIENTS RESPONSIBILITIES
1. Agree to utilize an approved EVV system for the waiver services being received from the
provider agency.
2. Confirm services were provided by electronically signing or initialing, as appropriate per
service plan, the EVV record that reflects the service rendered. If IVR is utilized, a vocal
confirmation is required.
2203.10 AUGMENTED PERSONAL CARE
Augmented Personal Care (APC) provided in a licensed Residential Group Homes for Seniors or
Assisted Living Facility is a 24-hour in home service that provides assistance for functionally
impaired elderly recipients with basic self-care and ADLs that include as part of the service:
A. Homemaker Services;
B. Personal Care Services;
C. Chore Services;
D. Companion Services;
E. Therapeutic social and recreational programming;
F. Medication oversight (to the extent permitted under State Law); and
G. Services which will ensure that residents of the facility are safe, secure, and adequately
supervised.
This care is over and above the mandatory service provision required by regulation for Residential
Group Homes for Seniors and Assisted Living Facility.
2203.10A COVERAGE AND LIMITATIONS
1. This service includes 24-hour on-site response staff to meet scheduled or unpredictable
needs in a way that promotes maximum dignity and independence; and provides
supervision, safety, and security.
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2. Once a FE Waiver recipient/applicant expresses an interest in a residential group setting,
they are provided with a list of qualified providers. A case manager is available to provide
additional information and guidance related to the individual’s specific needs.
Consideration may include size of the home, geographic location, proximity to friends and
family, available support, activities, food, staff, other residents, likes and dislikes, medical
or mental health concerns, whether pets are allowed, and a variety of other individualized
preferences.
3. There are four service levels of APC. The service level provided is based on the recipient’s
functional needs to ensure the recipient’s health, safety and welfare. The ADSD Case
Manager determines the service level as an administrative function of the FE Waiver.
a. Level One Daily (minimum assistance):
This level provides supervision and cueing to complete basic self-care and ADLs.
In home supervision is available when direct care tasks are not being completed.
b. Level Two Daily (moderate assistance):
This level provides physical assistance with moderate hands-on care of basic self-
care and ADLs. Some basic self-care may require a moderate level of assistance.
This service provides in home supervision with regularly scheduled checks as
needed.
c. Level Three Daily (maximum assistance):
This level provides physical assistance to complete basic self-care and ADLs. with
maximum hands-on care. Direct 24-hour supervision and/or safety system (alarm)
to ensure safety when supervision is not direct. It includes daily home making for
clean up after basic self-care tasks, weekly homemaking for general cleaning, and
up to twice daily assistance with meal preparation.
d. Level Four (Critical Behaviors):
In addition to meeting a level one, two or three for ADLs/IADLs care, level 4
requires substantial and/or extensive assistance with critical behaviors: Behavioral
Problems, Resists Care, Socially Inappropriate, Wandering, Physically Abusive to
self and/or others, Verbally Abusive, and behaviors that represent a safety risk.
Requiring the full attention of staff member when behaviors are present and/or
presents a need for additional staffing to redirect and address behaviors. Additional
documentation and agency approval required.
Documentation on the daily log for at least 60 days is required to justify amount
and types of care for service level determination and verification of proper billing.
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All four service levels provide help with laundry; housekeeping; meal preparation and
eating; bed mobility and transfers; bathing, dressing, and grooming; mobility and
ambulation; and access to social and recreational programs. The service level determines
the amount, duration and frequency of the services provided.
All service levels are reassessed annually, or as significant changes occur, and may increase
or decrease to reflect the recipient’s current level of need.
Documentation on the daily log is required to justify amount and types of care for service
level determination and verification of proper billing.
4. Section 1903(a)(1) of the SSA provides funding for Federal Financial Participation (FFP)
to States for expenditures for services under an approved State Plan. FFP is not available
to subsidize the cost of room and board furnished in a Residential Group Homes for Seniors
and Assisted Living Facility. The cost for room and board is a private agreement between
the recipient and the Residential Group Homes for Seniors or Assisted Living Facility.
5. Nursing and skilled services (except periodic nursing evaluations) are incidental, rather
than integral to the provision of group care services. Payment will not be made for 24-hour
skilled care or supervision.
6. Other individuals or agencies may also furnish care directly, or under arrangement with the
Residential Group Homes for Seniors or Assisted Living Facility. However, the care
provided by these other entities supplements what is being provided but does not supplant
it.
7. Personalized care furnished to individuals who choose to reside in a Residential Group
Homes for Seniors or Assisted Living Facility based on their individualized POC, which
is developed with the recipient, people chosen by the recipient, caregivers and the Case
Manager. Care must be furnished in a way that fosters the independence of each recipient.
8. The Residential Group Homes for Seniors or Assisted Living Facility provides
personalized care to the residents, and the general approach to operating the facility
incorporates these core principles:
a. Designed to create a residential environment that actively supports and promotes
each resident’s quality of life and right to privacy.
b. Committed to offering high-quality supportive services that are developed by the
facility in collaboration with the recipient’s individual needs.
c. Provides a variety of creative and innovative services that emphasize the specific
needs of each recipient and the personal choice of lifestyle.
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d. Operate and interact with recipients to support recipient’s need for autonomy and
the right to make decisions.
e. Designed to foster a social climate that allows the recipient to develop and maintain
personal relationships with fellow residents and with persons in the general
community.
f. Minimize the need for its recipients to move out of the facility as their respective
physical and mental conditions change over time.
g. Foster a culture that provides a high-quality environment for the recipients, their
families, the staff, any volunteers, and the community at large.
2203.10B AUGMENTED PERSONAL CARE PROVIDER RESPONSIBILITIES
In addition to the responsibilities listed in Section 2203.2B providers must:
1. Be licensed and maintain standards as outlined by, HCQC under NRS/NAC 449 “Medical
and other related entities.”
2. The provider for a Residential Group Homes or Assisted Living Facility must:
a. Notify the ADSD Case Manager within three business days when the recipient
states the desire to leave the facility.
b. Participate with the ADSD Case Manager in discharge planning.
c. Notify the ADSD Case Manager within one working day if the recipient’s living
arrangements have changed, eligibility status has changed or if there has been a
change in health status that could affect recipient’s health, safety, or welfare.
d. Notify the ADSD of any incidents pertaining to a waiver recipient that could affect
the health, safety, or welfare.
e. Notify the ADSD of any recipient complaints regarding delivery of service or
specific staff of the setting. If the recipient is not satisfied with their living
arrangements or services, the Case Manager will work with the recipient and the
provider to resolve any areas of dissatisfaction. If the recipient makes the decision
to relocate to another setting, the Case Manager will provide information and
facilitate visits to other contracted settings.
f. Provide the ADSD with at least a 30-calendar days’ notice before discharging a
recipient unless the recipient’s condition deteriorates and warrants immediate
discharge. When the Case Manager is notified, they assist in relocation and working
with staff on transfers/discharges.
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g. Privacy, dignity, and respect are maintained during the provisions of services.
Living units are not entered without permission.
h. Conduct business in such a way the recipient is free from coercion and restraint and
retains freedom of choice. Residential Group Homes and Assisted Living Facility
must provide services based on the recipient’s choice, direction, and preferences.
i. Provide transportation to and from the setting to the hospital, a NF, routine medical
appointment and social outings organized by the facility. Recipients may choose to
enjoy their privacy, participate in physical activities, relax, or associate with other
residents. Recipients may go out with family members or friends at any time and
may pursue personal interest outside of the residence.
j. Accept only those residents who meet the requirements of the licensure and
certification.
k. Provide services to FE Waiver eligible recipients in accordance with the recipient’s
POC, the rate, waiver limitations, and procedures of the DHCFP.
l. Not use or disclose any information concerning a recipient for any purpose not
directly connected with the administration of the FE Waiver except by written
consent of the recipient, designated/legal representative.
m. Have sufficient caregivers present at the facility to conduct activities and provide
care and protective supervision for the residents at all times. The provider must
comply with HCQC staffing requirements for the specific facility type (for
example, an Alzheimer facility).
n. There must be 24-hour on site staff to meet scheduled or unpredictable needs and
provide supervision, safety and security, and transportation if one or more residents
are present.
o. Not use Medicaid waiver funds to pay for the recipient’s room and board.
p. Each recipient must have privacy in their sleeping or living unit:
1. Units or rooms have locking doors. A bedroom or bathroom door in a
residential group setting which is equipped with a lock must open with a
single motion from the inside. Staff must knock before entering; recipients
have the right to choose who enters the bedroom.
2. Recipients sharing units have a choice of roommate.
3. Encourage recipients to utilize personal furniture, furnishing, photo and
decorative items to personalize their living space.
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3. Recipient Records
a. Each provider must have a file for each recipient. In the recipient’s file, the provider
must have a copy of the current POC and maintain daily records, fully documenting
the scope and frequency of services as specified on the POC.
The documentation will include the recipient’s acknowledgment of service . If the
recipient is unable to provide the acknowledgment due to cognitive and/or physical
limitations, this will be clearly documented on the POC, indicating the designated
representative or LRI. Recipients without an LRI can select an individual to act on
their behalf by completing the Designated Representative Attestation Form. The
Case Manager will be required to document the designated representative who can
sign documents and be provided information about the recipient’s care.
b. The provider will initial after the daily services are delivered, with a full signature
of the provider on each daily record. If a provider elects to use electronic signatures,
they must have weekly printouts of the daily record in the recipient’s file or make
available upon request. For electronic signatures, systems and software products
must include protection against modifications, with administrative safeguards that
correspond to policies and procedures of the ADSD. The individual whose name is
on the alternate signature method and the provider bear the responsibility for the
authenticity of the information being attested to.
c. Periodically, DHCFP and/or ADSD staff may request daily service documentation
to compare it to submitted claims. These records must be maintained by the
provider for at least six years after the date the claim is paid.
d. Services for waiver recipients residing in a Residential Facility for Groups and
Assisted Living Facility should be provided as specified on the POC and at the
appropriate authorized service level.
e. If fewer services are provided than what is authorized on the POC, the reason must
be adequately documented in the daily record and communicated to the Case
Manager.
2203.10C RECIPIENT RESPONSIBILITIES
1. Recipients are to cooperate with the providers of Residential Group Home for Seniors or
Assisted Living Facility in the delivery of services.
2. Recipients are to report any problems with the delivery of services to the Residential Group
Homes for Seniors or Assisted Living Facility administrator and/or ADSD Case Manager.
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2201.11 ADMINISTRATIVE CASE MANAGEMENT ACTIVITIES
Administrative case management activities are performed by ADSD case managers and refer to
data collection for eligibility verification, LOC evaluation, POC development, and other case
management activities that are not identified on the POC.
2203.11A COVERAGE AND LIMITATIONS
Administrative case management activities include:
1. Processing of Intake referrals;
2. Facilitating Medicaid eligibility, which may include assistance with the Medical
Assistance to the Aged, Blind and Disabled (MAABD) application and obtaining
documents required for eligibility determination;
3. Preliminary and ongoing assessments, evaluations and completion of forms required for
service eligibility such as:
a. Screening assessment for the LOC to determine if the individual has functional
deficits and requires the level of service offered in a NF or a more integrated service
that may be community-based.
b. Development of the POC identifying the waiver services as well as other ongoing
community support services that the recipient needs to live successfully in the
community.
The recipient’s LOC, functional status and needs addressed by the POC must be
reassessed annually or more often as needed. The recipient must also be reassessed
when there is a significant change in his/her condition which influences eligibility.
4. Request issuance of Notices of Decision (NOD) to the DHCFP LTSS when a waiver
application is denied;
5. Coordination of care and services and collaboration in discharge planning to transition
applicants;
6. Obtaining the necessary documentation for case files prior to applicant’s eligibility;
7. Case closure activities upon termination of service eligibility;
8. Outreach activities to educate recipients or potential recipients on how to access into care
and services through various Medicaid Program;
9. Distribution of the POC to all affected providers;
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10. Ensure completion of PA form, if required, for all waiver services identified on the POC
for submission into the Medicaid Management Information System (MMIS) Inter-Change.
2203.11B PROVIDER RESPONSIBILITIES
In addition to the provider responsibilities listed in MSM Section 2203.2B Case Manager:
1. Must be currently licensed as a Social Worker by the State of Nevada Board of Examiners
for Social Workers or as a Registered Nurse by the Nevada State Board of Nursing.
2. Must have a valid driver’s license and the ability to conduct home visits.
3. Must adhere to HIPAA requirements.
4. Must have a Federal Bureau of Investigation (FBI) criminal history background check.
2203.11C RECIPIENT RESPONSIBILITIES
1. Applicant/recipients and/or their designated representative/LRI must cooperate with the
ADSD by assisting with the assessment and reassessment process, accurately representing
skill level needs, wants, resources and personalized goals.
2. Applicants/recipients and/or their designated representative/LRI together with the case
manager must develop and/or review the POC.
2203.12 INTAKE PROCEDURES
ADSD has developed policies and procedures to ensure fair and adequate access to the FE
Waiver.
2203.12A COVERAGE AND LIMITATIONS
1. Referral
a. A referral or inquiry for the FE waiver may be initiated by phone, mail, fax, in
person, email or by an applicant or another party on behalf of the applicant.
b. The ADSD intake specialist will make phone/verbal contact with the applicant/
designated representative/LRI within 15 working days from the referral date.
c. If the applicant appears to be eligible, a face-to-face visit must be scheduled and
completed within 45 calendar days from the referral date to assess eligibility
including the NF LOC determination.
If the ADSD intake specialist determines during the face-to-face visit the applicant
does not appear to meet the FE waiver criteria financial eligibility, LOC, or waiver
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service need, the applicant will be referred to other agencies for any needed services
or assistance.
d. If the applicant does not meet the FE Waiver criteria, the applicant must be verbally
informed of the right to continue the Medicaid application process through the
DWSS. If the DWSS determines the applicant to be ineligible for Medicaid, the
applicant may have the right to a fair hearing through the DWSS.
2. Placement on the: Wait List.
a. Once the ADSD has identified the applicant meets the LOC and has a waiver
service need, the applicant is placed on the wait list by priority and referral date.
b. Applicants may be considered for an adjusted placement on the wait list based on
a significant change of condition/circumstances.
c. If it has been determined no slot is expected to be available within the 90 calendar
days determination period, a notification letter is sent to the applicant indicating
“No slot is available.”
3. A Waiver Slot Allocation:
Once a slot for the waiver is available, the applicant will be processed for the waiver.
The procedure used for processing an applicant is as follows:
a. The ADSD Case Manager will conduct a second face-to-face interview with
the applicant to complete the initial assessment.
b. The initial assessment includes addressing ADLs, IADLs, service need,
support system and personalized goals.
c. An Authorization for the Use and Disclosure of Protected Health
Information Form is needed for all waiver applicants and provides written
consent for the ADSD to release information about the applicant to others.
d. The applicant/designated representative/LRI must understand and agree
that personal information may be shared with providers of services and
others as specified on the form.
e. The applicant will be given the right to choose waiver services in lieu of
placement in a NF. If the applicant and/or legal representative prefers
placement in a nursing facility, the case manager will assist the applicant in
arranging for facility placement.
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f. The applicant will be given the right to request a Fair Hearing if not given
a choice between HCBS Waiver services and NF placement.
4. The ADSD will send the HCBS Waiver Eligibility Status Form to DWSS for review and
approval of Medicaid application:
5. On a monthly basis, the DHCFP Long Term Services and Supports (LTSS) Unit will
review a random sample of intake packets for completeness to ensure waiver requirements
are being met. The intake packet for review must include:
a. The current CSHA with the following items embedded:
1. The NF LOC screening to verify the applicant meets the NF LOC criteria;
2. At least one waiver service need identified;
3. The narrative section of the assessment confirming a face-to-face visit was
conducted for the initial assessment
b. the Statement of Understanding/Choice (SOU) must be complete with signature
and dates; and
c. The HCBS Acknowledgement Form completed including initials, signature, and
date.
d. All forms must be completed with initials, signatures, and dates by the
recipient/designated representative/LRI. Electronic signatures are acceptable
pursuant to NRS 179 “Electronic Records and Transactions” on forms that require
a signature.
e. The applicant has been informed of their right to participate in the development of
the POC using the person-centered approach with the support systems, friends,
family of their choice involved. Applicants will be given free choice of all qualified
Medicaid providers of each Medicaid covered service included in the written POC.
Current POC information as it relates to the services provided must be given to all
service providers.
6. Once DWSS have approved the application, waiver service can be initiated;
7. If the application is denied, DWSS will send a denial NOD to the applicant.
If the applicant is denied by ADSD for waiver services, the ADSD will submit the HCBS
Waiver Eligibility Form to the DHCFP LTSS unit requesting a denial NOD be sent to the
applicant. The request must include the reason(s) for the denial. The DHCFP LTSS unit
will send the applicant the denial NOD. The DHCFP will return the processed HCBS
Waiver Eligibility Form and a copy of the NOD to ADSD for their record.
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8. Effective Date for Waiver Services
The effective date for waiver services is determined by eligibility criteria verified by
ADSD, and financial eligibility approval date by DWSS, and the residential facility for
groups placement move in date, whichever is later.
If the applicant is in an institution, the effective date cannot be prior to the date of discharge
from the institution.
9. Waiver Cost
The DHCFP must assure CMS that the average per capita expenditures under the waiver
will not exceed 100% of the average per capita expenditures for the institutional LOC under
the state plan that would have been made in that fiscal year, had the waiver not been
granted.
2203.13 ANNUAL WAIVER REVIEW
The DHCFP and ADSD have formal systems in place to conduct annual reviews. The purpose of
the review is to assure the health and welfare of the recipients, the recipients’ satisfaction with the
waiver services and providers, the qualifications of waiver providers to deliver services/supports,
and assurance of the cost effectiveness of these services.
2203.13A COVERAGE AND LIMITATIONS
The State conducts an annual review; collaboratively with the ADSD, with the DHCFP being the
lead agency. The CMS has designated waiver assurances and sub-assurances which states must
include as part of an overall quality improvement strategy. The annual review is conducted using
the state specified performance measures identified in the approved FE waiver to evaluate
operation.
The DHCFP:
1. Provides CMS annually with information regarding the impact of the waiver on the type,
amount, and cost of services provided under the waiver and under the State Plan, and
through an ongoing process of discovery, remediation and improvement, the State assures
the health and welfare of the recipients served on the waiver;
2. Assures financial accountability for funds expended for HCBS Waiver services;
3. Evaluates that all provider standards are continuously met, and that the POCs are
periodically reviewed to assure that the services furnished are consistent with the identified
needs of the recipients;
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4. Evaluates the recipients’ satisfaction with the waiver using Personal Experience Survey
(PES) conducted with a random sampling of the recipients to ensure waiver satisfaction.
Interviews will be completed throughout the year; and
5. Further assures that all problems identified by this monitoring will be addressed by the
provider in an appropriate and timely manner, consistent with the severity and nature of
the deficiencies.
2203.13B PROVIDER RESPONSIBILITIES
ADSD and waiver providers must cooperate with the DHCFP and ADSD’s annual review process.
2203.14 ELECTRONIC VISIT VERIFICATION (EVV):
The 21st Century Cures Act requires the use of an EVV system to document services that are
provided for all personal care services under a Medicaid state plan or waiver program. This
mandate requires provider agencies to use an EVV system to record service delivery visit
information. Nevada Medicaid utilizes the open-system model, procuring a vendor but also allows
agencies to utilize their own if it meets the 21st Century Cures Act requirements for documentation.
All service information must be recorded in an electronic system that interfaces with either a
telephone or an electronic device that generates a timestamp. The provider agency must verify the
EVV record, including any visit maintenance, prior to submitting a claim associated with the EVV
record. All claims must be supported by an EVV entry into an EVV system prior to claim
submission.
Agencies must ensure each personal care attendant has a unique identifier (National Provider
Identification – NPI) associated with their worker profile in the EVV system.
A. STATE OPTION:
1. The EVV system electronically captures:
a. The type of service performed, based on procedure code;
b. The individual receiving the service;
c. The date of the service;
d. The location where service is provided;
e. The individual providing the service;
f. The time the service begins and ends.
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2. The EVV system must utilize one or more of the following:
a. The agency/personal care attendant’s smartphone;
b. The agency/personal care attendant’s tablet;
c. The recipient’s landline telephone;
d. The recipient’s cellular phone (for Interactive Voice Response (IVR)
purposes only);
e. Other GPS-based device as approved by the DHCFP.
B. DATA AGGREGATOR OPTION:
1. All Personal Care Agencies that utilize a different EVV system (as approved by the
DHCFP) must comply with all documentation requirements of this chapter and
must utilize the data aggregator to report encounter or claim data.
a. Appropriate form must be approved by the DHCFP before use of system to
ensure all data requirements are being collected to meet the 21st Century
Cures Act.
b. At a minimum, data uploads must be completed monthly into data
aggregator.
2203.15 PROVIDER ENROLLMENT
To become a Waiver provider, as a Provider Type (PT) 48, PT 57 or PT 59, providers must comply
with all the DHCFP fiscal agents. Enrollment checklist and forms can be found on the fiscal agent’s
website at www.medicaid.nv.gov.
All providers are to refer to the MSM Chapter 100 for enrollment procedures.
2203.16 BILLING PROCEDURES
The DHCFP assures that claims for payment of waiver services are made only when a recipient is
Medicaid eligible, when the service is included in the approved POC and PA is in place when
required.
Refer to the Fiscal Agent’s website at: www.medicaid.nv.gov for the Provider Billing Guide
Manual.
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2203.17 ADVANCE DIRECTIVES
Section 1902(w) of the Social Security Act requires licensed provider agencies give their clients
information about their decision-making rights about health care, declarations (living wills) and
durable powers of attorney for health care decisions. Refer to MSM 100 for further information.
ADSD will provide information on Advance Directives to each applicant and/or the
authorized/legal representative. The signed form is kept in each applicant’s file at the local ADSD
office. Whether an applicant chooses to write his or her own Advance Directives or complete the
Advance Directives form in full is the individual choice of each applicant and/or each applicant
authorized/legal representative.
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2204 HEARINGS REQUESTS DUE TO ADVERSE ACTIONS
An adverse action refers to denials, terminations, reductions, or suspensions of applicant’s request
for services or a recipient’s eligibility determination. The DHCFP must grant an opportunity for a
hearing to an applicant/recipient/designated representative in the event an adverse action is taken
by the DHCFP.
2204.1 SUSPENDED WAIVER SERVICES
A. A recipient’s case must be suspended, instead of closed if it is likely the recipient will be
eligible again for waiver services within the next 60 days.
For example, if a recipient is admitted to a hospital, NF or Intermediate Care Facility for
the Intellectually Disabled (ICF/IID).
B. After receiving written documentation from the Case Manager (HCBS Waiver Eligibility
Form) of the suspension of waiver services, a NOD identifying the effective date and the
reason for suspension will be sent to the recipient by the DHCFP LTSS Unit.
Waiver services will not be paid for the days that a recipient’s eligibility is in suspension.
C. If at the end of the 45 calendar days since admission the recipient has not been removed
from suspended status, the case must be closed. The ADSD sends the “HCBS Waiver
Eligibility Status Form” to the DHCFP LTSS Unit on or before the 45th day of suspension,
identifying the 60th day of suspension as the effective date of termination and the reason
for the waiver termination.
D. The DHCFP Unit sends a NOD, to the recipient and/or the designated representative/LRI
advising him or her of the date and reason for the waiver closure/termination.
2204.2 RELEASE FROM SUSPENDED WAIVER SERVICES
When a recipient has been released from the hospital or NF before 60 calendar days of the admit
date, the Case Manager must do the following within five business days of the recipient’s
discharge:
A. Complete a reassessment if there has been a significant change in the recipient’s condition
or status;
B. Complete a new POC if there has been a change in services (medical, social or waiver). If
a change in services is expected to resolve in less than 30 days, a new POC is not necessary.
Documentation of the temporary change must be made in the Case Manager’s narrative.
The date of resolution must also be documented in the Case Manager’s narrative; and
C. Contact the service provider(s) to reestablish services.
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2204.3 DENIAL OF WAIVER APPLICATION
Basis of denial for waiver services:
A. The applicant is under the age of 65 years.
B. The applicant does not meet the LOC criteria for NF placement.
C. The applicant has withdrawn his or her request for waiver services.
D. The applicant fails to cooperate with the ADSD or HCBS Waiver service providers in
establishing and/or implementing the POC, implementing waiver services or verifying
eligibility for waiver services. (The applicant’s and/or designated representative/LRI’s
signature is necessary for all required paperwork.)
E. The applicant’s support system is not adequate to provide a safe environment during the
time when HCBS Waiver services are not being provided.
F. The ADSD has lost contact with the applicant.
G. The applicant fails to show a need for HCBS Waiver services.
H. The applicant would not require NF placement within 30 days or less if HCBS services
were not available.
I. The applicant has moved out of state.
J. Another agency or program will provide the services.
K. The ADSD has filled the number of positions (slots) allocated. The applicant has been
approved for the waiver wait list and will be contacted when a slot is available.
L. The applicant is in an institution (e.g. hospital, NF, correctional facility, ICF/IID) and
discharge within 60 calendar days is not anticipated.
M. The applicant has chosen a provider or facility that is not an enrolled or qualified Medicaid
provider. Note: The Case Manager should provide a list of Medicaid providers to the
applicant. The Case Manager will inform the provider that all entities providing services
must be enrolled as a Medicaid provider and facilitate contact information to the DHCFP’s
Fiscal Agent.
N. There are no enrolled Medicaid providers or facilities in the applicant’s area.
When the application for waiver services is denied, the ADSD Case Manager sends a “HCBS
Waiver Eligibility Status Form” to the DHCFP LTSS Unit. The DHCFP LTSS Unit sends a NOD
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to the applicant, letting them know that waiver services have been denied and the reason for the
denial.
2204.4 TERMINATION OF WAIVER SERVICES
Reasons to terminate a recipient from the waiver or to terminate the recipient from the waiver wait
list:
A. The recipient no longer meets the LOC criteria for NF placement.
B. The recipient no longer meets other eligibility criteria as determined by the DWSS.
C. The recipient and/or designated representative/LRI have requested termination of waiver
services.
D. The recipient has failed to cooperate with the ADSD or HCBS Waiver service providers in
establishing and/or implementing the POC, implementing waiver services, or verifying
eligibility for waiver services. (The recipient’s and/or the designated representative/LRI’s
signature is necessary on all required paperwork).
E. The recipient’s support system is not adequate to provide a safe environment during the
time when HCBS Waiver services are not being provided.
F. The recipient fails to show a continued need for HCBS Waiver services.
G. The recipient is no longer at risk of imminent placement in an institution within 30 days or
less if waiver services were not available.
H. The recipient has moved out of state.
I. The recipient has signed fraudulent documentation on one or more of the provider time
sheets and/or forms.
J. Another agency or program will provide the services.
K. The recipient has been, or is expected to be, institutionalized over 60 days (in a hospital,
NF, correctional facility, or intermediate facility or ICF/IID).
L. The ADSD has lost contact with the recipient.
M. The physical environment in a residential facility for groups is not safe for the recipient’s
individual health condition.
N. The recipient’s swallowing ability is not intact and requires skilled service for safe
feeding/nutrition. Residential facilities for groups are not licensed to provide skilled
services. Recipients with a gastrostomy-tube must be competent and manage their tube
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feeding or they are prohibited by HCQC licensure to be admitted into a residential facility
for groups.
O. The recipient has been placed in a residential facility for groups that does not have a
provider agreement with the DHCFP. Note: The ADSD’s Case Manager should work with
the provider before terminating the recipient waiver services, explain that all entities
providing services must be enrolled as a Medicaid provider and facilitate contact
information to the DHCFP’s Fiscal Agent.
P. The recipient of a residential facility for groups chooses to return to independent
community living which may not be a safe environment.
Q. Death of Recipient.
When a recipient is terminated from the waiver, the Case Manager sends the DHCFP LTSS Unit
the “HCBS Waiver Eligibility Form” stating the date of termination and the reason(s) for the
termination. The DHCFP LTSS Unit sends a NOD to the recipient and/or designated
representative/LRI. The NOD must be mailed to the DHCFP, Hearings Unit, at least 13 calendar
days before the listed date of action on the form. Refer to MSM, Chapter 3100 Hearings, for
specific instructions regarding notice and recipient hearings.
When a termination from waiver services is due to the death of a recipient, the DWSS will
terminate the case, and it will notify the ADSD, and the DHCFP of the date of .death.
2204.5 REDUCTION OF WAIVER SERVICES
Reasons to reduce services are:
A. The recipient no longer requires the number of service hours/level of service which was
previously provided.
B. The recipient no longer requires the service previously provided.
C. The recipient’s support system is capable of providing the service.
D. The recipient has failed to cooperate with the ADSD Case Manager or HCBS Waiver
service provider(s) in establishing and/or implementing the POC, implementing waiver
services or verifying eligibility for waiver services (the recipient and/or designated
representative/LRI’s signature is necessary on all required paperwork.)
E. The recipient has requested the reduction of services.
F. The recipient’s ability to perform ADLs has improved.
G. Another agency or program will provide the service.
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H. Another service will be substituted for the existing service.
When there is a reduction of waiver services, the updated prior authorization will be submitted,
and a NOD will be generated. A hearing can be requested through the Hearings Unit by the
recipient and/or designated representative/LRI. The NOD must be mailed to the DHCFP Hearings
Unit at least 13 calendar days before the Date of Action on the form.
Refer to MSM Chapter 3100 Hearings, for specific instructions regarding notice and recipient
hearings.
2204.6 REAUTHORIZATION WITHIN 90 DAYS OF WAIVER TERMINATION
If a recipient is placed in a NF or hospital and waiver services have been terminated, the recipient
may request to be re-instated within 90 days of closure.
2204.6A COVERAGE AND LIMITATIONS
1. The waiver slot must be held for 90 days from the NOD date.
2. The recipient may request to be placed back on the waiver if:
a. They still meet LOC;
b. There is a slot available;
c. And is released within 90 days.
3. If the termination took place in a prior waiver year and the recipient still meets a LOC, slot
availability and emergent need will be taken into consideration for readmission into the
waiver. If 90 calendar days has elapsed from the NOD date, the slot is allocated to the next
person on the waitlist.
2204.6B PROVIDER RESPONSIBILITIES
ADSD will ensure appropriate action is taken when re-authorizing a recipient.
2204.6C RECIPIENT RESPONSIBILITIES
Recipients must cooperate fully with the reauthorization process to assure approval of request for
readmission to the waiver.
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2205 APPEALS AND HEARINGS
Refer to MSM Chapter 3100 Hearings for specific instructions regarding notice and hearing
procedures. Recipients are informed of their rights to a fair hearing at the initial face-to-face visit
and annually thereafter when they are given the Recipients Rights Form.
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TRANSMITTAL LETTER
September 24, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: TAMMY MOFFITT, CHIEF OF OPERATIONS �
)<
SUBJECT: MEDICAID SERVICES MANUAL CHANGES �
CHAPTER 2300 - HOME AND COMMUNITY BASED WAIVER
(HCBW) FOR PERSONS WITH PHYSICAL DISABILITIES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2300 - Home and Community Based
Waiver (HCBW) for Persons with Physical Disabilities are being proposed to include mandate as
per the 21st Century Cures Act.
In December 2016, Congress passed H.R. 34 - 21st Century Cures Act, mandating that all States
require the use of an Electronic Visit Verification (EVV) System for all Medicaid funded personal
care services that are provided under a State plan or a waiver of the plan, including services
provided under section 1915(c).
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: Entities Financially Affected: This proposed change affects all
Medicaid-enrolled providers delivering specific waiver services. Those provider types (PT)
include but are not limited to: Waiver for Persons with Physical Disabilities (PT 58).
Financial Impact on Local Government: Unknown at this time.
These changes are effective September 25, 2019 .
.__I __ MATERI_AL_T_R__ ANS _M_I TTED_ I MATERIAL SUPERSEDED
MTL 19/19 MTL 08/13, 33/10
MSM Ch 2300 - Home and Community MSM Ch 2300 - Home and Community Based
Based Waiver (HCBW) for Persons with Waiver (HCBW) for Persons with Physical
Physical Disabilities Disabilities
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
2301 Authority Added new authorities as per the new policy mandate.
2303.3B Provider Deleted information regarding prior authorization as
Responsibilities not every waiver service requires a prior
authorization.
Added information regarding Electronic Visit
Verification policy under new section 2303.3B.2b.
2303.3C Recipient Corrected/renumbered list at the end of this section
Responsibilities and added two new recipient responsibilities.
2303.4B Homemaker Added two new provider responsibilities related to
Provider EVV policy.
Responsibilities
2303.5B Chore Services Added provider responsibility related to EVV policy
Provider and further clarification regarding requirement,
Responsibilities expectations and documentation.
2303.6B Respite Care Added provider responsibility related to EVV policy
Provider and further clarification regarding requirement,
Responsibilities expectations and documentation.
2303.7B Environmental Added specific service requirement regarding prior
Accessibility authorization.
Adaptations
Provider
Responsibility
2303.9B PERS Provider Added specific service requirement regarding prior
Responsibilities authorization.
2303.10B Assisted Living Added specific service requirement regarding prior
Provider authorization.
Responsibilities
2303.11B Home Delivered Added specific service requirement regarding prior
Meals Provider authorization.
Responsibilities
2303.12B Attendant Care Added two new provider responsibilities related to
Provider EVV policy.
Responsibilities
Page 2 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
HOME AND COMMUNITY-BASED WAIVER (HCBW) FOR PERSONS WITH PHYSICAL DISABILITIES
2300 INTRODUCTION ............................................................................................................................ 1
2301 AUTHORITY ................................................................................................................................... 1
2302 RESERVED ...................................................................................................................................... 1
2303 POLICY ............................................................................................................................................ 1
2303.1 ADMINISTRATIVE CASE MANAGEMENT ACTIVITIES ........................................................ 1
2303.1A COVERAGE AND LIMITATIONS ................................................................................................ 1
2303.1B ADMINISTRATIVE CASE MANAGEMENT PROVIDER RESPONSIBILITIES ...................... 2
2303.1C RECIPIENT RESPONSIBILITIES .................................................................................................. 2
2303.2 ELIGIBILITY CRITERIA................................................................................................................ 2
2303.2A COVERAGE AND LIMITATIONS ................................................................................................ 3
2303.2B MEDICAID EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT
(EPSDT)............................................................................................................................................ 4
2303.3 WAIVER SERVICES ....................................................................................................................... 5
2303.3A COVERAGE AND LIMITATIONS ................................................................................................ 5
2303.3B PROVIDER RESPONSIBILITIES ................................................................................................. 5
2303.3C RECIPIENT RESPONSIBILITIES ................................................................................................ 13
2303.3D DIRECT SERVICE CASE MANAGEMENT ............................................................................... 15
2303.3E COVERAGE AND LIMITATIONS .............................................................................................. 15
2303.3F DIRECT SERVICES CASE MANAGEMENT PROVIDER RESPONSIBILITIES .................... 16
2303.3G RECIPIENT RESPONSIBILITIES ................................................................................................ 17
2303.4 HOMEMAKER SERVICES .......................................................................................................... 17
2303.4A COVERAGE AND LIMITATIONS .............................................................................................. 17
2303.4B HOMEMAKER PROVIDER RESPONSIBILITIES ..................................................................... 18
2303.5 CHORE SERVICES ....................................................................................................................... 19
2303.5A COVERAGE AND LIMITATIONS .............................................................................................. 19
2303.5B CHORE SERVICES PROVIDER RESPONSIBILITIES .............................................................. 20
2303.6 RESPITE CARE ............................................................................................................................. 20
2303.6A COVERAGE AND LIMITATIONS .............................................................................................. 20
2303.6B RESPITE CARE PROVIDER RESPONSIBILITIES .................................................................... 20
2303.7 ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS .......................................................... 21
2303.7A COVERAGE AND LIMITATIONS .............................................................................................. 21
2303.7B ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS PROVIDER RESPONSIBILITIES . 22
2303.8 SPECIALIZED MEDICAL EQUIPMENT AND SUPPLIES ....................................................... 22
2303.8A COVERAGE AND LIMITATIONS .............................................................................................. 22
2303.8B SPECIALIZED MEDICAL EQUIPMENT PROVIDER RESPONSIBILITIES ........................... 23
2303.9 PERSONAL EMERGENCY RESPONSE SYSTEMS (PERS) ..................................................... 23
2303.9A COVERAGE AND LIMITATIONS .............................................................................................. 23
2303.9B PERS PROVIDER RESPONSIBILITIES ...................................................................................... 24
2303.9C RECIPIENT RESPONSIBILITIES ................................................................................................ 24
2303.10 ASSISTED LIVING SERVICES ................................................................................................... 24
1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
2303.10A COVERAGE AND LIMITATIONS .............................................................................................. 24
2303.10B ASSISTED LIVING PROVIDER RESPONSIBILITIES .............................................................. 25
2303.11 HOME DELIVERED MEALS ....................................................................................................... 27
2303.11A COVERAGE AND LIMITATIONS .............................................................................................. 27
2303.11B HOME DELIVERED MEALS PROVIDER RESPONSIBILITIES .............................................. 28
2303.12 ATTENDANT CARE ..................................................................................................................... 29
2303.12A COVERAGE AND LIMITATIONS .............................................................................................. 29
2303.12B ATTENDANT CARE PROVIDER RESPONSIBILITIES ........................................................... 30
2303.13 PROVIDER ENROLLMENT/TERMINATION............................................................................ 31
2303.14 INTAKE PROCEDURES ............................................................................................................... 31
2303.14A COVERAGE AND LIMITATIONS .............................................................................................. 31
2303.15 BILLING PROCEDURES ............................................................................................................. 34
2303.15A COVERAGE AND LIMITATIONS .............................................................................................. 34
2303.15B PROVIDER RESPONSIBILITY.................................................................................................... 34
2303.16 ADVANCE DIRECTIVES............................................................................................................. 34
2303.17 ANNUAL REVIEW ....................................................................................................................... 34
2303.17A PROVIDER RESPONSIBILITIES ................................................................................................ 35
2304 HEARINGS ...................................................................................................................................... 1
2304.1A SUSPENDED WAIVER SERVICES............................................................................................... 1
2304.1B RELEASE FROM SUSPENDED WAIVER SERVICES ................................................................ 1
2304.1C DENIAL OF WAIVER SERVICES ................................................................................................ 1
2304.1D TERMINATION OF WAIVER SERVICES .................................................................................... 2
2304.1E REDUCTION OF WAIVER SERVICES ........................................................................................ 3
2304.2 REAUTHORIZATION WITHIN 90 DAYS OF WAIVER TERMINATION ................................ 4
2304.3 APPEALS AND HEARINGS .......................................................................................................... 4
2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2300
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
2300 INTRODUCTION
The Home and Community Based Waiver (HCBW) for Persons with Physical Disabilities
recognizes many individuals at risk of being placed in hospitals or nursing facilities can be cared
for in their homes and communities, preserving independence and ties to family and friends at a
cost no higher than institutional care.
The Division of Health Care Financing and Policy’s (DHCFP) HCBW for Persons with Physical
Disabilities originated in 1990. Waiver service provision is based on the identified needs of waiver
recipients. Nevada is committed to the goal of integrating persons with disabilities into the
community. Nevada understands persons with disabilities are able to lead satisfying and productive
lives, and are able to self-direct care when provided needed services and supports to do so.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2301
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
2301 AUTHORITY
Section 1915(c) of the Social Security Act permits states to waive certain Medicaid statutory
requirements in order to offer an array of home and community-based services that an individual
requires to remain in a community setting and avoid institutionalization. The Division of Health
Care Financing and Policy’s (DHCFP) Home and Community Based Waiver (HCBW) for Persons
with Physical Disabilities is an optional program approved by the Centers for Medicare and
Medicaid Services (CMS). The waiver is designed to provide to eligible Medicaid waiver
recipients State Plan Services and certain extended Medicaid covered services unique to this
waiver. The goal is to allow recipients to live in their own homes or community settings, when
appropriate.
Nevada has the flexibility to design this waiver and select the mix of waiver services best meeting
the goal to keep people in the community. Such flexibility is predicated on administrative and
legislative support, as well as federal approval.
Statutes and Regulations
• Social Security Act: 1915 (c)
• Social Security Act: 1916 (e)
• Social Security Act: 1902 (w)
• Omnibus Budget Reconciliation Act of 1987
• Balanced Budget Act of 1997
• Health Insurance Portability and Accountability Act of 1996 (HIPAA)
• State Medicaid Manual, Section 44442.3.B.13
• State Medicaid Director Letter (SMDL) #01-006 attachment 4-B
• Title 42, Code of Federal Regulations (CFR) Part 441, subparts G
• 42 CFR Part 431, Subpart E
• 42 CFR Part 431, Subpart B
• 42 CFR 489, Subpart I
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Section:
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Subject:
MEDICAID SERVICES MANUAL AUTHORITY
• Nevada’s Home and Community Based Waiver Agreement for People with Physical
Disabilities Nevada Revised Statutes (NRS) Chapter 449, 706, 446, 629, 630, 630a, and
633
• Nevada Administrative Code (NAC) Chapters 441A.375 and 706.
• 21st Century Cures Act, H.R. 34, Sec. 12006 – 114th Congress
• H.R. 6042 – 115th Congress
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2302 RESERVED
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2303 POLICY
2303.1 ADMINISTRATIVE CASE MANAGEMENT ACTIVITIES
Administrative case management occurs prior to an applicant being determined eligible for a
waiver and during a re-evaluation or reassessment of eligibility. Administrative case management
may only be provided by qualified staff.
2303.1A COVERAGE AND LIMITATIONS
Administrative case management activities include:
1. Intake referral;
2. Facilitating Medicaid eligibility, which may include assistance with the Medical
Assistance for the Aged, Blind and Disabled (MAABD) application and obtaining
documents required for eligibility determination;
3. Preliminary and ongoing assessments, evaluations and completion of forms required for
service eligibility:
a. The Plan of Care (POC) identifies the waiver services as well as other ongoing
community support services that the recipient needs in order to live successfully in
the community. The POC must reflect the recipient’s service needs and include
both waiver and non-waiver services in place at the time of POC completion, along
with informal supports that are necessary to address those needs.
b. The recipient’s Level of Care (LOC), functional status and needs addressed by the
POC must be reassessed annually or more often as needed. The recipient must also
be reassessed when there is a significant change in his/her condition which
influences eligibility. The reassessment is to be conducted during a face-to-face
visit.
c. If services documented on a POC are approved by the recipient and the case
manager and the recipient signature cannot be obtained due to extenuating
circumstances, services can commence with verbal approval from the recipient.
Case managers must document the recipient’s verbal approval in the case notes and
obtain the recipient signature on the POC as soon as possible.
4. Issuance of a Notice of Decision (NOD) when a waiver application is denied;
5. Coordination of care and services to collaborate in discharge planning to transition
applicants from facilities;
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6. Documentation for case files prior to applicant’s eligibility;
7. Case closure activities upon termination of service eligibility;
8. Outreach activities to educate recipients or potential recipients on how to enter into care
through a Medicaid Program;
9. Communication of the POC to all affected providers;
10. If attendant care services are medically necessary, the case manager is then responsible for
implementation of services and continued authorization of services;
11. Completion of prior authorization form in the Medicaid Management Information System
(MMIS).
12. Travel time to and from scheduled home visits.
2303.1B ADMINISTRATIVE CASE MANAGEMENT PROVIDER RESPONSIBILITIES
Employees of the Division of Health Care Financing and Policy (DHCFP), Health Care
Coordinator (HCC) I, II, or III are qualified Medicaid case managers for the Waiver. Professional
or medical licensure recognized by a Nevada Professional State Board, such as social worker,
registered nurse, occupational therapist or physical therapist is required. A Licensed Practical
Nurse (LPN) may complete back up case management, operating under a previously developed
LOC and POC under the supervision of the primary case manager.
2303.1C RECIPIENT RESPONSIBILITIES
1. Participate in the waiver assessment and reassessment process.
2. Participate in monthly contacts and home visits with the case manager.
3. Together with the waiver case manager, develop and/or review the POC.
4. If services documented on the POC are approved by the recipient and the case manager
and the recipient signature cannot be obtained due to extenuating circumstances, services
can commence or continue with verbal approval from the recipient. Case managers must
document the recipient’s verbal approval in the case notes and obtain the recipient signature
on the POC as soon as possible.
2303.2 ELIGIBILITY CRITERIA
The DHCFP Home and Community-Based Waiver (HCBW) for Persons with Physical Disabilities
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waives certain statutory requirements and offers Home and Community-Based Services (HCBS)
to eligible recipients to assist them to remain in the community.
2303.2A COVERAGE AND LIMITATIONS
1. Services are offered to eligible recipients who, without the waiver services, would require
institutional care provided in a hospital or Nursing Facility (NF). Recipients on the waiver
must meet and maintain waiver eligibility requirements for the waiver.
2. Persons with Physical Disabilities Waiver Eligibility Criteria
Eligibility for the HCBW for Persons with Physical Disabilities is determined by the
combined efforts of the DHCFP and the Division of Welfare and Supportive Services
(DWSS).
The following determinations must be made for eligibility purposes. Services will not be
provided unless the applicant is found eligible in all areas:
a. The applicant must be physically disabled.
1. Applicants must be certified as physically disabled by the DHCFP Central
Office Physician Consultant. Disabling impairments must result from
anatomical or physiological abnormalities and must be demonstrable by
medically acceptable clinical and laboratory diagnostic techniques and be
established by competent medical evidence.
2. The DHCFP Physician Consultant and other health care professionals
(Disability Determination Team) review medical and non-medical
documentation, and determine whether an applicant qualifies as physically
disabled.
b. The applicant must meet and maintain an LOC for admission into an NF within 30
days if HCBW services or other supports were not available.
1. The applicant must require provision of at least one ongoing waiver service
monthly to be determined to need waiver services as documented in the
POC.
c. Applicants must meet financial eligibility for Medicaid as determined by DWSS.
3. The HCBW for Persons with Physical Disabilities is limited, by legislative authority to a
specific number of recipients who can be served through the waiver per year (slots). When
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all waiver slots are full, the DHCFP utilizes a wait list for applicants who have been pre-
determined to be eligible for the waiver.
4. Wait List Prioritization
a. Nursing facility residents.
b. Applicants who have a severe functional disability as defined by Nevada Revised
Statute (NRS) 426.721 to 731. Applicants must be dependent or require assistance
in the functional areas of eating, bathing and toileting as identified on the LOC
screening assessment.
c. All other applicants not listed above.
5. The DHCFP must assure the Center for Medicare and Medicaid Services (CMS) that the
DHCFP’s total expenditure for home and community-based and other State Plan Medicaid
services for all recipients under this waiver will not, in any calendar/waiver year, exceed
100% of the amount that would be incurred by the DHCFP for all these recipients if they
had been in an institutional setting in the absence of the waiver. The DHCFP must also
document there are safeguards in place to protect the health and welfare of recipients.
6. Waiver services may not be provided while a recipient is an inpatient of an institution.
7. Recipients of the HCBW for Persons with Physical Disabilities who are enrolled or elect
to enroll in a hospice program may be eligible to remain on the waiver if they require
waiver services to remain in the community. Close case coordination between the hospice
agency and the waiver case manager is required to prevent any duplication of services.
Refer to Medicaid Services Manual (MSM) Chapter 3200 for additional information on
hospice services.
8. HBCS are not a substitute for natural and informal supports provided by family, friends or
other available community resources. Waiver services alone may not address all of the
applicant’s identified needs.
9. If an applicant is determined eligible for more than one HCBW program, the individual
cannot receive services under two or more such programs at the same time. The
applicant/recipient must choose one HCBW program and receive services provided by that
program.
2303.2B MEDICAID EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT
(EPSDT)
The children made eligible for Medicaid through their enrollment in the HCBW for Persons with
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Physical Disabilities receive all medically necessary Medicaid covered services available under
EPSDT. A child’s enrollment in the waiver will not be used to deny, delay, or limit access to
medically necessary service(s) required to be available to Medicaid-eligible children under federal
EPSDT rules. The waiver service package is a supplement to EPSDT services.
2303.3 WAIVER SERVICES
The DHCFP determines which services will be offered under the HCBW for Persons with Physical
Disabilities. Providers and recipients must agree to comply with the requirements for service
provision.
2303.3A COVERAGE AND LIMITATIONS
Under the waiver, the following services are covered if identified in the POC as necessary to avoid
institutionalization:
1. Case Management;
2. Homemaker Services;
3. Chore Services;
4. Respite;
5. Environmental Accessibility Adaptations;
6. Specialized Medical Equipment and Supplies;
7. Personal Emergency Response System (PERS);
8. Assisted Living Services;
9. Home Delivered Meals; and/or
10. Attendant Care Services.
2303.3B PROVIDER RESPONSIBILITIES
1. All Providers
a. Providers are responsible for confirming the recipient’s Medicaid eligibility each
month prior to rendering service.
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b. Providers must meet and comply with all provider requirements as specified in
MSM Chapter 100.
c. Must enroll and maintain an active HCBW for Persons with Physical Disabilities
provider number (Type 58).
d. May only provide services that have been identified in the recipient POC and, if
required, have prior authorization.
e. The total weekly authorized hours for Activities of Daily Living (ADLs) and
Instrumental Activities of Daily Living (IADLs) may be combined and tailored to
meet the needs of the recipient, as long as the plan does not alter medical necessity.
The provider and recipient will determine how to use the weekly authorized hours
on an ongoing basis; however, any changes that do not increase the total authorized
hours can be made within a single week without an additional authorization.
Flexibility of services may not take place solely for the convenience of the provider.
f. Payments will not be made for services provided by a recipient’s legally responsible
individual.
2. Provider Agencies
a. Agencies employing providers of service for the waiver program must arrange
training in at least the following subjects:
1. policies, procedures and expectations of the contract agency relevant to
the provider, including recipient’s and provider’s rights and
responsibilities;
2. procedures for billing and payment, if applicable;
3. record keeping and reporting;
4. information about the specific disabilities of the persons to be served and,
more generally, about the types of disabilities among the populations the
provider will serve, including physical and psychological aspects and
implications, types of resulting functional deficits, and service needs;
5. recognizing and appropriately responding to medical and safety
emergencies;
6. working effectively with recipients including: understanding recipient
direction and the independent living philosophy; respecting consumer rights
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and needs; respect for age, cultural and ethnic differences; recognizing
family relationships; confidentiality; respecting personal property; active
listening and responding; emotional support and empathy; ethics in dealing
with the recipient, legally responsible individual and other providers;
handling conflict and complaints; dealing with death and dying; and other
topics as relevant.
7. Exemptions from Training
a. The agency may exempt a prospective service provider from those
parts of the required training where the agency verifies the person
possesses adequate knowledge or experience, or where the
provider’s duties will not require the particular skills.
b. The exemption and its rationale must be provided in writing and a
copy of the exemption must be placed in the recipient’s and
caregiver’s case record. Where the recipient or other private third
party functions as the employer, such individuals may exercise the
exemption authority identified above.
8. Recipients Providing Training
a. Where a recipient desires to provide training and the recipient is able
to state and convey his/her needs to a caregiver, the agency will
allow the recipient to do so.
b. Any such decision shall be agreed to by the recipient and
documented in the case record as to what training the recipient is to
provide.
c. Where the recipient or other private third-party functions as the
employer such individual may exercise the exemption from training
authority identified above.
9. Completion and Documentation of Training
The provider shall complete required training within six months of
beginning employment. Training as documented in the MSM 2303.2 B.2.b.,
except for the service areas requiring completion of Cardiopulmonary
Resuscitation (CPR) (as listed in the specific service area sections of this
chapter) which should be completed in a six month timeframe, and 2303.2
B.2.b.(6-8), which must be completed prior to service provision.
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10. Each provider agency must have a file for each recipient. In the recipient’s
file, the agency must maintain the daily records. Periodically, the DHCFP
Central Office staff may request this documentation to compare to billings
submitted. These records must be maintained by the provider for at least six
years after the date the claim is paid.
11. Flexibility of service delivery which does not alter medical necessity may
occur within a single week period without an additional authorization.
Reference Section 2303B.e.
b. ELECTRONIC VISIT VERIFICATION (EVV):
The 21st Century Cures Act requires the use of an EVV system to document services
that are provided for all personal care services under a Medicaid State plan or
waiver program. This mandate requires provider agencies to use an EVV system
to record service delivery visit information. Nevada Medicaid utilizes the open-
system model, procuring a vendor but also allows agencies to utilize their own if it
meets the 21st Century Cures Act requirements for documentation.
All service information must be recorded in an electronic system that interfaces
with either a telephone or an electronic device that generates a timestamp. The
provider agency must verify the EVV record, including any visit maintenance, prior
to submitting a claim associated with the EVV record. All claims must be supported
by an EVV entry into an EVV system prior to claim submission.
Agencies must ensure each personal care attendant has a unique identifier (National
Provider Identification – NPI) associated with their worker profile in the EVV
system.
1. STATE OPTION:
a. The EVV system electronically captures:
1. The type of service performed, based on procedure code;
2. The individual receiving the service;
3. The date of the service;
4. The location where service is provided;
5. The individual providing the service;
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6. The time the service begins and ends.
b. The EVV system must utilize one or more of the following:
1. The agency/personal care attendant’s smartphone;
2. The agency/personal care attendant’s tablet;
3. The recipient’s landline telephone;
4. The recipient’s cellular phone (for Interactive Voice
Response (IVR) purposes only);
5. Other GPS-based device as approved by the DHCFP.
2. DATA AGGREGATOR OPTION:
a. All Personal Care Agencies that utilize a different EVV system (as
approved by the DHCFP) must comply with all documentation
requirements of this chapter and must utilize the data aggregator to
report encounter or claim data.
1. Appropriate form must be approved by the DHCFP before
use of system to ensure all data requirements are being
collected to meet the 21st Century Cures Act.
2. At a minimum, data uploads must be completed monthly into
data aggregator.
c. All waiver providers must provide the local DHCFP District Office Waiver Case
Manager with written notification of serious occurrences involving the recipient
within 24 hours of discovery.
Serious occurrences include, but are not limited to the following:
1. Unplanned hospital or Emergency Room (ER) visit;
2. Injury or fall requiring medical intervention;
3. Alleged physical, verbal, sexual abuse or sexual harassment;
4. Alleged theft or exploitation;
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5. Medication error;
6. Death of the recipient or significant care giver; or
7. Loss of contact with the recipient for three consecutive scheduled days.
d. State law requires that persons employed in certain capacities must make a report
to a child protective service agency or law enforcement agency immediately, but in
no event later than 24 hours after there is reason to suspect a child has been abused
or neglected. The DHCFP expects that all providers be in compliance with the
intent of all applicable laws.
For recipients under the age of 18, the Division of Child and Family Services
(DCFS) or the appropriate county agency accepts reports of suspected child abuse
and neglect. For adults aged 60 and over, the Aging and Disability Services
Division (ADSD) accepts reports of suspected abuse, neglect or self-neglect,
exploitation or isolation.
1. Child Abuse - Refer to NRS 432B regarding child abuse or neglect.
2. Elder Abuse - Refer to NRS 200.5091 to 200.50995 regarding elder abuse
or neglect.
3. Other Age Groups - For all other individuals or vulnerable persons (NRS
200.5091 to 200.50995) defined as “a person 18 years of age or older who:
a. suffers from a condition of physical or mental incapacitation
because of a developmental disability, organic brain damage or
mental illness; or
b. has one or more physical or mental limitations that restrict the ability
of the person to perform the normal ADLs,” contact local law
enforcement agencies.
e. Before initial employment, an employee must have a:
1. Physical examination or certification from a licensed physician that the
person is in a state of good health, is free from active Tuberculosis (TB) and
any other communicable disease in a contagious stage; and
2. TB screening test within the preceding 12 months, including persons with a
history of Bacillus Calmett-Guerin (BCG) vaccination.
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If the employee has only completed the first step of a 2-step Mantoux Tuberculin
skin test within the preceding 12 months, then the second step of the 2-step
Mantoux Tuberculin skin test or other single-step TB screening test must be
administered. A single annual TB screening test must be administered thereafter.
An employee who tests positive to either of the 2-step Mantoux Tuberculin skin
tests must obtain a chest x-ray and medical evaluation for active TB.
An employee with a documented history of a positive TB screening test is exempt
from skin testing and chest x-rays unless he/she develops symptoms suggestive of
active TB.
An employee who is exempt from skin testing and chest x-rays must submit to an
annual screening for signs and symptoms of active disease which must be
completed prior to the one-year anniversary of the last screening. Documentation
of the annual screening and the results must be maintained in the employee’s file.
The annual screening must address each of the following areas of concern and must
be administered and/or reviewed by a qualified health care professional.
1. Has had a cough for more than three weeks;
2. Has a cough which is productive;
3. Has blood in his/her sputum;
4. Has a fever which is not associated with a cold, flu or other apparent illness;
5. Is experiencing night sweats;
6. Is experiencing unexplained weight loss; or
7. Has been in close contact with a person who has active TB.
Annual screening for signs and symptoms of active disease must be completed prior
to the one year anniversary of the last screening. Documentation of the annual
screening and the results must be maintained in the employee’s file.
Documentation of TB testing must be issued by a medical facility or licensed
medical professional qualified to administer the test, signed by the physician or
his/her designee, stating the date of the test, the date the test was read, and the
results, and maintained in the employee’s file. Any lapse in the required timelines
above results in non-compliance with this Section.
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In addition, providers must also comply with the TB requirements outlined in
Nevada Administrative Code (NAC) 441A.375 and 441A.380.
f. All waiver providers, including owners, officers, administrators, managers,
employees (who have direct contact with recipients) and consultants must undergo
State and Federal Bureau of Investigation (FBI) background checks upon
enrollment as a provider and then at a minimum of every five years thereafter to
ensure no convictions of applicable offenses have been incurred and the safety of
recipients is not compromised.
1. The DHCFP policy requires all waiver providers have State and Federal
criminal history background checks completed. The DHCFP fiscal agent
will not enroll any provider agency whose owner or operator has been
convicted of a felony under State or Federal law for any offense which the
DHCFP determines is inconsistent with the best interest of recipients.
Additional information may be found in MSM Chapter 100, Section 102.2.
2. Criminal background checks must be conducted through the Nevada
Department of Public Safety (DPS). Agencies do not have to have a DPS
account. Individuals may request their own personal criminal history
directly from DPS and the FBI and must have the results sent directly to the
employer. Information and instructions may be found on the Health website
at: http://health.nv.gov/HCQC_CriminalHistory_Fingerprints.htm.
3. The employer is responsible for reviewing the results of employee criminal
background checks and maintaining the results within the employee’s
personnel records. Continued employment is at the sole discretion of the
servicing agency. However, the DHCFP has determined certain felonies and
misdemeanors to be inconsistent with the best interests of recipients. The
employer should gather information regarding the circumstances
surrounding the conviction when considering ongoing employment and
have this documented in the employee’s personnel file. These convictions
include (not all inclusive):
1. murder, voluntary manslaughter or mayhem;
2. assault with intent to kill or to commit sexual assault or mayhem;
3. sexual assault, statutory sexual seduction, incest, lewdness, indecent
exposure or any other sexually related crime;
4. abuse or neglect of a child or contributory delinquency;
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5. a violation of any federal or state law regulating the possession,
distribution or use of any controlled substance or any dangerous
drug as defined in NRS 454;
6. a violation of any provision of NRS 200.700 through 200.760;
7. criminal neglect of a patient as defined in NRS 200.495;
8. any offense involving fraud, theft, embezzlement, burglary, robbery,
fraudulent conversion or misappropriation of property;
9. any felony involving the use of a firearm or other deadly weapon;
10. abuse, neglect, exploitation or isolation of older persons;
11. kidnapping, false imprisonment or involuntary servitude;
12. any offense involving assault or battery, domestic or otherwise;
13. conduct inimical to the public health, morals, welfare and safety of
the people of the State of Nevada in the maintenance and operation
of the premises for which a provider contract is issued;
14. conduct or practice detrimental to the health or safety of the
occupants or employees of the facility or agency; or
15. any other offense that may be inconsistent with the best interests of
all recipients.
g. Providers are required to initiate diligent and effective follow up for results
of background checks within 90 days of submission of prints and continue
until results are received. An “undecided” result is not acceptable. If an
employee believes that the information provided as a result of the criminal
background check is incorrect, the individual must immediately inform the
employing agency in writing. Information regarding challenging a
disqualification is found on the DPS website at: http://dps.nv.gov under
Records and Technology.
2303.3C RECIPIENT RESPONSIBILITIES
The recipient or the recipient’s authorized representative will:
1. notify the provider(s) and case manager of a change in Medicaid eligibility.
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2. notify the provider(s) and case manager of changes in medical status, service needs,
address, and location, or of changes of status of legally responsible individual(s) or
authorized representative.
3. treat all staff and providers appropriately.
4. if capable, sign the provider daily record to verify services were provided.
5. notify the provider when scheduled visits cannot be kept or services are no longer required.
6. notify the provider agency of missed visits by provider agency staff.
7. notify the provider agency of unusual occurrences, complaints regarding delivery of
services, specific staff, or to request a change in caregiver.
8. furnish the provider agency with a copy of their Advance Directives.
9. establish a back-up plan in case a waiver attendant is unable to work at the scheduled time.
10. not request a provider to work more than the hours authorized in the service plan.
11. not request a provider to work or clean for a non-recipient, family, or household members.
12. not request a provider to perform services not included in the care plan.
13. contact the case manager to request a change of provider.
14. sign all required forms.
15. meet and maintain all criteria to be eligible, and to remain on the HCBW for Persons with
Physical Disabilities.
16. may have to pay patient liability. Failure to pay is grounds for termination from the waiver.
17. agree to utilize an approved EVV system for the waiver services being received from the
provider agency.
18. confirm services were provided by electronically signing or initialing, as appropriate per
service plan, the EVV record that reflects the service rendered. If IVR is utilized, a vocal
confirmation is required.
2303.3D DIRECT SERVICE CASE MANAGEMENT
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Direct Service Case Management is limited to eligible participants enrolled in HCBW services
program, when case management is identified as a service on the POC. The recipient has a choice
to have direct service case management services provided by qualified state staff or qualifying
provider agency staff.
2303.3E COVERAGE AND LIMITATIONS
These services include:
1. Identification of resources and assisting recipients in locating and gaining access to waiver
services, as well as needed medical, social, educational and other services regardless of the
funding source;
2. Coordination of multiple services and/or providers;
3. Monitoring the overall provision of waiver services, in an effort to protect the safety and
health of the recipient and to determine that the POC goals are being met;
4. Monitoring and documenting the quality of care through monthly contact:
a. The direct service case manager must have a monthly contact with each waiver
recipient and/or the recipient’s authorized representative; this may be a telephone
contact. At a minimum, there must be a face-to-face visit with each recipient once
every six months. More contacts may be made if the recipient has indicated a
significant change in his or her health care status or is concerned about his or her
health and/or safety.
b. When recipient service needs increase, due to a temporary condition or
circumstance, the direct service case manager must thoroughly document the
increased service needs in their case notes. The POC does not need to be revised
for temporary conditions or circumstances. A temporary condition or circumstance
is defined as an increase or decrease in service needs for a period not to exceed 30
days.
c. During the monthly contact, the direct service case manager monitors and
documents the quality of care of the recipient. Quality of care includes the
identification, remediation and follow-up of health and safety issues, needs and
concerns of the recipient, waiver service satisfaction and whether the services are
promoting goals stated in the POC. The direct service case manager also assesses
the need for any change in services or providers and communicates this information
to the administrative case manager.
NOTE: If a recipient has an independent contractor, the direct service case manager
may review the recipient daily record for completion and accuracy. The case
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manager will provide training to independent contractors in the completion and use
of daily records if needed.
5. Making certain that the recipient retains freedom of choice in the provision of services;
6. Notifying all affected providers of changes in the recipient’s medical status, service needs,
address, and location, or of changes of the status of legally responsible individuals or
authorized representative;
7. Notifying all affected providers of any unusual occurrence or change in status of a waiver
recipient;
8. Notifying all affected providers of any recipient complaints regarding delivery of service
or specific provider staff;
9. Notifying all affected providers if a recipient requests a change in the provider staff or
provider agency; and
10. Case Managers must provide recipients with appropriate amount of case management
services necessary to ensure the recipient is safe and receives sufficient services. Case
management will be considered an “as needed” service. Case managers must continue to
have monthly contact with recipients and/or the recipients authorized representative of at
least 15 minutes, per recipient, per month. The amount of case management services must
be adequately documented and substantiated by the case manager’s notes.
2303.3F DIRECT SERVICES CASE MANAGEMENT PROVIDER RESPONSIBILITIES
Verification of compliance with these administrative requirements must be provided:
1. A fixed business landline telephone number published in a public telephone directory.
2. A business office accessible to the public during established and posted business hours.
Employees of the case management provider agency who provide direct service case management
services must be licensed as a Social Worker by the State of Nevada Board of Examiners for Social
Workers, licensed as a Registered Nurse by the State of Nevada Board of Nursing, or have a
professional license or certificate in a medical specialty applicable to the assignment, have at least
one year experience as a case manager and must have a valid driver’s license. Employees must
pass a State and FBI criminal background check. In addition, providers must meet and comply
with all provider requirements as specified in MSM Chapters 100 and/or 3500.
2303.3G RECIPIENT RESPONSIBILITIES
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1. Participate in the waiver assessment, monthly contacts and reassessment process,
accurately representing his or her skill level needs, wants, resources, and goals.
2. Together with the waiver case manager, develop and/or review and sign the POC. If the
recipient is unable to provide a signature due to intellectual and/or physical limitations, this
will be clearly documented in the recipient file. The provider will initial after the daily
services are delivered, with a full signature of the provider on each daily record.
3. Choose to have direct service case management provided by qualifying state staff or
qualifying provider agency staff.
2303.4 HOMEMAKER SERVICES
2303.4A COVERAGE AND LIMITATIONS
1. Homemaker services are provided by individuals or agencies under contract with the
DHCFP.
2. Homemaker services are provided when the individual regularly responsible for these
activities is temporarily absent or unable to manage the home.
3. The DHCFP is not responsible for replacing goods damaged in the provision of service.
Homemaker services include:
a. general cleaning, including mopping floors, vacuuming, dusting, cleaning the
stove, changing and making beds, washing dishes, defrosting and cleaning the
refrigerator, keeping bathrooms and the kitchen clean, and washing windows as
high as the homemaker can reach while standing on the floor;
b. shopping for food and needed supplies;
c. planning and preparing varied meals, considering both cultural and economic
standards of the recipient, preparing tray meals when needed, and preparing special
diets under medical supervision;
d. washing, ironing and mending the recipient’s personal laundry. The recipient pays
any laundromat and/or cleaning fees;
e. assisting the recipient and legally responsible individuals or caregivers in learning
a homemaker routine and skills, so the recipient may carry on normal living when
the homemaker is not present;
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f. accompanying the recipient to homemaker activities such as shopping or the
laundromat. Any transportation to and from these activities is not reimbursable as
a Medicaid expense;
g. routine clean-up after up to two household pets. Walking a pet is not included unless
it is a service animal.
4. Activities the homemaker shall not perform and for which Medicaid will not pay include,
but are not limited to the following:
a. transporting (as the driver) the recipient in a private car;
b. cooking and cleaning for the recipient’s guests, other household members or for
entertaining;
c. repairing electrical equipment;
d. ironing sheets;
e. giving permanents, dying or cutting hair;
f. accompanying the recipient to social events;
g. washing walls;
h. moving heavy furniture, climbing on chairs or ladders;
i. purchasing alcoholic beverages which were not prescribed by the recipient’s
physician;
j. doing yard work such as weeding or mowing lawns, trimming trees, shoveling non-
essential snow covered areas and vehicle maintenance.
2303.4B HOMEMAKER PROVIDER RESPONSIBILITIES
In addition to the following requirements listed, please reference Section 2303.3B of this chapter
regarding Provider Responsibilities.
1. Providers are required to arrange and receive training related to household care, including
good nutrition, special diets, meal planning and preparation, shopping information,
housekeeping techniques, and maintenance of a clean, safe and healthy environment.
2. A legally responsible individual may not be paid for homemaker services.
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3. The DHCFP is not responsible for replacement of goods damaged in the provision of
service.
4. Service must be prior authorized and documented in an approved EVV.
5. Providers are responsible to ensure that EVV requirements and expectations are met,
including the documentation of all services in approved EVV system.
2303.5 CHORE SERVICES
2303.5A COVERAGE AND LIMITATIONS
1. This service includes heavy household chores such as:
a. cleaning windows and walls;
b. shampooing carpets;
c. tacking down loose rugs and tiles;
d. moving heaving items;
e. minor home repairs;
f. removing trash and debris from the yard; and
g. packing and unpacking boxes.
2. Chore services are intermittent in nature and may be authorized as a need arises for the
completion of a specific task which otherwise left undone poses a home safety issue. These
services are provided only in cases where neither the recipient, nor anyone else in the
household, is capable of performing or financially providing for them, and where no other
relative, caretaker, landlord, community volunteer/agency or third party payer is capable
of, or responsible for, their provision and without these services the recipient would be at
risk of institutionalization. This is not a skilled, professional service.
3. In the case of rental property, the responsibility of the landlord pursuant to the lease
agreement, must be examined and confirmed prior to any authorization of service. The
legal responsibility of the landlord to maintain and ensure safety on the rental property
shall supersede any waiver program covered services.
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2303.5B CHORE SERVICES PROVIDER RESPONSIBILITIES
In addition to the following requirements listed, reference Section 2303.3B of this Chapter
regarding Provider Responsibilities.
1. Persons performing heavy household chores and minor home repair services need to
maintain the home in a clean, sanitary, and safe environment.
2. Service must be prior authorized and documented in an approved EVV.
Providers are responsible to ensure that EVV requirements and expectations are met, including the
documentation of all services in approved EVV system.
2303.6 RESPITE CARE
2303.6A COVERAGE AND LIMITATIONS
1. Respite care is provided for relief of the primary unpaid caregiver.
2. Respite care is limited to 120 hours per waiver year per individual.
3. Respite care is only provided in the individual’s home or place of residence.
2303.6B RESPITE CARE PROVIDER RESPONSIBILITIES
In addition to the following requirements listed, reference Section 2303.3B of this Chapter
regarding Provider Responsibilities.
1. Respite providers must:
a. perform general assistance with ADLs and IADLs and provide supervision to
functionally impaired recipients in their homes to provide temporary relief for a
primary caregiver;
b. have the ability to read and write and to follow written or oral instructions;
c. have had experience and or training in providing the personal care needs of people
with disabilities;
d. meet the requirements of NRS 629.091, Section 2303.3B of this Chapter, and MSM
Chapter 2600 if a respite provider is providing attendant care services that are
considered skilled services;
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e. demonstrate the ability to perform the care tasks as prescribed;
f. be tolerant of the varied lifestyles of the people served;
g. identify emergency situations and act accordingly, including completion of CPR
certification which may be obtained outside the agency;
h. have the ability to communicate effectively and document in writing services
provided;
i. maintain confidentiality regarding details of case circumstances;
j. arrange training in personal hygiene needs and techniques for assisting with ADLs,
such as bathing, grooming, skin care, transfer, ambulation, exercise, feeding,
dressing, and use of adaptive aids and equipment, homemaking and household care.
k. Services must be prior authorized and documented in an approved EVV System.
l. Providers are responsible to ensure that EVV requirements and expectations are
met, including the documentation of all services in approved EVV system.
2303.7 ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS
2303.7A COVERAGE AND LIMITATIONS
1. Adaptations may include the purchase of environmental controls, the installation of ramps
and grab-bars, widening of doorways, modification of bathroom facilities, or installation
of specialized electric and plumbing systems necessary to accommodate the medical
equipment and supplies needed for the welfare of the recipient. Adaptations must be prior
authorized and are subject to legislative budget constraints.
2. All services, modifications, improvements or repairs must be provided in accordance
with applicable state or local housing and building codes.
3. Excluded Adaptations
a. Improvements to the home which are of general utility, and are not of direct medical
or remedial benefit to the individual, such as carpeting, roof repair, central air
conditioning, etc.
b. Adaptations which increase the total square footage of the home except when
necessary to complete an adaptation, for example, in order to improve
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entrance/egress to a residence or to configure a bathroom to accommodate a
wheelchair.
2303.7B ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS PROVIDER RESPONSIBILITIES
1. All agencies contracting with the DHCFP who provide environmental accessibility
adaptation assessments will employ persons who have graduated from an accredited
college or university in Special Education, rehabilitation, rehabilitation engineering,
occupational or speech therapy or other related fields and who are licensed to practice if
applicable and have at least one year experience working with individuals with disabilities
and their families or graduation from high school and three years experience working with
individuals with disabilities and their families as a technologist and possess a
Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)
Technology Certification.
2. All sub-contractors must be licensed or certified if applicable. Modifications,
improvements or repairs must be made in accordance with local and state housing and
building codes.
3. Durable Medical Equipment (DME) providers must meet the standards to provide
equipment under the Medicaid State Plan Program.
4. The service must be prior authorized.
2303.8 SPECIALIZED MEDICAL EQUIPMENT AND SUPPLIES
2303.8A COVERAGE AND LIMITATIONS
1. Specialized medical equipment and supplies are those devices, controls, or appliances
specified in the plan of care that enable recipients to increase their abilities to perform
ADLs.
2. This service also includes devices, controls, or applications which enable the recipient to
perceive, control, or communicate with the environment in which they live; items
necessary for life support, ancillary supplies and equipment necessary to the proper
functioning of such items, and durable and non-durable medical equipment not available
under the Medicaid State Plan.
3. Items reimbursed with waiver funds shall be, in addition to any medical equipment and
supplies, furnished under the State Plan and shall exclude those items which are not of
direct medical or remedial benefit to the recipient.
4. All items shall meet applicable standards of manufacture, design, and installation and
where indicated, will be purchased from and installed by authorized dealers.
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5. Vehicle Adaptations
All modifications and equipment must be purchased from authorized dealers, meet
acceptable industry standards and have payment approved by the case manager.
6. Assistive Technology
All equipment must be purchased from authorized dealers when appropriate. Equipment
must meet acceptable standards (e.g., Federal Communications Commission (FCC) and/or
Underwriter’s Laboratory requirements when applicable, and requirements under the
Nevada Lemon Law NRS 597.600 to 597.680).
7. Supplies
Supplies must be purchased through a provider enrolled to provide such services under the
existing state Medicaid plan or as otherwise approved by the DHCFP for services under
this waiver.
2303.8B SPECIALIZED MEDICAL EQUIPMENT PROVIDER RESPONSIBILITIES
Providers must be licensed through the Nevada State Board of Pharmacy (BOP) as a Medical
Device, Equipment, and Gases (MDEG) supplier, with the exception of a pharmacy that has a
Nevada State Board of Pharmacy license and provides DME, Prosthetic Devices, Orthotic Devices
and Disposable Medical Supplies (DMEPOS). Once licensed, providers must maintain compliance
with all Nevada BOP licensing requirements.
2303.9 PERSONAL EMERGENCY RESPONSE SYSTEMS (PERS)
2303.9A COVERAGE AND LIMITATIONS
1. PERS is an electronic device which enables certain recipients at high risk of
institutionalization to secure help in an emergency. The recipient may also wear a portable
"help" button to allow for mobility. The system is connected to a landline and programmed
to signal a response center once the "help" button is activated.
2. PERS services are limited to those recipients who live alone, who are alone for significant
parts of the day, have no regular caregiver for extended periods of time and who would
otherwise require extensive routine supervision.
3. The waiver service pays for the device rental and funds ongoing monitoring on a monthly
basis.
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2303.9B PERS PROVIDER RESPONSIBILITIES
1. The provider must provide documentation showing tax identification number.
2. The provider is responsible for ensuring that the response center is staffed by trained
professionals at all times.
3. The provider is responsible for any replacement or repair needs that may occur.
4. Providers of this service must utilize devices that meet FCC standards, Underwriter’s
Laboratory standards or equivalent standards.
5. Providers must inform recipients of any liability the recipient may incur as a result of the
recipient’s disposal of provider property.
6. The service must be prior authorized.
2303.9C RECIPIENT RESPONSIBILITIES
1. The recipient is responsible to utilize the leased PERS equipment with care and caution
and to notify the PERS provider when the equipment is no longer working.
2. The recipient must return the equipment to the provider when it is no longer needed or
utilized, when the recipient terminates from the waiver program, or when the recipient
moves out of state.
3. The recipient may not throw away the PERS equipment. This is leased equipment and
belongs to the PERS provider.
2303.10 ASSISTED LIVING SERVICES
2303.10A COVERAGE AND LIMITATIONS
1. Assisted living services are all inclusive services furnished by the assisted living provider.
Assisted living services are meant to provide all support services needed in the community
and may include personal care, homemaker, chore, attendant care, meal preparation,
companion, medication oversight (to the extent permitted under state law), transportation,
diet and nutrition, orientation and mobility, community mobility/ transportation training,
advocacy for related social services, health maintenance, active supervision, home and
community safety training, therapeutic social and recreational programming, provided in a
home-like environment in a licensed (where applicable) community care facility. Services
provided by a third party must be coordinated with the assisted living facility. This service
may include skilled or nursing care to the extent permitted by state law. Nursing and skilled
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therapy services are incidental, rather than integral to the provision of assisted living
services. Payment is not to be made for 24 hour skilled care. If a recipient chooses assisted
living services, other individual waiver services may not be provided, except case
management services.
2. The service includes 24-hour on-site response staff to meet scheduled or unpredictable
needs in a way promoting maximum dignity and independence, and to provide supervision,
safety and security.
3. Assisted living providers are expected to furnish a full array of services except when
another Federal program is required to provide the service. Other individuals or agencies
may also furnish care directly, or under arrangement with the assisted living provider, but
the care provided by other entities supplements that provided by the assisted living provider
and does not supplant it.
4. Federal Financial Participation (FFP) is not available for room and board, items of comfort,
or the cost of facility maintenance, upkeep and improvement.
2303.10B ASSISTED LIVING PROVIDER RESPONSIBILITIES
1. The assisted living environment must evidence a setting providing:
a. living units that are separate and distinct from each other;
b. a central dining room, living room or parlor and common activity center(s) except
in the case of individual apartments;
c. 24 hour on-site response staff.
2. All persons performing services to recipients from this category must have criminal history
clearances obtained from the FBI through the submission of fingerprints to the FBI. In
addition, provider agencies are required to conduct routine screenings on all applicants who
will perform services to recipients to ensure the health and welfare of recipients and to
make every effort possible to prevent recipient abuse. Reference Section 2303.3B2.d.
3. Providers must arrange training in personal hygiene needs and techniques for assisting with
ADLs such as bathing, dressing, grooming, skin care, transfer, ambulation, exercise,
feeding, use of adaptive aids and equipment, identifying emergency situations and how to
act accordingly.
4. Must have current CPR certification which may be obtained outside the agency prior to
initiation of services to a Medicaid recipient.
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5. Caregiver Supervisors will:
a. possess at least one year of supervisory experience and a minimum of two years
experience working with adults with physical disabilities, including traumatic brain
injury.
b. demonstrate competence in designing and implementing strategies for life skills
training and independent living.
c. possess a bachelor’s degree in a human service field preferably, or education above
the high school level combined with the experience noted in paragraph (a) above.
Supporting Qualifications of the Caregiver Supervisor are:
1. experience in collecting, monitoring, and analyzing service provision;
ability to identify solutions and satisfy staff/resident schedules for site
operations.
2. ability to interpret professional reports.
3. knowledge of life skills training, personal assistance services, disabled
advocacy groups, accessible housing, and long-term care alternatives for
adults with physical disabilities and/or traumatic brain injuries.
4. dependable, possess strong organization skills and have the ability to work
independent of constant supervision.
6. Assisted Living Attendants
Assisted living attendants shall provide personal care services, community integration,
independent living assistance, and supervisory care to assist the recipient in following the
POC. Assisted living attendants shall possess:
a. a high school diploma or GED.
b. some post-secondary educational experience is desired.
c. a minimum of two positive, verifiable employment experiences.
d. two years of related experience is desired.
e. job experience demonstrating the ability to teach, work independently without
constant supervision, and demonstrating regard and respect for recipients and co-
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workers.
f. verbal and written communication skills.
g. the ability to handle many details at the same time.
h. the ability to follow-through with designated tasks.
i. knowledge in the philosophy and techniques for independent living for people with
disabilities.
j. if the attendant is providing attendant care services, that include skilled services,
the attendant must meet the requirements of NRS 629.091.
k. a current CPR certificate.
7. Supporting Qualifications of the assisted living attendant are:
a. dependability, able to work with minimal supervision;
b. demonstrates problem solving ability;
c. the ability to perform the functional tasks of the job.
8. The service must be prior authorized.
2303.11 HOME DELIVERED MEALS
2303.11A COVERAGE AND LIMITATIONS
Home delivered meals are the provision of meals to persons at risk of institutional care due to
inadequate nutrition. Home delivered meals include the planning, purchase, preparation and
delivery or transportation costs of meals to a person’s home.
Recipients who require home delivered meals are unable to prepare or obtain nutritional meals
without assistance or are unable to manage a special diet recommended by their physician.
1. Home delivered meals must be prepared by an agency and be delivered to the recipient’s
home.
2. Meals provided by or in a child foster home, adult family home, community based
residential facility or adult day care are not included, nor is meal preparation.
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3. The direct purchase of commercial meals, frozen meals, Ensure or other food or nutritional
supplements is not allowed under this service category.
4. Home delivered meals are not intended to meet the full daily nutritional needs of a
recipient. More than one provider may be used to meet a recipient’s need.
5. Case managers determine the need for this service based on a Standardized Nutritional
Profile, or assessment, and by personal interviews with the recipient related to individual
nutritional status.
6. All meals must comply with the Dietary Guidelines for Americans published by the
Secretaries of the Department of Health and Human Services (DHHS) and the United
States Department of Agriculture; and provide a minimum of 33 1/3% of the current daily
Recommended Dietary Allowances (RDA) as established by the Food and Nutrition Board,
National Research Council of the National Academy of Sciences.
7. Nutrition programs are encouraged to provide eligible participants meals which meet
particular dietary needs arising from health or religious requirements or the ethnic
background of recipients.
2303.11B HOME DELIVERED MEALS PROVIDER RESPONSIBILITIES
1. Meals are provided by governmental or community providers who meet the requirements
of a meal provider under NRS 446 and who are enrolled with the DHCFP as a Medicaid
Provider.
2. Pursuant to NRS 446: All nutrition sites which prepare meals must have a Food Service
Establishment Permit as follows:
a. All Nutrition Programs must follow the Health and Safety Guidelines established
for Food and Drink Establishments in NAC, Chapter 446 or local health code
regulations.
b. All kitchen staff must hold a valid health certificate if required by local health
ordinances.
c. Report all incidents of suspected food borne illness to the affected recipients and
local health authority within 24 hours and to the DHCFP District Office case
manager by the next business day.
3. All employees must pass State/FBI background checks.
4. Provide documentation of taxpayer identification number.
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5. The service must be prior authorized.
2303.12 ATTENDANT CARE
2303.12A COVERAGE AND LIMITATIONS
Extended State plan personal care attendant service may include assistance with eating, bathing,
dressing, personal hygiene, ADLs, shopping, laundry, meal preparation and accompanying the
recipient to appointments as necessary to enable the individual to remain in the community. The
service may include hands-on care, of both a supportive and health-related nature, specific to the
needs of a medically stable, physically disabled individual. Supportive services are those which
substitute for the absence, loss, diminution, or impairment of a physical or cognitive function. This
service may include skilled services to the extent permitted by State law. This service may include
an extension of task completion time allowed under the state plan with documented medical
necessity.
1. Where possible and preferred by the recipient, he/she will direct his/her own service
through an Intermediary Services Organization (ISO). Refer to MSM Chapter 2600. When
the recipient recruits and selects a caregiver, the individual is referred to the ISO for hire.
The recipient may also terminate the assistant. When utilizing this option, the recipient will
work with his/her case manager to identify an appropriate back up plan. If this option is
not used, the recipient will choose a provider agency that will otherwise recruit, screen,
schedule assistants, provide backup and assurance of emergency assistance.
2. Extended personal care attendant services in the recipient’s plan of care may include
assistance with:
a. eating;
b. bathing;
c. dressing;
d. personal hygiene;
e. ADLs;
f. hands-on care, of both a supportive and health-related nature, specific to the needs
of a medically stable, physically disabled individual. Supportive services are those
which substitute for the absence, loss, diminution or impairment of a physical or
cognitive function.
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3. Flexibility of Services
Flexibility of service delivery which does not alter medical necessity may occur within a
single week period without an additional authorization. Reference 2303.3B.1.e of this
chapter.
2303.12B ATTENDANT CARE PROVIDER RESPONSIBILITIES
In addition to the following requirements listed, reference Section 2303.3B of this Chapter
regarding Individual Provider Responsibilities.
1. Personal care attendants may be members of the individual’s family. However, payment
will not be made for services furnished by legally responsible individuals.
2. When the provision of services includes an unskilled provider completing skilled care,
qualifications and requirements must be followed as in NRS 629.091, and MSM Chapter
2600.
3. Providers must demonstrate the ability to:
a. perform the care tasks as prescribed;
b. identify emergency situations and to act accordingly, including CPR certification
which may be obtained outside the agency;
c. maintain confidentiality in regard to the details of case circumstances; and
d. document in writing the services provided.
4. Provider Agencies must arrange training in:
a. procedures for arranging backup when not available, agency contact person(s), and
other information as appropriate. (Note: This material may be provided separate
from a training program as part of the provider’s orientation to the agency.)
b. personal hygiene needs and techniques for assisting with ADLs, such as bathing,
grooming, skin care, transfer, ambulation, exercise, feeding, dressing, and use of
adaptive aids and equipment.
c. home making and household care, including good nutrition, special diets, meal
planning and preparation, essential shopping, housekeeping techniques and
maintenance of a clean, safe and healthy environment.
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5. Service must be prior authorized and documented in an approved EVV System.
6. Provider is responsible to ensure that EVV requirements and expectations are met, including
the documentation of all services in approved EVV System.
2303.13 PROVIDER ENROLLMENT/TERMINATION
All providers must comply with all the DHCFP provider enrollment requirements, provider
responsibilities/qualifications, and the DHCFP provider agreement limitations. Provider non-
compliance with all or any of these stipulations may result in Nevada Medicaid’s decision to
exercise its right to terminate the provider’s contract. Refer to MSM Chapter 100 for general
enrollment policies.
2303.14 INTAKE PROCEDURES
The DHCFP developed procedures to ensure fair and adequate access to services covered under
the HCBW for Persons with Physical Disabilities.
2303.14A COVERAGE AND LIMITATIONS
1. Slot Provisions
a. The allocation of waiver slots is maintained statewide based on priority and referral
date. Slots are allocated by priority based on the earliest referral date.
b. Recipients must be terminated from the waiver when they move out of state, fail to
cooperate with program requirements or request termination; their slot may be
given to the next person on the waitlist.
c. When a recipient is placed in an NF or hospital, they must be sent a NOD
terminating them from the waiver 45 days from admit date. Their waiver slot must
be held for 90 days from the NOD date. They may be placed back in that slot if
they are released within 90 days of the NOD date and request reinstatement. They
must continue to meet program eligibility criteria. After 90 days, their slot may be
given to the next individual on the waitlist.
2. Referral Pre-Screening
a. A referral or inquiry for the waiver may be made by the potential applicant or by
another party on behalf of the potential applicant by contacting the local DHCFP
District Office. The DHCFP District Office staff will discuss waiver services,
including the eligibility requirements, with the referring party or potential
applicant.
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b. If the case manager determines the applicant does not appear to meet the waiver
criteria, the individual may proceed with the application process if they choose to.
Once the application is denied, they will receive a NOD which includes the right to
a fair hearing. The case manager will provide referrals to other community
resources.
c. If the case manager determines the applicant does appear to meet waiver criteria, a
face-to-face home visit is scheduled to conduct an LOC screening and medical
records are obtained for a disability determination.
NOTE: If the applicant does not meet LOC, they will receive a NOD which includes
the right to a fair hearing.
3. Placement on the Wait List
a. All applicants who meet program criteria must be placed on the statewide waitlist
by priority and referral date. The following must be completed prior to placement
on the waitlist.
1. The applicant must meet LOC criteria for placement in an NF.
2. The applicant must require at least one ongoing waiver service.
3. The applicant must be certified as physically disabled by Medicaid’s
Central Office Disability Determination Team.
4. Applicants must be sent a NOD indicating “no slot available.”
4. Waiver Slot Allocation
Once a slot for the waiver is available, the applicant will be assigned a waiver slot and be
processed for the waiver.
a. Intake:
1. The DHCFP District Office staff will schedule a face-to-face home visit
with the recipient to complete the full waiver assessment.
2. The case manager will obtain all applicable forms, including the
Authorization for Release of Information Form.
The applicant or designated representative must understand and agree that
personal information may be shared with providers of services and others,
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as specified on the form.
The case manager will provide an application to apply for Medicaid benefits
through the DWSS. The recipient is responsible for completing the
application and submitting all requested information to the DWSS. The case
manager will assist upon request.
3. The applicant is given the right to choose waiver services in lieu of
placement in an NF. When the applicant or designated legal representative
prefers placement in an NF, the case manager will assist the applicant in
arranging for facility placement.
4. The applicant is given the right to request a hearing if not given a choice
between HCBS and NF placement.
5. When the applicant is approved for the waiver:
a. A written POC is developed in conjunction with the recipient by the
DHCFP District Office case manager for each recipient under the
waiver. The POC is based on the assessment of the recipient’s health
and welfare needs.
b. The recipient or representative is included in the development of the
POC.
c. The POC is subject to the approval of the DHCFP’s Central Office
Waiver Unit.
d. Recipients are given free choice of all qualified Medicaid providers
for each Medicaid covered service included in the POC. Current
POC information as it relates to the services provided must be given
to all service providers.
6. All forms must be complete with signature and dates when required.
7. If an applicant is denied waiver services, the case manager sends the NOD.
5. Effective Date for Waiver Services
The effective date for waiver services approval is the completion date of all the intake
forms and the Medicaid determination date made by the DWSS, whichever is later. When
the recipient resides in an institution, the effective date cannot be prior to the date of
discharge from the institution.
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6. Waiver Costs
The DHCFP must assure CMS the average per capita expenditures under the waiver do not
exceed 100% of the average per capita expenditures for the institutional level of care under
the state plan that would have been made in that fiscal year, had the waiver not been
granted.
2303.15 BILLING PROCEDURES
The DHCFP must assure CMS all claims for payment of waiver services are made only when an
individual is Medicaid eligible, when the service(s) are identified on the approved POC, and if the
service(s) has been prior authorized.
2303.15A COVERAGE AND LIMITATIONS
Provider Type 58, HCBW for Persons with Physical Disabilities, must complete the CMS 1500
for payment of waiver services. Incomplete or inaccurate claims are returned to the provider by
the DHCFP’s fiscal agent. If the wrong form is submitted it is also returned to the provider by the
DHCFP’s fiscal agent.
2303.15B PROVIDER RESPONSIBILITY
Providers must submit claims to the DHCFP’s QIO-like vendor.
Providers may also refer to the DHCFP’s website for a complete list of codes/modifiers billable
under Provider Type 58 (select “Rates” from the main menu, then click on Provider Type 58 –
HCBW for Persons with Physical Disabilities).
2303.16 ADVANCE DIRECTIVES
Section 1902(w) of the Social Security Act requires licensed provider agencies providing personal
care aide services to give clients’ information regarding each individual’s decision-making rights
about health care, declarations (living wills) and durable powers of attorney for health care
decisions. Refer to MSM Chapter 100 for further information.
2303.17 ANNUAL REVIEW
The State has in place a formal system in which an annual review is conducted to assure the health
and welfare of the recipients served on the waiver, the recipient satisfaction with the waiver, and
assurance of the cost effectiveness of these services.
The state will conduct an annual review; and
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1. provide CMS with information on the impact of the waiver. This includes the type, amount
and cost of services provided under the waiver and provided under the State Plan and the
health and welfare of the recipients served on the waiver.
2. assure financial accountability for funds expended for HCBS.
3. evaluate all provider standards are continuously met and plans of care are periodically
reviewed to assure services furnished are consistent with the identified needs of the
recipients.
4. evaluate the recipients’ satisfaction with the waiver program.
5. ensure health and welfare of all recipients.
2303.17A PROVIDER RESPONSIBILITIES
Providers must cooperate with the DHCFP’s annual review process.
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2304 HEARINGS
2304.1A SUSPENDED WAIVER SERVICES
1. Recipients must be suspended when they are admitted to a hospital or Nursing Facility
(NF).
2. If the recipient has not been removed from suspended status 45 days from the admit date,
the case must be closed. A Notice of Decision (NOD) must be sent identifying the 60th day
of the admit date as the effective date for closure.
2304.1B RELEASE FROM SUSPENDED WAIVER SERVICES
When a recipient is released from the hospital, an NF or other institutional setting, within 60 days
of the admit date, the case manager must do the following within five working days:
1. complete a new Level of Care (LOC), if there has been a significant change in the
recipient’s condition;
2. complete a new Plan of Care (POC) if there has been a change in services (medical, social,
or waiver). When a change in services is expected to resolve in less than 30 days a new
POC is not necessary. Documentation of the temporary change must be noted in the case
record;
3. contact the service provider(s) to reestablish services.
2304.1C DENIAL OF WAIVER SERVICES
Reasons to deny applicant request for waiver services:
1. The applicant does not meet physical disability criteria as determined by the DHCFP’s
physician consultant.
2. The applicant does not meet the LOC criteria for an NF placement.
3. The applicant has withdrawn their request for waiver services.
4. The applicant fails to cooperate with the DHCFP Case Manager or Home and Community
Based Services (HCBS) providers in establishing and/or implementing the POC,
implementing waiver services or verifying eligibility for waiver services. (The recipient’s
or the recipient’s authorized representative’s signature is necessary for all required
paperwork).
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5. The applicant’s support system is not adequate to provide a safe environment during the
time when home and community based services are not being provided.
6. The DHCFP has lost contact with the applicant.
7. The applicant fails to show a need for Home and Community Based Waiver (HCBW)
services.
8. The applicant would not require NF placement if HCBS were not available.
9. The applicant has moved out of state.
10. Another agency or program will provide the services.
11. The DHCFP District Office has filled the number of positions allocated to the HCBW for
Persons with Physical Disabilities. The applicant will be approved for the waiver waitlist
and will be contacted when a slot is available.
12. The applicant has failed to provide adequate medical documentation for a disability
determination within 45 days of the request.
13. The applicant has reached their annual limit for Environmental Adaptations.
14. The requested adaption, equipment or supply is not medically necessary to prevent
institutionalization.
15. The landlord has not approved requested adaption or modification.
16. The recipient’s needs can be met by a legally responsible individual.
When an application for waiver services is denied the case manager sends a NOD indicating the
reason for denial.
2304.1D TERMINATION OF WAIVER SERVICES
Reasons to terminate a recipient from the waiver or to terminate the recipient from the waiver wait
list:
1. The recipient has failed to pay his/her patient liability.
2. The recipient no longer meets the physical disability criteria as determined by the DHCFP’s
physician consultant.
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3. The recipient no longer meets the LOC criteria for NF placement.
4. The recipient has requested termination of waiver services.
5. The recipient has failed to cooperate with the DHCFP case manager or HCBS providers in
establishing and/or implementing the POC, implementing waiver services, or verifying
eligibility for waiver services. (The recipient’s or the recipient’s authorized
representative’s signature is necessary on all required paperwork).
6. The recipient fails to show a continued need for HCBW services.
7. The recipient no longer requires NF placement if HCBS were not available.
8. The recipient has moved out of state.
9. The recipient has submitted fraudulent documentation on Attendant Care provider time
sheets and/or forms.
10. Another agency or program will provide the services.
11. The recipient has been, or is expected to be, institutionalized over 60 days (in a hospital,
NF, intermediate facility for persons with mental retardation or incarcerated).
12. The DHCFP has lost contact with the recipient.
13. The recipient’s needs can be met by a legally responsible individual.
When a recipient is terminated from the waiver program, the case manager sends a NOD indicating
the reason for termination. The NOD must be mailed to the recipient at least 13 calendar days
before the Date of Action. Refer to MSM Chapter 3100 for exceptions to the advance notice.
2304.1E REDUCTION OF WAIVER SERVICES
Reasons to reduce waiver services:
1. The recipient no longer needs the number of service hours authorized.
2. The recipient no longer needs the service previously authorized.
3. The recipient has requested the reduction of services.
4. The recipient’s ability to perform Activities of Daily Living (ADLs) has improved.
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5. Another agency or program will provide the service.
6. The recipient fails to cooperate with the waiver service provider.
7. The recipient’s needs can be met by a legally responsible individual.
When there is a reduction of waiver services the case manager will send a NOD indicating the
reason for the reduction. The NOD must be mailed to the recipient at least 13 calendar days before
the Date of Action.
2304.2 REAUTHORIZATION WITHIN 90 DAYS OF WAIVER TERMINATION
A. If a recipient is placed in an NF or hospital, and waiver services have been terminated, the
recipient may request reinstatement within 90 days of the notice date. The case manager
must complete the following:
1. A new LOC;
2. A new Social Health Assessment;
3. The new Statement of Understanding; and
4. The new POC.
B. If 90 days from the notice date has elapsed, the slot is allocated to the next person on the
waitlist. An individual who requests reinstatement after 90 days from the notice date must
be processed as a new referral.
2304.3 APPEALS AND HEARINGS
Refer to MSM Chapter 3100 for specific instructions regarding notice and participant hearings.
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2400 INTRODUCTION
2400.1 HOME BASED HABILITATION SERVICES (HBHS)
Home Based Habilitation Services (HBHS) are medically prescribed treatment for improving or restoring
functions, which have been impaired by illness or injury or, where function has been permanently
lost or reduced by illness or injury.
HBHS include services designed to assist individuals in acquiring, retaining and improving the self-help,
socialization and adaptive skills necessary to reside successfully in a home and community-based
settings. HBHS are prescribed by a physician and provided by the appropriate qualified staff.
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2401 AUTHORITY
Home Based Habilitation Services (HBHS) is an optional Medicaid State Plan service authorized
by the Nevada Medicaid Program under State Plan authority titled Nevada 1915(i) State Plan
Home and Community-Based Services (HCBS). The State Plan was amended in 2008 in response
to the Deficit Reduction Act, Section 6086. Congress amended the Social Security Act with
Section 1915(i) allowing states to provide traditional 1915(c) services as covered State Plan
benefits. Home Based Habilitation was covered under Nevada’s State Plan as Comprehensive
Outpatient Rehabilitation (COR) Services.
Statutes and Regulations:
Social Security Act: 1915(i)
42 Code of Federal Regulations (CFR) 440.130
42 CFR 440.180
34 CFR 300.7
Nevada Administrative Code (NAC) 388.134
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2402 RESERVED
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2403 POLICY
2403.1 HOME BASED HABILITATION SERVICES (HBHS) DAY TREATMENT PROGRAM
HBHS include a day treatment program in which services are designed to assist individuals in
acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to
reside successfully in home and community-based settings. Habilitation Services are prescribed
by a physician, provided by the appropriate qualified staff and include the following:
a. Care Coordination.
Adaptive Skill Development.
Assistance with Activities of Daily Living (ADLs).
Community Inclusion.
Transportation (not duplicative of State Plan Non-Emergency Transportation (NET)).
Adult Educational Supports.
Social and Leisure Skill Development.
Physical Therapy.
Speech Therapy.
Occupational Therapy.
Licensed professionals must perform an initial assessment, develop a plan of care, assess the
recipient’s progress and assume legal responsibility for the services provided.
2403.1A COVERAGE AND LIMITATIONS
1. Admission Criteria for Day Treatment Programs
a. The recipient is Medicaid eligible;
b. The recipient has a medically verifiable Traumatic Brain Injury (TBI) or Acquired
Brain Injury (ABI);
c. The individual must meet the eligibility requirements of the 1915(i) HCBS
Universal Needs Assessment Tool or must qualify for a 1915(c) waiver;
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d. The recipient has not previously completed a habilitation program for the same
condition, unless a substantial intervening event has occurred that would require an
abbreviated program to maintain community placement. The decision to impose
such an exception is the sole determination of the Division of Health Care
Financing and Policy (DHCFP) and requires supporting medical rationale;
e. The recipient’s functional or cognitive impairment is the result of an illness or
injury within the past 90 days, or 90 days from the original inpatient hospitalization,
or directly after continuous outpatient therapy post the original inpatient
hospitalization, or 90 days from Medicaid eligibility determination, or has a chronic
illness or injury with recent exacerbation, or complication which resulted in a
change in function, or has a more remote injury with recent improvement in
condition and/or advancement in technology;
f. The recipient must be medically stable for intensive habilitation as evidenced by
the absence of medical conditions requiring acute medical interventions (e.g., acute
infectious process, uncontrolled irregular heartbeat, unstable diabetes mellitus, etc);
g. The recipient is willing, and demonstrates capacity for endurance for at least three
(3) hours of habilitation services per day, five (5) days per week;
h. The recipient has a prognosis and potential to increase his or her functional
independence towards returning to independent or assisted living after discharge,
achievable within a reasonable period of time, as determined by the DHCFP or its
QIO-like vendor;
i. The recipient has sufficient mental alertness and is able to actively participate in a
complete therapy program on a daily basis;
j. The recipient is responsive to verbal or visual stimuli and can consistently follow
single step commands in a meaningful way; and
k. The recipient’s functional abilities indicate a potential for improvement.
2. Covered Services
a. Day Treatment programs are provided as Full Day – six (6) hours per day of
habilitative services or as Half Day – a minimum of three (3) hours per day. All
programs provide services five days per week, or more, and may occur in the
recipient’s home, inpatient settings who provide HBHS services, outpatient settings
or in other community-based settings.
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b. Day treatment programs must meet the following service requirements, when the
specialty area is included in the individual plan of care approved by the primary
physician after any needed consultation with the licensed/certified therapy provider
(RN, PT, OT, SLP and case manager):
1. Physical Therapy services: Only a licensed physical therapist has the
knowledge, training and experience required to evaluate and, as necessary,
re-evaluate a recipient’s level of function, determine whether a physical
therapy program could reasonably be expected to improve, restore, or
compensate for lost function. Implementation of a plan of care should be
carried out pursuant to the Practice Act governing physical therapy.
2. Occupational Therapy services: Only a registered and licensed occupational
therapist has the knowledge, training, and experience required to evaluate
and, as necessary, re-evaluate a recipient’s level of function; determine
whether an occupational therapy program could reasonably be expected to
improve, restore, or compensate for lost function. Implementation of a plan
of care shall be carried out pursuant to the Practice Act governing
occupational therapy.
3. Speech-Language Pathology (SLP) services: Only a SLP has the
knowledge, training, and experience required to evaluate and, as necessary,
re-evaluate a recipient’s level of function; determine whether a speech
therapy program could reasonably be expected to improve, restore, or
compensate for lost function. Implementation of a plan of care shall be
carried out pursuant to the Practice Act governing speech-language
pathology.
4. Case Management services: Case management services must be provided
by a licensed nurse or social worker, or Certified Case Manager (CCM), or
other licensed individual eligible to apply for certification or who is working
under the direct supervision of a CCM, who has the education, skills
abilities and experience to perform case management services. The case
manager may also need language skills, cultural sensitivity, and acquired
knowledge and expertise unique to a geographic area. The case manager
coordinates and implements individualized plans of care in conjunction
with recipient’s families or legal guardians physicians and others involved
in the care of the individual.
5. Cognitive Therapy services:
The provision of this service is included as a component of a habilitation
program for the severely neurologically impaired individual such as those
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with TB. Other diagnoses that may require cognitive remediation include,
but are not limited to, severe Cerebral Vascular Accident (CVA), anoxic
injuries, and intracranial hemorrhage. For these diagnoses, as well as with
TBI, major impairments exist in arousal or alerting, perception, selective
attention, discrimination, orientation, organization, recall and high level
thought processes, including convergent thinking, deductive reasoning,
inductive reasoning, divergent thinking, and multiprocess reasoning.
6. Therapeutic Recreation services: Therapeutic recreation services are
included as a component of a habilitation program when the service is
directly related to the plan of care.
7. Prosthetic/Orthotic services: Refer to Medicaid Services Manual
(MSM) Chapter 1300 for further information and program requirements.
8. Durable Medical Equipment (DME): Refer to MSM Chapter 500 for
DME coverage guidelines for recipients who reside in or will be discharged
to an extended care facility.
3. Non-Covered Services
The following are not covered benefits under day treatment programs and
therefore are not reimbursable by Nevada Medicaid:
a. A maintenance program is the point at which the recipient
demonstrates no further improvement, or the skills of a qualified therapist
are not required to carry out an activity to maintain function at the level to
which it has been restored;
b. Duplicative services are not considered medically justified and will
not be covered by Medicaid. An inquiry or referral for services does not
indicate the necessity for services. If the Medicaid recipient is receiving
services from another provider, it is the responsibility of the evaluating
provider to determine if additional services are appropriate and request prior
authorization as indicated;
c. Time spent conducting a team conference is included in the
established all-inclusive rate and is not a separately billable service;
d. Pre-Admission screenings completed in order to determine the
appropriateness of the recipient for a particular program is considered a cost
of doing business and is not a reimbursable visit;
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e. Admissions or continued stays for evaluation or training for solely vocational or
educational purposes or for developmental or behavioral assessments are not
covered services;
f. Admissions solely for the convenience of the recipient, their family or the provider,
are not covered services;
g. Pain management services, i.e. relaxation techniques, stress management and
biofeedback programs;
h. Day treatment programs are not covered for individuals who have been admitted to
an institutional setting such as a hospital, nursing facility or an intermediate care
facility; or
i. Day treatment programs will not be provided to an individual at the same time as
another service that is the same in nature and scope regardless of source, including:
Federal, State, local and private entities. For habilitation services, the State
includes, within the record of each individual, an explanation that these services do
not include special education and related services defined in the Individuals with
Disabilities Improvement Act of 2004 that otherwise are available to the individual
through a local education agency or vocational rehabilitation services that
otherwise are available to the individual through a program funded under §110 of
the Rehabilitation Act of 1973.
4. Continued Stay Criteria for Day Treatment Services
For continued day treatment services, prior authorization must be submitted to the
DHCFP’s QIO-like vendor in time to meet processing timelines so an interruption in
services may be avoided. Supporting documentation must be provided, including the most
recent team conference report, which demonstrates that the recipient continues to meet
admission criteria and continues to:
a. demonstrate an ability to actively participate in the program;
b. have documented progression toward written goals; and
c. continue to need the services provided by the day treatment program.
Services provided without prior authorization are not reimbursable.
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5. Discharge Criteria
A day treatment program is a medically prescribed treatment for improving or restoring
functions and must be considered for termination, regardless of the approved length of stay,
when further progress toward the established goals is unlikely or further treatment can be
achieved in a less intensive setting.
A maintenance program is not a covered benefit and services provided once this level has
been reached will not be reimbursed. Specifically, if no further progress is observed,
discharge would be required. A recipient in a habilitation program must be considered for
discharge, when any one of the following conditions is met:
a. The recipient’s needs exceed the scope of the day treatment program so transfer to
an inpatient hospital or skilled nursing facility is indicated;
b. The recipient no longer meets the criteria for the day treatment program;
c. The specialized knowledge and skills of the interdisciplinary team are no longer
required;
d. Lack of attendance and/or participation in the activities specific to the residential
program setting for more than three (3) consecutive days;
e. The recipient has reached his or her goals and a safe and effective program has been
developed with informal supports to allow the recipient to live at home or elsewhere
in the community;
f. There is limited motivation on the part of the recipient or caregiver which is
impacting the individual’s progress for over one week; or
g. The established goals serve no purpose to increase functional or cognitive
capabilities towards living in a community based setting.
2403.1B HOME BASED HABILITATION SERVICES (HBHS) PROVIDER RESPONSIBILITY
1. Provider Enrollment
a. Each provider of HBHS must enroll as a Provider Type 55 and enter into the
agreement with the DHCFP, through the QIO-like vendor and must submit required
licenses, registrations, certificates, etc., upon request, to determine that conditions
of participation, as stated in MSM 100, are met.
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c. Home Based Habilitation providers must hold current accreditation, in good standing, by
the Commission on Accreditation of Rehabilitation Facilities (CARF) or the Joint
Commission accreditation.
c. Providers must comply with all Internal Revenue Service (IRS), Federal Insurance
Contributions Act (FICA) and Occupational Safety and Health Administration
(OSHA), Local, State, and Federal regulations and applicable statutes.
Criminal Background Checks
Under Nevada Revised Statutes (NRS) 449.176 through NRS 449.188, people who
have been convicted of certain crimes may not work at certain long term care
facilities or agencies. The complete statute is available at:
http://leg.state.nv.us/NRS/NRS-449.html and the requirements applying to
agencies are discussed at length at the Bureau of Health Care Quality and
Compliance (HCQC) website: http://health.nv.gov/HCQC_CriminalHistory.htm.
Agency personnel, including administrators, managers, employees and consultants
must undergo State and Federal Bureau of Investigation (FBI) background checks
upon licensure or accreditation and then at a minimum of every five (5) years
thereafter to ensure no convictions of applicable offenses have been incurred.
Documentation of the request, and applicable results, must be maintained in each
employee personnel record and made available to the DHCFP upon request.
Employees must have the criminal background check through their State
Department of Public Safety (DPS) or initiated by the hiring/employing agency
prior to providing any Medicaid reimbursable services to a recipient.
Providers are required to initiate diligent and effective follow up for results of
background checks within 90 days of submission of prints and continue until results
are received. This is particularly important when an “undecided” result is received.
Documentation must be maintained in the employee’s personnel file and submitted
to the DHCFP upon request.
1. The DHCFP or their designee must not enroll any person or entity convicted
of a felony or misdemeanor for any offense which the State agency
determines is inconsistent with the best interests of recipients. Such
determinations are solely the responsibility of the DHCFP.
2. The DHCFP applies the requirements of NRS 449.176 through NRS
449.188 and will deny a provider contract to any applicant, or may suspend
or revoke all associated provider contracts of any provider, to participate in
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the Medicaid program if the requirements of the referenced NRS sections
are not met. In addition, see MSM Chapter 100.
a. If the Provider receives information related to NRS 449.176 through NRS
449.188 resulting from the criminal background check or from any other
source and continues to employ a person who has been convicted of an
offense as listed above, the DHCFP will take appropriate action, which may
include suspension or termination of the agency’s Medicaid provider
contract.
b. If the hiring/employing agency does not take timely and appropriate action
on the results of the background check as defined in NRS 449.176 through
449.188 and on the HCQC website, the DHCFP will take appropriate action,
which may include suspension or termination of the agency’s Medicaid
provider contract.
If an employee believes that the information provided as a result of the criminal
background check is incorrect, the individual must immediately inform the
employing agency and the DHCFP in writing. Information regarding
challenging a disqualification is found on the HCQC website at:
http://health.nv.gov/HCQC_CriminalHistory.htm.
NOTE: Out of state providers must obtain background checks through their local
DPS.
Tuberculosis (TB) Testing
Employees of provider facilities must complete either a QuantiFERON R-TB Gold
blood test (QFT-G) or a two step (TB) Tuberculin skin test prior to initiation
of services for a Medicaid recipient. If the employee tests negative on initial
test, prior to the annual expiration of the initial test, they must receive either
a QFT-G blood test or a one step TB skin test. Annually, thereafter, as long
as the result is negative, prior to the expiration of the year’s previous test, a
QFT-G blood or a one step TB skin test must be performed. If the employee
tests positive on the initial QFT-G blood test or the two step TB skin test
(+10 mm induration or larger), or if the employee has a prior history of a
positive test, the individual must have clearance by a chest X-ray prior to
initiation of services for a Medicaid recipient. Annually, thereafter, prior to
the date of initial clearance by the chest X-ray, the individual must have
documentation which demonstrates no signs or symptoms of active
tuberculosis (see Nevada Administrative Code (NAC) 441A.375).
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If the employee has been medically cleared after a documented history of a positive
QFT-G or TB skin test which was 10 mm or larger and then by chest x-ray, the
employee must have documentation annually which demonstrates they are not
exhibiting any signs or symptoms of active tuberculosis. The annual screening for
signs and symptoms must address each of the following areas of concern and must
be administered by a qualified health care provider:
Has had a cough for more than three (3) weeks;
Has a cough which is productive;
Has blood in his sputum;
Has a fever which is not associated with a cold, flu or other apparent illness;
Is experiencing night sweats;
Is experiencing unexplained weight loss; or
Has been in close contact with a person who has active tuberculosis. Annual
screening for signs and symptoms of active disease must be completed prior
to the one year anniversary of the last screening.
Documentation of the annual screening, when required as defined herein, and the
results must be maintained in the employee’s file.
Documentation of TB testing must be issued by a medical facility or licensed
medical professional qualified to administer the test, signed by the physician or
his/her designee, stating the date of the test, the date the test was read, and the
results. Any lapse in the required timelines above will result in a finding of non-
compliance with this section.
2. Staffing Requirements
A provider of HBHS must employ persons with the necessary education, skills and
training to provide the Medicaid required services. Medical services must be
provided by licensed/certified professional. Copies of current licensure,
certificates, and education must be maintained in employee files.
b. Habilitation Aides may provide personal assistance services, supervisory care,
direction and guidance to assist recipients, following written plan of care and
clinical protocols under the direct supervision of the licensed/certified therapy
provider.
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Habilitation aides must have:
1. a high school diploma or General Education Diploma (GED);
2. some post-secondary educational experience is desired;
3. a minimum of two positive, verifiable employment experiences;
4. two years of related experience is desired
5. job experience that demonstrates the ability to teach, work independent of
constant supervision, and demonstrate regard and respect for recipients and
co-workers;
6. verbal and written communication skills;
7. the ability to handle many details at the same time;
8. the ability to follow through with designated tasks; and
9. knowledge of the philosophy and principles of independent living for
people with disabilities.
Supporting Qualifications include:
10. dependability, able to work with minimal supervision;
11. demonstrates problem solving ability;
12. the ability to perform the functional tasks of the job; and
13. the ability to identify emergency situations and act accordingly including
Cardiopulmonary resuscitation (CPR) certification, which may be obtained
outside the agency.
3. Initial Evaluation
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The intent of HBHS is to increase the individual’s functional abilities in order to eventually
live in a community setting. The initial evaluation must contain all of the following
information and be signed by the treating physician to be considered for authorization:
a. Origin and rationale of referral, including a copy of the order;
b. The principal and significant associated diagnosis;
c. Brief history including the date of onset of illness or injury;
d. Current medical status and confirmation of medical stability;
e. Current and pre-morbid functional status, including baseline evaluation, prognosis
and potential for improvement;
f. Indication of medical necessity;
g. Identified barriers;
h. Short and long-term goals that are functional, objective and measurable;
i. The composition of the team, the plan of care and the duration of the habilitation
program;
j. Summary of any previous treatment received and results of such treatment;
k. Anticipated time for completion of the program;
l. If the recipient is to participate in any group therapy sessions, documentation must
include:
1. the description of the purpose of the group;
2. number of patients and staff members in group;
3. the minimum ratio of staff to patients;
4. duration on each session; and
the number of group sessions anticipated per week.
m. A viable, written discharge plan with appropriate post placement resources,
including the identified support system that will facilitate community re-entry.
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The proposed plan of care must include specific goals, how those goals will be
achieved and the duration of achievement.
Universal Needs Assessment
The 1915(i) HCBS Universal Needs Assessment Tool must be used to evaluate and
reevaluate whether an individual is eligible for the Nevada 1915(i) HCBS state plan
services. In order to qualify for services, the individual meets at least two of the
following:
the inability to perform 2 or more ADL’s;
Bathing/Dressing/Grooming;
Mobility;
Toileting;
Eating; and/or
Transferring.
cognitive and/or behavioral impairments;
medical needs;
supervision needs;
substance abuse; and/or
multiple social service system involvement.
This evaluation must be face-to-face.
A physician within the scope of their professional practice as defined and limited by
Federal and State law with experience in conducting assessments will be responsible
for conducting the face-to-face independent assessments and reassessments of an
individual’s support needs and capabilities.
The individual performing the assessment must be an independent third party and
must not be:
a. related by blood or marriage to the individual;
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b. any paid caregiver of the individual;
c. financially responsible for the individual;
empowered to make financial or health-related decisions on behalf of the individual;
or
service providers or individuals or corporations with financial relationships with any
providers.
The physician must re-evaluate the recipient’s eligibility annually.
5. Service Plan
The service plan is developed by the service provider. An interdisciplinary team will
formulate the plan in conjunction with the recipient. The team must include staff
trained in person centered planning, and must include a licensed health care
professional and may include other individuals who can contribute to the plan
development.
The service plan must include the identified need from the Universal Needs
Assessment.
The provider must ensure the recipient, or the recipient’s legal representative, is fully
involved in the treatment planning process and choice of providers. Recipient,
family (when appropriate) and/or legal representative participation in treatment
planning must be documented on the service plan. The service plan must include a
written statement that the recipient was offered a choice of HBHS providers, if
applicable, and must be kept in a file maintained for the recipient.
A service plan must be completed and submitted as part of the prior authorization
process. The service plan requires pre-approval by the QIO-like vendor prior to
authorizing services and must include the description of services, amount of time
(hourly, daily, weekly) and the title of the staff that will be providing the specific
services.
The recipient must provide a signature on the service plan. If the recipient is unable
to provide a signature due to cognitive and/or physical limitation, this must be
clearly documented in the recipient file. A legal representative may sign for the
recipient.
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The facility may create a signature page which can encompass a recipient signature
for the service plan, the plan of care, and any other signature requirements. If the
facility uses a signature page, it must be included in the packet to the DHCFP district
office and the QIO-like vendor for prior authorization.
Additionally, the DHCFP must review a representative sample of participant service
plans each year.
The Service Plan must be re-evaluated annually or when a significant change occurs.
6. Plan of Care
A plan of care must be initiated on the day of admission to HBHS. The plan of care
must be in agreement with the Service Plan, and the 1915(i) HCBS Universal Needs
Assessment Tool. The individualized plan of care must be developed and meet the
requirement of NAC 449.4088.
The plan of care specifically outlines the services and activities of a recipient and
must be available to all staff members providing home based habilitation services.
The Plan of Care:
is developed by the licensed interdisciplinary habilitation team using a person-
centered process involving the individual, and where appropriate, the individual’s
family, caregiver, or representative, and the DHCFP care coordinator;
a. identifies the necessary services to be furnished to the individual;
includes objectives and directives for HBHS services needed;
takes into account the extent of, and need for, any family or other supports for the
individual;
prevents the provision of unnecessary or inappropriate care;
is guided by best practices and research on effective strategies for improved health
and quality of life outcomes; and
is reviewed and updated by the licensed interdisciplinary habilitation team annually
or as needed or when there is significant change in the individual’s circumstances.
The plan of care must be kept in a file maintained for the recipient and must include
a signature of the recipient. If the recipient is unable to provide a signature due to
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cognitive and/or physical limitation, this must be clearly documented in the recipient
file. A legal representative may sign for the recipient.
The facility may create a signature page which can encompass a recipient signature
for the service plan, the plan of care, and any other signature requirements. If the
facility uses a signature page, it must be included in the packet to the DHCFP district
office and the QIO-like vendor for prior authorization.
Records Requirements
In compliance with NAC 449.40835, the facility must maintain records on each
employee.
Employee Records must include:
finger prints and background results;
annual TB tests; and
training, required licenses, registrations, and certificates.
In compliance with NAC 449.40835, the facility must maintain records on recipients
including daily records and attendance records. All entries made in the recipient’s
file must be signed and dated by the employee making the entry. The delivery of
specific services including those required by Medicaid must be documented in the
daily records.
Recipient records must include the following:
Medicaid Eligibility - The facility must maintain proof of each recipient’s Medicaid
eligibility. Verification of eligibility is the provider’s responsibility. Eligibility
should be verified monthly. Refer to MSM Chapter 100 for additional information
regarding verification of eligibility.
Universal Needs Assessment.
Service Plan.
Statement indicating recipient made an informed choice in providers.
Plan of Care.
Attendance Records.
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Daily Records.
Annual TB tests.
The case manager is responsible for maintaining a record for the recipient.
The facility must maintain an accurate record of the recipient’s attendance by using
an attendance record as defined in the MSM Addendum. The record must also reflect
any absence from the facility by the recipient for purposes of obtaining other services
must be documented. This record is to include date, duration of absence and
destination or purpose for absence.
8. Confidentiality and Release of Recipient Records
The facility is required to comply with applicable state and federal laws, rules and
regulations regarding privacy and protection of an individual’s health information.
9. Provider Liability
Provider liability responsibilities are included in the Medicaid and Nevada Check
Up (NCU) Provider Contract and are incorporated in this chapter by reference.
10. Notification of Suspected Abuse and Neglect
State law requires that persons employed in certain capacities must make a report to
the appropriate agency immediately, but in no event later than 24 hours after there
is reason to suspect abuse or neglect. The DHCFP expects that all providers be in
compliance with the intent of all applicable laws.
For adults aged 60 and over, the Aging and Disability Services Division (ADSD)
accepts reports of suspected abuse, neglect or self-neglect, exploitation or isolation.
Refer to NRS 200.5091 to 200.50995 regarding elder abuse or neglect.
2403.1C RECIPIENT RESPONSIBILITY
1. Medicaid recipients are required to maintain and provide a valid Medicaid
eligibility card to their service providers and to notify their providers of any changes
to the type of eligibility, or other insurance benefits that may be in effect such as
Medicare.
2. Medicaid recipients are expected to comply with and participate in their
development of their plan of care including making and keeping medical
appointments.
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3. The recipient is responsible to notify the provider of changes in medical
status, service needs address, and location.
4. In accordance with the Health Insurance Portability and Accountability Act
(HIPAA) of 1996, protected health information may be disclosed for the purposes
of treatment, payment, or health care operations without a signed Authorization for
Disclosure from the participant or designated representative. However, most other
disclosures require authorization. Additional details about allowable uses and
disclosures are available to participants in the DHCFP Notice of Privacy Practices,
which is provided to all new enrollees.
Additionally, in accordance with NRS 232.357, an individual’s health information
may be shared without an Authorization for Disclosure among the divisions of the
Department of Human Resources in the performance of official duties and with local
governments that help the Department carry out official duties as long as the
disclosure is related to treatment, payment, or health care operations.
2403.1D PRIOR AUTHORIZATION
The purpose of prior-authorization is to validate that the service being requested is
medically necessary and meets Medicaid criteria for reimbursement.
1. Prior authorization is not a guarantee of payment for the service; payment is
contingent upon passing all edits contained within the claims payment process; the
recipient’s continued Medicaid eligibility; and the ongoing medical necessity for the
service being provided.
2. Prior authorizations are specific to a recipient, a provider, a service code, and
established quantity of units, and for specific dates of service.
3. Prior authorization is required for all services and must be obtained
regardless of whether or not Medicaid is the primary payer, except for Medicare-
crossover claims.
Prior Authorization Process
HBHS must be prior authorized. The HBHS provider must submit the completed
1915(i) HCBS Universal Needs Assessment Tool and Service Plan (including the
statement that the recipient was offered a choice of HBHS providers) and all relevant
assessments to the QIO-like vendor before services are provided. All prior
authorization requests must be complete and accurate. If insufficient information is
provided to support the completion of a request, the HBHS provider must supply the
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needed information within 72 hours of notification. When complete information is
submitted, the QIO-like vendor must make a decision within five (5) business days.
In the case when an individual becomes eligible for Medicaid during the course of
treatment or after services were provided, the HBHS provider may request a retro-
eligible authorization by submitting the completed 1915(i) HCBS Universal Needs
Assessment Tool and Service Plan (including the statement that the recipient was
offered a choice of HBHS providers) and all relevant assessments to the QIO-like
vendor.
The retro-eligible request must be submitted within 90 days of the notice of decision
from Division of Welfare and Supportive Services (DWSS) on Medicaid eligibility
determination. When complete information is submitted, the QIO-like vendor must
make a determination within five (5) days.
The QIO-like vendor must review and provide a determination for all service plans
and provide a written authorization to the HBHS provider which includes a prior
authorization number and service authorization. The prior authorization number
must be included on all claims.
Types of prior authorization requests include:
An initial prior authorization request must be submitted before providing services to
a Medicaid recipient for the first time.
A concurrent prior authorization is required if a provider believes it is medically
necessary for additional services to be rendered beyond that of the current
authorization. The concurrent prior authorization must be submitted in time to meet
QIO-Like processing timelines so an interruption in services may be avoided.
A retro-eligible request-may occur when an individual becomes eligible for
Medicaid after services have been provided. Retro-eligible requests must be
submitted within 90 days from the eligibility determination date (date of decision).
Unscheduled changes to a current prior authorization are required when a recipient’s
needs change during the current authorization period. If this occurs, a revision prior
authorization must be submitted for approval.
Prior authorization may be approved for a maximum of one (1) year through the end
of the eligibility month. The prior authorization is dependent upon meeting the
eligibility criteria using the 1915(i) HCBS Universal Needs Assessment Tool and
medical necessity as described by medical evidence relating to a TBI/ABI. If
services are needed after the current authorization ends, the facility must submit a
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new prior authorization request to the QIO-like vendor and include the same
information that is required with an initial prior authorization request.
Services provided without prior authorization are not reimbursable.
A prior authorization number is required on all claims and must correspond directly
to all dates of service on the claim. No dates of service billed outside of the dates
approved on the corresponding prior authorization will be paid.
The QIO-like vendor will provide a written authorization to the HBHS facility which
includes a prior authorization number and service authorization.
Reimbursement is not available for services furnished by legally responsible
individuals.
2403.2 RESIDENTIAL HABILITATION PROGRAM (RHP)
RHPs are a covered benefit when medically necessary services are furnished in a
safe, efficient and cost-effective setting to Medicaid eligible recipients who require
services 24 hours per day in a normalized living environment.
2403.2A COVERAGE AND LIMITATIONS
Reimbursement is available for time limited RHPs which have been prior authorized
by Nevada Medicaid’s QIO-like vendor. Programs must include a day treatment
program and a 24-hour residential component for those eligible recipients who are
not ready to return to independent, or supported independent, living due to their
functional or cognitive impairments.
1. Admission Criteria
In addition to the admission criteria identified in Section 2403.1A, of this Chapter,
the following criteria apply for residential habilitation programs:
a. Eligible recipients are unable to return to independent living due to a
significant cognitive or physical impairment which requires intensive, short-term
specialized intervention to reintegrate into the community;
b. A program must consist of an interdisciplinary coordinated team approach,
based on supporting medical rational, to improve the recipient’s ability to function
as independently as possible;
c. The recipient has a viable discharge plan with appropriate post placement
resources, including a support system identified that will facilitate community re-
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entry and a realistic expectation and plan for non-institutional living post-discharge;
and
d. Documentation is made available, upon request, to support that the
individual’s goals cannot be safely and adequately carried out at a less intensive
level such as a day treatment program.
2. Covered Services
a. A residential habilitation program must include a medically necessary day
treatment program component focused on community reintegration. This program
may consist of community reintegration training, personal care assistance and
supervision in a 24 hour residential setting.
b. The residential component of the RHP must provide continued training,
supervision and personal care services appropriate in amount and frequency to meet
the needs of the recipient in a safe environment 24 hours per day, 7 days per week.
c. The interdisciplinary team must establish a plan of care which is developed
and updated annually, or as needed, for each resident.
d. Nevada Medicaid does not reimburse for costs associated with room and
board in the residential setting. Arrangements for reimbursement of such costs must
be made with the recipient, or their family, prior to the program admission.
e. A component of community reintegration includes community visits.
Payment for community visits must be properly documented, and prior authorized
subject to the following conditions:
1. The purpose of community visits is for preparation for discharge to the
community.
2. The recipient’s primary physician authorizes the visit and the plan of care
provides for such absences.
The community visit is to be reimbursed the lesser of billed charges or the
established community visit per diem rate for a maximum of 2 days per month. For
this purpose, a month is any continuous 31 day period.
3. Continued Stay Criteria for Residential Habilitation Program
For continued residential habilitation services, prior authorization must be submitted
to Medicaid’s QIO-like vendor a minimum in time to meet processing timelines so
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an interruption in services may be avoided. To be considered for continued stay,
supporting documentation must be provided including the most recent team
conference report, which demonstrates that the recipient continues to meet RHP
admission criteria and continues to:
a. demonstrate the ability to actively participate in the program;
b. have documented progression toward written goals;
c. need 24-hour habilitation services as described in 2403.1A and 2403.1A.2.a.
If continuation of services is determined to be medically appropriate, a new length
of stay will be assigned and continued in this manner until the discharge of the
recipient is indicated. Services provided without prior authorization are not
reimbursable.
4. Discharge Criteria
A recipient in a residential habilitation program must be considered for discharge,
regardless of the authorized length of stay or program completion, when the
following conditions are met:
a. The recipient’s needs exceed the scope of the residential habilitation program
so transfer to an inpatient hospital or skilled nursing facility is indicated;
b. The recipient no longer meets the criteria for the program;
c. The specialized knowledge and skills of the interdisciplinary team are no
longer required;
d. Lack of attendance and/or participation in the activities specific to the
residential program setting for more than three consecutive days;
e. The recipient has reached his or her goals and a safe and effective program
has been developed with informal supports to allow the recipient to live at home or
elsewhere in the community;
f. There is limited motivation on the part of the recipient or caregiver which is
impacting the individual’s progress for over one week; or
g. The established goals serve no purpose to increase functional or cognitive
capabilities towards independent or assisted living.
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2403.2B PROVIDER RESPONSIBILITY
In addition to the policies discussed in Section 2403.1B “Provider Responsibility”
of this Chapter, the following policies apply to the Residential Habilitation Program.
1. Providers must maintain compliance with all regulatory requirements for a
residential habilitation provider for the State in which they operate;
2. Providers must maintain either CARF or the Joint Commission accreditation
as a residential facility to be in good standing;
3. The provider shall provide qualified habilitation aides at the appropriate
staffing ratios as determined by applicable licensure, certification and/or
accreditation requirements;
4. Providers establish, maintain and update an emergency plan specific to the
recipient, including appropriate emergency information on-site for each recipient at
all times;
5. Providers must establish a mechanism for residents or their families to report,
without retribution, any complaints or occurrences that may compromise the safety
or well being of the residents within the home; and
6. Providers must establish and enforce policies to ensure the safety and well
being of all residents of the facility.
2403.2C RECIPIENT RESPONSIBILITY
In addition to the policies discussed in Section 2403.1C “Recipient Responsibility”
of this Chapter, the following policies apply to residents of the Residential
Habilitation Program:
1. Recipients and their guests must comply with all reasonable and necessary
posted “house rules” as established by the provider, in order to maintain a safe
environment for all residents.
2. Recipients should notify the provider and the DHCFP of any occurrences
that may compromise the safety or well being of residents within the home.
2403.2D AUTHORIZATION PROCESS
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The policies discussed in Section 2403.1D “Authorization Process” of this Chapter,
apply to the Residential Habilitation Program.
2403.3 COMMUNITY RE-INTEGRATION SERVICES (CRS)
Community reintegration services are designed to provide temporary assistance and
support to those recipients with significant neurological impairment, incorporating
those skills developed during a Habilitation program into their daily lives as they
become reintegrated into their community.
Appropriate services are intended to enable the individual to function with greater
independence, to prevent additional disabilities or an increase in the severity of an
existing disability, without which the individual would require institutionalization.
2403.3A COVERAGE AND LIMITATIONS
Reimbursement is available for CRS which have been prior authorized by the
DHCFP’s QIO-like vendor. Services must be ordered by a physician as a reasonable
and medically necessary part of the recipient’s treatment plan and must be
determined safe, efficient and cost-effective by the DHCFP or its QIO-like vendor.
1. Admission Criteria
a. The recipient must be eligible for services under Medicaid and must have
behaviors which are manageable in the community re-integration environment;
b. Eligible recipients have successfully progressed through their habilitation
plan of care, but they require specialized transition assistance to fully reintegrate
into the community;
c. Community reintegration services are required, based on supporting medical
rational, to ensure the recipient’s ability to function as independently as possible in
the community; and
d. Documentation is provided, to support that the reintegration goals cannot be
safely and adequately carried out utilizing more informal supports, such as willing
family members and neighbors;
e. The recipient has a viable written discharge plan, established by the
multidisciplinary team, with appropriate resources in place, including the support
system that will facilitate the community reintegration process and a realistic
expectation of successful non-institutional living.
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f. The medical condition is stable and compatible with an active reintegration
program.
2. Covered Services
a. Community reintegration services are a covered benefit for recipients
admitted within 14 days of completing a habilitation program or from the date
determined to be eligible for Medicaid;
b. Services may be provided in the recipient’s residence (non-institutional
setting), work environment, or other appropriate community-based setting;
c. Habilitation aides must assist the recipient in utilizing those skills taught by
the interdisciplinary team and involve coaching, advising, supporting and cueing
recipients in Instrumental Activities of Daily Living (IADLs) such as:
household management;
behavioral management;
safety;
navigating in their immediate community using public transportation; and
socialization skills.
3. Service Limitations
a. Services must be provided in accordance with individualized plan of care
under the direction of a habilitation provider;
b. Community reintegration services are limited to a maximum of 20 hours per
week, and must be prior authorized.
4. Non Covered Services
a. Maintenance Therapy – is defined as the point where the recipient
demonstrates no further significant improvement, or the skills of a qualified
rehabilitative aide are not required to carry out an activity or a home program to
maintain function at the level to which it has been restored. Services in this category
are non-covered.
February 15, 2012 HOME BASED HABILITATION SERVICES (HBHS) Section 2403 Page 24
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2403
Subject:
MEDICAID SERVICES MANUAL POLICY
b. Duplicative Services are not considered medically justified and will not be
covered by Nevada Medicaid. An inquiry or referral for services does not indicate
the necessity for services.
c. Community reintegration services solely for vocational, educational or
convenience purposes or for developmental or behavioral concerns is not covered
services within this program.
5. Continuing Stay Criteria
a. All services must be part of, and specifically related to, an active plan of care
that the physician reviews periodically, but not less than every 30 days or when
deemed necessary;
The physician is responsible for certifying that the service is medically necessary
and that the treatment prescribed is in accordance with standards of best medical
practice;
b. The re-integration plan of care must incorporate the written discharge plan
established during the habilitation program or re-integration stay, identifying formal
and informal resources that are currently in place, as well as the identified support
system that will be facilitating the community re-entry.
1. The plan of care must also contain:
a. Identified barriers; and corresponding short and long-term goals that are
functional, objective and measurable;
b. Specific services to be provided, including the frequency, duration and
modalities to be implemented; and
c. The proposed plan of care must include specific functional goals and a
reasonable estimate of when they will be reached (e.g., 6 weeks). It is not adequate
to estimate “1 to 2 months on an ongoing basis.”
c. Ongoing documentation of discharge planning including appropriate follow-
up care with consideration of physical, emotional and mental status needs at time of
discharge. Since discharge planning is an integral part of any habilitation program
and should begin upon the patient’s admittance to the program, an extended period
of time for discharge action is not reasonable after established goals have been
reached, or a determination made that further progress is unlikely.
d. The recipient must demonstrate the ability and willingness to actively
participate in goal oriented interventions developed with the interdisciplinary team.
February 15, 2012 HOME BASED HABILITATION SERVICES (HBHS) Section 2403 Page 25
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2403
Subject:
MEDICAID SERVICES MANUAL POLICY
This shall be evidenced by regular attendance in interventions that are a part of the
reintegration action plan and documented progression toward the established goals;
e. Documentation must reflect that the community reintegration activities are
reduced as the recipient’s level of independence increases.
6. Discharge Criteria
Community reintegration services must be considered for termination regardless of
the pre-authorized length of stay when any one of the following conditions are met:
b. The recipient has a safe discharge plan to the community.
c. The recipient has met all of their established goals.
d. The recipient requires a more restrictive setting.
e. The recipient has an unstable condition that affects their ability to participate
in community reintegration activities.
2403.3B PROVIDER RESPONSIBILITY
The policies discussed in Section 2403.1B “Provider Enrollment” of this Chapter,
apply to Community Re-integration Services.
2403.3C RECIPIENT RESPONSIBILITY
The policies discussed in Section 2403.1C “Recipient Responsibility” of this
Chapter, apply to Community Re-integration Services.
2403.3D PRIOR AUTHORIZATION
The policies discussed in Section 2403.1D “Prior Authorization” of this Chapter,
apply to Community Re-integration Services.
February 15, 2012 HOME BASED HABILITATION SERVICES (HBHS) Section 2403 Page 26
MTL 01/12
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2404
Subject:
MEDICAID SERVICES MANUAL QUALITY ASSURANCE
QUALITY ASSURANCE
The DHCFP will conduct an annual review to assure the health and welfare, of the
recipients served by HBHS. The review will consist of the program requirements
identified in this chapter.
Additionally, a review of the providers will be conducted annually to verify that the
providers meet requirements established for each service, such as licensure,
accreditation, etc, and to ensure claims are paid in accordance with the State Plan
and all federal state regulations. Providers must cooperate with the DHCFP’s annual
review process.
February 15, 2012 HOME BASED HABILITATION SERVICES (HBHS) Section 2404 Page 1
MTL 01/12
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2405
Subject:
MEDICAID SERVICES MANUAL HEARINGS
2405 HEARINGS
Please reference Nevada MSM, Chapter 3100, for Medicaid Hearing Process.
February 15, 2012 HOME BASED HABILITATION SERVICES (HBHS) Section 2405 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
January 29, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: LYNNE FOSTER, CHIEF OF DIVISION COMPLIANCE
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 2500 – CASE MANAGEMENT
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2500 – Case Management are being
proposed for the re-structuring of this policy to ensure uniformity by merging the target group
information and aligning provider requirements for better understanding. The DHCFP is proposing
to combine each of the nine target group definitions with their corresponding Service Eligibility
Determination, Provider Qualifications and Service Criteria. This is not a change to policy, service
limitations or requirements, the proposed changes are strictly intended to reorganize the chapter.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
These changes are effective January 30, 2019.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 05/19 MTL 22/15, 04/17
MSM 2500 – Case Management MSM 2500 – Case Management
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2502 Target Group This section has been moved to renumbered Section
Definitions 2503. Section 2502 is replaced with Section 2503
“Policy.”
2502.1 Lead Case Manager This section has been moved to renumbered Section
2502.3. Section 2502.1 is replaced with Section 2503.1
“Case Management Services Policy.”
Page 1 of 3
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2502.2 Target Group – This section has been moved to renumbered Section
Child Protective 2503.5. Section 2502.2 is replaced with Section 2502.11
Services (CPS) “Case Management Services.”
2502.3 Target Group – This section has been moved to renumbered Section
Developmentally 2503.6. Section 2502.3 is replaced with Section 2502.1
Delayed Infants and “Lead Case Manager.”
Toddlers Under Age
Three
2502.4 Target Group – This section has been moved to renumbered Section
Juvenile Parole 2503.7. Section 2502.4 is replaced with Section
Population 2502.11A “Case Record Documentation.”
2502.5 Target Group – This section has been moved to renumbered Section
Juvenile Probation 2503.8. Section 2502.5 is replaced with Section 2503.1A
Services “Coverage and Limitations.”
2502.6 Target Group – This section has been moved to renumbered Section
Persons with 2503.9. Section 2502.6 is replaced with Section 2503.1B
Intellectual “Recipient Responsibilities.”
Disabilities or
Related Conditions
2502.7 Target Group – This section has been moved to renumbered Section
Non-Seriously 2503.1. Section 2502.7 has been replaced with Section
Mentally Ill Adults 2503.1C “Authorization Process.”
2502.8 Target Group – This section has been moved to renumbered Section
Seriously Mentally 2503.2. Section 2502.8 is replaced with Section 2502
Ill Adults “Target Group Definitions.” This has been re-titled to
“Target Groups.”
2502.9 Target Group – This section has been moved to renumbered Section
Non-Severely 2503.3. Section 2502.9 has been replaced with Sections
Emotionally 2502.7 and 2503.1A(3) “Target Group – Non-Seriously
Disturbed Children Mentally Ill Adults.” This target group has been re-titled
and Adolescents to “Adults with a Non-Serious Mental Illness.”
2502.10 Target Group – This section has been moved to renumbered Section
Severe Emotional 2503.4. Section 2502.10 has been replaced with Sections
Disturbance 2502.8 and 2503.1A(4) “Target Group – Seriously
Mentally Ill Adults.” This target group has been re-titled
to “Adults with a Serious Mental Illness.”
Page 2 of 3
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2502.11 Case Management This section has been moved to renumbered Section
Services 2502.2. Section 2502.11 has been replaced with Sections
2502.9 and 2503.1A(5) “Target Group – Non-Severely
Emotionally Disturbed Children and Adolescents.” This
target group has been re-titled to “Children and
Adolescents with a Non-Severe Emotional Disturbance.”
2502.11A Case Record This section has been moved to renumbered Section
Documentation 2502.4. Section 2502.11A has been replaced with
Sections 2502.10 and 2503.1A(6) “Target Group –
Severe Emotional Disturbance.” This target group has
been re-titled to “Target Group – Children and
Adolescents with a Severe Emotional Disturbance.”
2503 Policy This section has been moved to renumbered Section
2502. Section 2503 has been replaced with Sections
2502.2 and 2503.1A(11) “Target Group – Child
Protective Services.”
2503.1 Case Management This section has been moved to renumbered Section
Services Policy 2502.1. Section 2503.1 has been replaced with Sections
2502.3 and 2503.1A(8) “Developmentally Delayed
Infants and Toddlers Under Age Three.” This target
group has been re-titled to “Infants and Toddlers
Developmentally Delayed Under Age Three.”
2503.1A Coverage and This section has been moved to renumbered Section
Limitations 2502.5. Section 2503.1A has been replaced with Sections
2502.4 and 2503.1A(9) “Target Group – Juvenile Parole
Population.” This target group has been re-titled to
“Juvenile Parole Services.”
2503.1B Recipient This section has been moved to renumbered Section
Responsibilities 2502.5A. Section 2503.1B has been replaced with
Sections 2502.5 and 2503.1A(10) “Target Group –
Juvenile Probation Services.”
2503.1C Authorization This section has been moved to renumbered Section
Process 2502.5B. Section 2503.1C has been replaced with
Sections 2502.6 and 2503.1A(7) “Target Group –
Persons with Intellectual Disabilities or Related
Conditions.”
Page 3 of 3
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
CASE MANAGEMENT
2500 INTRODUCTION ........................................................................................................1
2501 AUTHORITY ...............................................................................................................1
2502 POLICY ........................................................................................................................1
2502.1 CASE MANAGEMENT SERVICES POLICY ...........................................................1
2502.2 CASE MANAGEMENT SERVICES ..........................................................................1
2502.3 LEAD CASE MANAGER ...........................................................................................2
2502.4 CASE RECORD DOCUMENTATION.......................................................................2
2502.5 COVERAGE AND LIMITATIONS ............................................................................3
2502.6 RECIPIENT RESPONSIBILITIES .............................................................................7
2502.7 AUTHORIZATION PROCESS ...................................................................................7
2503 TARGET GROUPS......................................................................................................1
2503.1 TARGET GROUPS – ADULTS WITH A NON-SERIOUS MENTAL ILLNESS
(NON-SMI) ..................................................................................................................1
2503.2 TARGET GROUPS – ADULTS WITH A SERIOUS MENTAL ILLNESS (SMI) ...2
2503.3 TARGET GROUP – CHILDREN AND ADOLESCENTS WITH A NON-SEVERE
EMOTIONAL DISTURBANCE (NON-SED) ............................................................4
2503.4 TARGET GROUP – CHILDREN AND ADOLESCENTS WITH A SEVERE
EMOTIONAL DISTURBANCE (SED) ......................................................................5
2503.5 TARGET GROUP – CHILD PROTECTIVE SERVICES (CPS) ...............................8
2503.6 TARGET GROUP – INFANTS AND TODDLERS DEVELOPMENTALLY
DELAYED UNDER AGE THREE .............................................................................9
2503.7 TARGET GROUP – JUVENILE PAROLE SERVICES ..........................................12
2503.8 TARGET GROUP – JUVENILE PROBATION SERVICES (JPS) .........................15
2503.9 TARGET GROUP – PERSONS WITH INTELLECTUAL DISABILITIES OR
RELATED CONDITIONS ........................................................................................17
2504 HEARINGS ..................................................................................................................1
2505 RESERVED.................... .............................................................................................1
MTL 04/17
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2500
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
CASE MANAGEMENT
2500 INTRODUCTION
Case Management is an optional Medicaid service pursuant to federal regulations. It may be
provided without the use of a waiver and the state may limit the provision of services to a specific
target group or defined location in the state. States are allowed to limit the providers of case
management services available for individuals with developmental disabilities or chronic mental
illness to ensure that these recipients receive needed services. The receipt of case management
services does not alter an individual's eligibility to receive other services under the State Plan and
recipients must have free choice of any qualified Medicaid provider. A recipient cannot be
compelled to receive case management services, services cannot be a condition of receipt of other
Medicaid services and other covered services cannot be a condition to receive case management
services. Case management services provided in accordance with Section 1915(g) of the Social
Security Act (SSA) will not duplicate payments made to public agencies or private entities under
State Plan and other program authorities. Case managers cannot authorize, approve or deny the
provision of services.
The intent of case management services is to assist recipients eligible under the State Plan in
gaining access to needed medical, social, educational, and other support services including housing
and transportation needs. Case management services do not include the direct delivery of medical,
clinical or other direct services. Components of the service include assessment, care planning,
referral/linkage and monitoring/follow-up. Case management services are provided to eligible
recipients who are residing in a community setting or transitioning to a community setting
following an institutional stay.
There are nine target groups eligible to receive this service. These groups are: (1) children and
adolescents who are Non-Severely Emotionally Disturbed (Non-SED) with a mental illness; (2)
children and adolescents who are Severely Emotionally Disturbed (SED); (3) adults who are Non-
Seriously Mentally Ill (Non-SMI) with a mental illness; (4) adults who are Seriously Mentally Ill
(SMI); (5) persons with intellectual disabilities or related conditions; (6) developmentally delayed
infants and toddlers under age three; (7) Juvenile Parole Population; (8) Juvenile Probation
Services (JPS), and (9) Child Protective Services (CPS).
All providers who participate in the Medicaid program must provide services in accordance with
the rules and regulations of the Division of Health Care Financing and Policy (DHCFP), all policies
and procedures described here in Medicaid Services Manual (MSM) Chapter 2500, as well as state
and federal regulations and statutes.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), with the exception of the areas where Medicaid and Nevada Check Up policies
differ as documented in the Nevada Check Up Manual, Chapter 1000.
February 23, 2017 CASE MANAGEMENT Section 2500 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2501
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
2501 AUTHORITY
A. In 1965, the 89th Congress added Title XIX of the SSA authorizing varying percentages
of Federal Financial Participation (FFP) to states that elect to offer medical programs. The
state must offer the 11 basic required medical services. FFP is also available, should states
elect to cover some optional services. One of these optional services is Case Management.
B. Authorities include:
• Section 1905(a)(19) of the SSA
• Section 1915(b) of the SSA
• Section 1915(c) of the SSA
• Section 1915(g) of the SSA
• 42 Code of Federal Regulations (CFR) Parts 431, 440 and 441
• 42 CFR 483.430
• Section 60-52 of the Deficit Reduction Act of 2005
• The Supplemental Appropriations Act 2008
February 23, 2017 CASE MANAGEMENT Section 2501 Page 1
MTL 05/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2502
Subject:
MEDICAID SERVICES MANUAL POLICY
2502 POLICY
2502.1 CASE MANAGEMENT SERVICES POLICY
2502.2 CASE MANAGEMENT SERVICES
A. Case management services are services which assist an individual in gaining access to
needed medical, social, educational and other supportive services and must include the
following components:
1. Assessment of the eligible individual to determine service needs.
2. Development of a person-centered care plan.
3. Referral and related activities to help the individual obtain needed services.
4. Monitoring and follow-up.
B. Case management services involve the following activities to assist the eligible recipient
in obtaining needed services:
1. Assessment and periodic reassessment of individual needs, to determine the need
for any medical, educational, social or other services. The assessment activities
include the following:
a. Taking client history.
b. Identifying the needs of the individual and completing related
documentation.
c. Gathering information from other sources, such as family members,
medical providers, social workers and educators (if necessary) to form a
complete assessment of the eligible recipient.
2. Development (and periodic revision) of a specific care plan based on the
information collected through the assessment, that includes the following:
a. Specifies the goals and actions to address the medical, social, educational
and other services needed by the eligible recipient.
b. Includes activities such as ensuring the active participation of the eligible
recipient and working with the recipient (or the individual's authorized
health care decision maker) and others to develop those goals.
January 30, 2019 CASE MANAGEMENT Section 2502 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2502
Subject:
MEDICAID SERVICES MANUAL POLICY
c. Identifies a course of action to respond to the assessed needs of the eligible
recipient.
3. Referral and related activities (such as scheduling appointments for the recipient)
to help the eligible individual obtain needed services, including activities that help
link the individual with medical, social and educational providers or other programs
and services that are capable of providing needed services to address identified
needs and achieve goals specified in the care plan.
4. Monitoring and follow-up; activities include activities and contacts that are
necessary to ensure that the care plan is effectively implemented and adequately
addresses the needs of the eligible individual and may be with the individual, family
members, service provider or other entities or individuals. The monitoring should
be conducted as frequently as necessary, and include at least one annual monitoring,
to help determine whether the following conditions are met:
a. Services are being furnished in accordance with the individual's care plan.
b. Services in the care plan are adequate.
c. There are changes in the needs or status of the eligible recipient.
Monitoring and follow-up activities include making necessary adjustments in the
care plan and service arrangements with providers. Monitoring may involve either
face-to-face or telephone contact, at least annually.
2502.3 LEAD CASE MANAGER
The Lead Case Manager is only used if a recipient is included in more than one target group at a
given time. The Lead Case Manager is a case manager and represents Severely Emotionally
Disturbed (SED) children and adolescents or Seriously Mentally Ill (SMI) adults. The Lead Case
Manager coordinates the recipient's care and services with another case manager. The Lead Case
Manager is responsible for coordinating the additional case management services, whether or not,
chronologically, the Lead Case Manager was the original or the subsequent case manager.
2502.4 CASE RECORD DOCUMENTATION
A case record documentation shall be maintained for each recipient and shall contain the following
items:
A. The name of the individual receiving services, the dates of case management services, the
name of the provider agency and person chosen by the recipient to provide services.
January 30, 2019 CASE MANAGEMENT Section 2502 Page 2
MTL 05/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2502
Subject:
MEDICAID SERVICES MANUAL POLICY
B. The nature, content and units of case management services received. Units, for
documentation purposes, are further defined as actual case management activities
performed.
1. If paid per unit, document date, time, number of units and activities completed.
2. If paid per monthly cap rate, document date, time and activities completed.
C. Whether the goals specified in the care plan have been achieved.
D. If an individual declines services listed in the care plan, this must be documented in the
individual's case record.
E. Timelines for providing services and reassessment.
F. The need for and occurrences of coordination with case managers of other programs.
The case manager shall make available to Nevada Medicaid or Medicaid's Quality Improvement
Organization (QIO-like vendor), upon request, copies of the medical record, progress notes, care
plan, case record or summary documents which reflect the ongoing need for case management
services and support any additional services requested.
2502.5 COVERAGE AND LIMITATIONS
The maximum hours per target group, per calendar month, per recipient, allowed for case
management services are identified below. (Maximum hours do not apply to providers who are
paid a capitated, per member/per month rate). All service limits may be exceeded with a prior
authorization.
January 30, 2019 CASE MANAGEMENT Section 2502 Page 3
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2502
Subject:
MEDICAID SERVICES MANUAL POLICY
Service Limitation Grid by Target Group
Target Group Service Limitations
Child Protective Services (CPS) 30 hours, per calendar month, per recipient.
Developmentally Delayed Infants and 30 hours, per calendar month, per recipient.
Toddlers Under Age Three
Juvenile Parole Population 30 hours, per calendar month, per recipient.
Juvenile Probation Services (JPS) 30 hours, per calendar month, per recipient.
Persons with Intellectual Disabilities or 30 hours, per calendar month, per recipient.
Related Conditions
Non-Seriously Mentally Ill (Non-SMI) Adults 10 hours for initial calendar month, five hours
for the next three consecutive calendar months.
Services are allowed on a rolling calendar year.
Serious Mental Illness (SMI) Adults 30 hours, per calendar month, per recipient.
Non-Severally Emotionally Disturbed (Non- 10 hours for initial calendar month, five hours
SED) Children and Adolescents for the next three consecutive calendar months.
Services are allowed on a rolling calendar year.
Severe Emotional Disturbance (SED) 30 hours, per calendar month, per recipient.
A. Case management services are reimbursable when:
1. Provided to Medicaid eligible recipients, on a one-to-one (telephone or face-to-
face) basis.
2. Medically necessary.
3. Provided by a qualified provider enrolled to serve the target group in which the
recipient belongs.
4. Provided by the recipient's chosen provider.
5. Contacts by the case manager with individuals who are not eligible for Medicaid
when the purpose of the contact is directly related to the management of the eligible
recipient's care.
6. There are no third parties liable to pay for these services, including as
reimbursement under a medical, social, educational or other federally funded
program. Third party insurance payments for case management services must be
pursued for all recipients.
The provider must determine whether the recipient has other health insurance.
Providers may survey health care insurance companies to determine whether case
management is a covered benefit. Exception: This is not necessary for Medicare
January 30, 2019 CASE MANAGEMENT Section 2502 Page 4
MTL 05/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2502
Subject:
MEDICAID SERVICES MANUAL POLICY
since it is not a covered service. If the health care provider covers case management,
it must be billed for all recipients for services provided. For Medicaid recipients,
the health care insurance company must be billed before Medicaid is billed. Once
payment is received, if the other company did not pay the entire cost of services,
Medicaid may be billed. If the health care insurance company will not pay for case
management services, documentation of this must be maintained in the recipient’s
case record.
7. The service is not an integral component or administrative service of another
covered Medicaid service.
B. Case management services not reimbursable under the Nevada Medicaid Program include,
but are not limited to:
1. The actual or direct provision of medical services or treatment. Examples include,
but are not limited to:
a. Training in daily living skills;
b. Training in work skills and social skills;
c. Grooming and other personal services;
d. Training in housekeeping, laundry, cooking;
e. Transportation services;
f. Individual, group or family therapy services;
g. Crisis intervention services; and/or
h. Diagnostic testing and assessments.
2. Services which go beyond assisting individuals in gaining access to needed services.
Examples include, but are not limited to:
a. Paying bills and/or balancing the recipient’s checkbook;
b. Completing application forms, paper work, evaluations and reports
including applying for Medicaid eligibility;
c. Escorting or transporting recipients to scheduled medical appointments;
and/or
January 30, 2019 CASE MANAGEMENT Section 2502 Page 5
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2502
Subject:
MEDICAID SERVICES MANUAL POLICY
d. Providing child care so the recipient can access services.
3. Traveling to and from appointments with recipients.
4. Traveling to and from appointments (without recipients).
5. Case management services provided to recipients between 22 and 64 years of age
who are in an Institution for Mental Disease (IMD).
6. Using case management codes for billing, when the recipient does not meet the
criteria for the target group.
7. Recipient Outreach – Outreach activities in which a state agency or other provider
attempts to contact potential recipients of a service do not constitute case
management services.
8. The direct delivery of foster care services and therapeutic foster care services. The
following activities are not considered to qualify as components of Medicaid case
management services:
a. Research gathering and completion of documentation required by the foster
care program.
b. Assessing adoption placements.
c. Recruiting or interviewing potential foster care parents.
d. Serving legal papers and attendance at court appearances.
e. Home investigations.
f. Providing transportation.
g. Administering foster care subsidies.
h. Making placement arrangements.
i. Training, supervision, compensation for foster care parents.
9. If the case manager also provides other services under the plan, the State must ensure
that a conflict of interest does not exist that will result in the case manager making
self-referrals. Individuals must be free to choose their case management provider
January 30, 2019 CASE MANAGEMENT Section 2502 Page 6
MTL 05/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2502
Subject:
MEDICAID SERVICES MANUAL POLICY
from among those that have qualified to participate in Medicaid and are willing to
provide the service.
10. Services provided as “administrative case management,” including Medicaid
eligibility determination, intake processing, preadmission screening for inpatient
care, utilization review and prior authorization for Medicaid services are not
reimbursable.
11. Administrative functions for recipients under the Individuals with Disabilities
Education Act (IDEA) such as the development of an Individual Education Plan and
the implementation and development of an Individual Family Service Plan for Early
Intervention Services are not reimbursable as case management services.
2502.6 RECIPIENT RESPONSIBILITIES
A. Medicaid recipients, their families or legal guardians are required to provide a valid
Medicaid eligibility card to their case management service providers.
B. Medicaid recipients, their families or legal guardians are expected to comply with the
recipient’s treatment and care plans.
2502.7 AUTHORIZATION PROCESS
Medicaid recipients are entitled to receive a maximum amount of hours of case management
services identified in the Service Limitation Grid, Section 2502.5 per target group, per calendar
month, per recipient. (Maximum hours do not apply to providers who are paid a capitated, per
member/per month rate).
If the recipient requires more than the allotted hours per month, the case manager must thoroughly
document in the recipient’s case record the justification for the additional hours and submit a prior
authorization request to the QIO-like vendor.
January 30, 2019 CASE MANAGEMENT Section 2502 Page 7
MTL 05/19
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2503
Subject:
MEDICAID SERVICES MANUAL TARGET GROUPS
2503 TARGET GROUPS
2503.1 TARGET GROUP – ADULTS WITH A NON-SERIOUS MENTAL ILLNESS (NON-SMI)
A. Adults, who are Non-SMI, excluding dementia and intellectual disabilities, are recipients
18 years of age and older with significant life stressors and have:
1. A current International Classification of Diseases (ICD) diagnosis from the current
Mental, Behavioral, Neurodevelopmental Disorders section including Z-Codes 55-
65, R45.850 and R45.851, which does not meet SMI criteria.
2. A Level of Care Utilization System (LOCUS) score of Level I or II.
B. Service Eligibility
The determination for adults with a Non-SMI is made by a licensed, qualified mental health
professional (psychiatrist, psychologist, Licensed Clinical Social Worker (LCSW),
Licensed Marriage and Family Therapist (LMFT) or master’s degree psychiatric nurse).
C. Provider Qualifications
Minimum qualification of a case manager providing services for Non-SMI adults are a
service coordinator with a bachelor’s degree in a health-related field, Registered Nurse
(RN), master’s level professional (LCSW or LMFT), Advanced Practice Registered Nurse
(APRN) in mental health, psychologist or mental health professional who works under the
direct supervision of a person listed above.
D. Service Criteria
1. Admission Criteria includes:
a. A current ICD diagnosis from the Mental, Behavioral, Neurodevelopmental
Disorders section including Z-Codes 55-65, R45.850 and R45.851, which
does not meet SMI criteria (including dementia, intellectual disabilities or
primary diagnosis of a substance abuse disorder, unless these co-occur with
another mental illness that meets current ICD criteria).
b. Recipients require assistance in obtaining and coordinating medical, social,
educational and other support services.
2. Continuing Stay Criteria:
a. Continues to meet admission criteria.
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b. Individualized care plan identifies all medical, social, educational and other
support services currently being provided, as well as unmet needs of the
recipient.
c. Documentation supports progress towards specific case management goals
identified in the established care plan with barriers identified and addressed.
3. Discharge/Exclusionary Criteria:
a. No longer meets Non-SMI determination.
b. No longer meets the admission and continuing stay criteria.
c. Recipient or family chooses not to participate in the program or is non-
compliant.
d. Recipient requires inpatient psychiatric hospitalization, IMD or Nursing
Facility (NF) placement.
e. Has sufficient support system to sustain stability not requiring unnecessary
or frequent acute admission.
2503.2 TARGET GROUP — ADULTS WITH A SERIOUS MENTAL ILLNESS (SMI)
A. Adults with an SMI are persons:
1. 18 years of age and older;
2. Who currently, or at any time during the past year (continuous 12-month period);
a. Have had a diagnosable mental, behavioral or emotional disorder that meets
the coding and definition criteria specified within the current ICD
(excluding substance abuse or addictive disorders, irreversible dementias,
as well as intellectual disabilities, unless they co-occur with another SMI
that meets current ICD criteria);
b. That resulted in functional impairment which substantially interferes with
or limits one or more major life activities;
3. Have a functional impairment addressing the ability to function successfully in
several areas such as psychological, social, occupational or educational. It is seen
on a hypothetical continuum of mental health illness and is viewed from the
individual's perspective within the environmental context. Functional impairment
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is defined as difficulties that substantially interfere with or limit an adult from
achieving or maintaining housing, employment, education, relationships or safety.
B. Service Eligibility Determination
The determination for adults with a SMI is made by a licensed mental health professional
(psychiatrist, psychologist, LCSW, LMFT or master’s degree psychiatric nurse).
C. Provider Qualifications
Minimum qualifications of a case manager providing services for SMI adults (which can
only be provided by a state agency and its employees or contractors or an organization
affiliated with the University of Nevada School of Medicine) are a case manager with a
Bachelor’s degree in a health-related field, RN, master’s level professional (LCSW or
LMFT), APRN in mental health, psychologist or mental health professional who works
under the direct supervision of a person listed above.
D. Service Criteria
1. Admission Criteria
Must meet of all the following:
a. A current ICD diagnosis (excluding Z-Codes, dementia, intellectual
disabilities or a primary diagnosis of a substance abuse disorder, unless these
co-occur with another mental illness That meets current ICD criteria).
b. Recipient requires assistance in obtaining and coordinating medical, social,
educational and other support services.
2. Continuing Stay Criteria
Must meet all of the following:
a. Continues to meet admission criteria.
b. Individualized care plan identifies all medical, social, educational and other
support services currently being provided, as well as unmet needs of the
recipient.
c. Documentation supports progress towards specific case management goals
identified in the case management care plan and barriers have been identified
and addressed.
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d. Treatment plan and goals must be established.
3. Discharge Criteria
Must meet at least one of the following:
a. No longer meets SMI determination.
b. No longer meets the admission and continuing stay criteria.
c. Admission into a psychiatric hospital, IMD or NF.
d. Recipient or family chooses not to participate in the program or is non-
compliant.
e. Has sufficient support system to sustain stability not requiring unnecessary
or frequent acute treatment.
4. Exclusionary Criteria
Must meet at least one of the following:
a. No longer meets SMI determination.
b. No longer meets the admission and continuing stay criteria.
c. Admission into a psychiatric hospital, NF or IMD.
d. Recipient chooses not to participate in the program or is non-compliant.
e. Has sufficient support system to sustain stability not requiring unnecessary
or frequent acute treatment.
2503.3 TARGET GROUP — CHILDREN AND ADOLESCENTS WITH A NON-SEVERE
EMOTIONAL DISTURBANCE (NON-SED)
A. Children and adolescents, who are Non-SED, excluding dementia and intellectual
disabilities, are recipients with significant life stressors and have:
1. A current ICD diagnosis from the Mental, Behavioral, Neurodevelopmental
Disorders section which does not meet SED criteria.
2. Z-Codes 55-65, R45.850 and R45.851, as listed in the current ICD Manual which
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does not meet SED criteria.
3. Child and Adolescent Services Intensity Instrument (CASII) Level of 0, 1, 2 or
above.
B. Service Eligibility Determination
The determination for children and adolescents with a Non-SED is made by a
qualified mental health professional (psychiatrist, psychologist, LCSW, LMFT or
master’s degree psychiatric nurse).
C. Provider Qualifications
The minimum qualifications of a case manager providing services for a Non-SED
child are a case manager with a bachelor’s degree in a health related field, doctorate
degree and license in psychology, RN, master’s level professional (LCSW or
LMFT), APRN in mental health or a mental health professional who works under
the direct supervision of a person listed above, and LCSW or LMFT interns that are
supervised within the scope of their license.
2503.4 TARGET GROUP — CHILDREN AND ADOLESCENTS WITH A SEVERE EMOTIONAL
DISTURBANCE (SED)
A. Children with a SED are persons up to age 18 who currently or at any time during the past
year (continuous 12-month period) have a:
1. Diagnosable mental, behavioral or diagnostic criteria that meet the coding and
definition criteria specified in the current ICD. This excludes substance abuse or
addictive disorders, irreversible dementias, as well as intellectual disabilities and
other related conditions and Z-Codes, unless they co-occur with another SMI that
meets current ICD criteria that results in functional impairment which substantially
interferes with or limits the child's role or functioning in family, school or
community activities; and
2. These disorders include any disorder from the Mental, Behavioral,
Neurodevelopmental Disorders section (including those of biological etiology)
listed in current ICD Clinical Modification (CM) equivalent (and subsequent
revisions), with the exception of Z-Codes, substance use and developmental
disorders, which are excluded unless they co-occur with another diagnosable SED.
All of these disorders have episodic, recurrent or persistent features; however, they
vary in terms of severity and disabling effects; and
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3. Have a functional impairment defined as difficulties that substantially interfere
with or limit a child or adolescent from achieving or maintaining one or more
developmentally appropriate social, behavioral, cognitive, communicative or
adaptive skills. Functional impairments of episodic, recurrent and continuous
duration are included unless they are temporary and expected responses to stressful
events in the environment. Children who would have met functional impairment
criteria during the referenced year without the benefit of treatment or other support
services are included in this definition.
B. Service Eligibility Determination
The determination for children and adolescents with a SED is made by a licensed mental
health professional (psychiatrist, psychologist, LCSW, LMFT or master’s degree
psychiatric nurse).
C. Provider Qualifications
Minimum qualifications of a case manager providing services for SED children and
adolescents (which can only be provided by a state agency or organization affiliated with
the University of Nevada School of Medicine) are a case manager with a bachelor’s degree
in a health-related field, RN, master’s level professional (LCSW or LMFT), APRN in
mental health, psychologist or mental health professional who works under the direct
supervision of a person listed above.
D. Service Criteria
1. Admission
Must meet all of the following:
a. DSM-IV, AXIS I or II, diagnosis (excluding V-Codes, dementia, intellectual
disability or a primary diagnosis of a substance abuse disorder, unless they
co-occur with another mental illness that meets DSM-IV criteria).
b. Recipient requires assistance in obtaining and coordinating medical, social,
educational and other support services.
2. Continuing Stay Criteria
Must meet all of the following:
a. Continues to meet admission criteria.
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b. Individualized care plan identifies all medical, social, educational and other
support services currently being provided, as well as unmet needs of the
recipient.
c. Documentation supports progress towards specific case management goals
identified in the case management care plan and barriers have been identified
and addressed. Treatment plan and goals must be established.
3. Discharge Criteria
Must meet one of the following:
a. No longer meets SED determination.
b. No longer meets the admission and continuing stay criteria.
c. Recipient or family chooses not to participate in the program or is non-
compliant.
d. Requires inpatient psychiatric hospitalization, NF or Residential Treatment
Center (RTC) placement.
e. Has sufficient support system to sustain stability not requiring unnecessary
or frequent acute admissions.
4. Exclusionary Criteria
a. No longer meets SED determination.
b. No longer meets the admission and continuing stay criteria.
c. Requires inpatient psychiatric, NF or RTC hospitalization.
d. Recipient or family chooses not to participate in the program.
E. Transitional Targeted Case Management
1. Transitional Targeted Case Management services are provided to eligible recipients
transitioning to a community setting after a period of time in a psychiatric facility or
hospital for recipients under the age of 21.
a. Transitional Targeted Case Management services are provided 14 days prior
to discharge for an institutional stay.
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b. Transitional Targeted Case Management activities are coordinated with and
are not a duplication of institutional discharge planning services.
2503.5 TARGET GROUP — CHILD PROTECTIVE SERVICES (CPS)
A. Child Protective Services are:
1. Provided to children and young adults who are Medicaid recipients and abused or
neglected or suspected to be at risk thereof as evidenced by being in the care of the
Division of Child and Family Services (DCFS), Clark County Department of
Family Youth Services or Washoe County Department of Social Services.
2. Provided to families who are abused or neglected or suspected to be at risk thereof
as evidenced by being in the care of DCFS, Clark County Department of Family
Services or Washoe County Department of Social Services.
B. Provider Qualifications
The organization providing case management services for CPS must meet the following
requirements:
1. A minimum of five years’ experience of working successfully with children and
families in the target population, including a demonstrated capacity to provide all
components of case management.
2. A minimum of five years’ experience in responding successfully to the needs of
children and families in the target population on a countywide 24 hours, seven days
a week basis.
3. A minimum of five years’ case management experience in accordance and linking
community medical, social, educational or other resources needed by the target
population on a countywide basis.
4. A minimum of five years working with the target population.
5. A minimum of five years’ experience in documenting and maintaining individual
case records that is in accordance with all applicable state and federal requirements.
6. A minimum of five years’ experience of demonstrated capacity in meeting the case
management service needs of the target population.
7. Demonstrated capacity to provide training and supervision to individual case
managers, including training pertaining to Medicaid-covered services.
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8. Qualifications of individual case managers:
a. Bachelor’s degree in a related field; or equivalent college and field
experience; and
b. Ability to work in and with legal systems, including the court system; and
c. Ability to learn state and federal rules, laws and guidelines relating to the
target population and to gain knowledge about community resources.
C. Eligibility Determination
Medicaid eligible recipient’s status is determined by the County’s Department of Social
Services CPS.
D. Service Criteria
Medicaid eligible recipient is under the care of the County’s Department of Social Services
CPS. Scope of services must be in accordance with federal regulations.
E. Transitional Targeted Case Management
1. Transitional Targeted Case Management services are provided to eligible recipients
transitioning to a community setting after a period of time in a psychiatric facility or
hospital for recipients under the age of 21.
a. Transitional Targeted Case Management services are provided 180 days
prior to discharge for an institutional stay.
b. Transitional Targeted Case Management activities are coordinated with and
are not a duplication of institutional discharge planning services.
2503.6 TARGET GROUP - INFANTS AND TODDLERS DEVELOPMENTALLY DELAYED
UNDER AGE THREE
A. Developmentally delayed infants and toddlers are children ages birth through two years
determined eligible for early intervention services through the identification of a
developmental delay, a term which means:
1. A child exhibits a minimum of 50% delay of the child's chronological age in any
one of the areas listed below or a minimum of 25% delay of the child’s
chronological age in any two of the areas listed below. Delays for infants less than
36 weeks’ gestation shall be calculated according to their adjusted age.
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2. The delay(s) must be defined in one or more of the following areas:
a. Cognitive development;
b. Physical development, including vision and hearing;
c. Communication development;
d. Social or emotional development; or
e. Adaptive development.
3. Children also are eligible who have a diagnosed physical or mental condition which
has a high probability of resulting in developmental delays.
4. Informed clinical opinion must be used in determining eligibility for services as a
result of a development delay.
B. Service Eligibility Determination
Eligibility is determined by a multidisciplinary team consisting of two early intervention
professionals and the parent. Eligibility determination must include the following:
1. Be conducted by personnel trained to utilize appropriate methods and procedures;
2. Be based on informed clinical opinions; and
3. Include the following:
a. Review of pertinent records related to the child’s current health status and
medical history.
b. An evaluation of the child’s level of functioning in each of the following
developmental areas:
1. Cognitive development.
2. Physical development, including vision and hearing.
3. Communication development.
4. Social or emotional development.
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5. Adaptive development.
c. An assessment of the unique needs of the child including the identification
of services appropriate to meet those needs.
C. Provider Qualifications
Qualifications of a case manager providing services to an infant or toddler with
developmental delays in an employee or contractor of the Department of Health and Human
Services (DHHS) or one of its qualified Divisions; and
1. An individual with a master’s degree from an accredited college or university in
early childhood special education, childhood human growth and development,
psychology, counseling, social work or a closely related field; or
2. An individual with a bachelor’s degree from an accredited college or university with
major work in early childhood growth and development, early childhood special
education, psychology, counseling, social work or a closely related field, and one
year of full-time professional experience in an early integrated preschool program,
mental health facility or a clinical setting providing developmental or special
education or treatment-oriented services to preschool or school age children with
physical or mental disabilities, or emotional or behavioral disorders.
D. Service Criteria
1. Admission Criteria
a. Medicaid eligible.
b. Meets criteria addressed in Section 2503.6(A)
2. Continuing Stay Criteria
Continues to meet admission criteria.
3. Discharge Criteria
a. Does not meet admission criteria.
b. Child has demonstrated age appropriate skills for six consecutive months.
c. Child turns age three.
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d. Meets criteria for admission to an inpatient facility.
e. Family chooses not to participate in the program or is non-compliant.
f. Has sufficient support system to sustain stability, not requiring unnecessary
or frequent acute admissions.
4. Exclusionary Criteria
a. Does not meet admission criteria.
b. Child is age three or older.
c. Meets criteria for admission to an inpatient facility.
d. Family chooses not to participate in the program or is non-compliant.
E. Transitional Targeted Case Management
1. Transitional Targeted Case Management services are provided to eligible recipients
transitioning to a community setting after a period of time in a psychiatric facility or
hospital for recipients under the age of 21.
a. Transitional Targeted Case Management services are provided 180 days
prior to discharge for an institutional stay.
b. Transitional Targeted Case Management activities are coordinated with and
are not a duplication of institutional discharge planning services.
2503.7 TARGET GROUP – JUVENILE PAROLE SERVICES
A. Juvenile Parole Services are:
1. Covered services provided to juveniles on parole (referred or under the supervision
of juvenile caseworkers) within all counties of Nevada.
2. Covered services provided to family member(s) who are Medicaid eligible whose
children are on parole.
3. At high risk for medical compromise due to one of the following conditions:
a. Failure to take advantage of necessary health care services; or
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b. Non-compliance with their prescribed medical regime; or
c. An inability to coordinate multiple medical, social and other services due to
the existence of an unstable medical condition in need of stabilization; or
d. An inability to understand medical directions because of comprehension
barriers; or
e. A lack of community support system to assist in appropriate follow-up care
at home; or
f. Substance abuse; or
g. A victim of abuse, neglect or violence; and
4. In need of assistance in accessing necessary medical, social, educational or other
services, when comprehensive case management is not being provided elsewhere.
B. Provider Qualifications
The organization providing case management services for Juvenile Parole Services must
meet the following provider qualification requirements:
1. A minimum of five years’ experience of working successfully with children and
families in the target population, including a demonstrated capacity to provide all
components of case management; and
2. Establish a system to coordinate services for individuals who may be covered under
another program which offers components of case management or coordination
similar to Targeted Case Management including, but not limited to, the
coordination of services with Managed Care providers, DCFS, as well as State
waiver programs; and
3. Demonstrated programmatic and administrative experience in providing
comprehensive case management services and the ability to increase their
capability to provide their services to the target group; and
4. Must be an agency employing staff with case management qualifications; and
5. Establish referral systems and demonstrated linkages and referral ability with
essential social and health service agencies; and
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6. A minimum of five years’ experience in responding successfully to the needs of
children and families in the target population on a countywide 24 hours, seven days
a week basis; and
7. A minimum of five years’ case management experience in coordinating and linking
community medical, social, educational or other resources needed by the target
population on a countywide basis; and
8. A minimum of five years’ experience in documenting and maintaining individual
case records that is in accordance with all applicable state and federal requirements;
and
9. A minimum of five years’ experience of demonstrated capacity in meeting the case
management service needs of the target population; and
10. Demonstrated capacity to provide training and supervision to individual case
managers, including training pertaining to Medicaid-covered services.
11. Qualifications of individual case manager
a. Bachelor’s degree in criminal justice, psychology, social work or a closely
related field; or equivalent college and two years of experience in the
criminal justice system to include conducting casework services, making
program eligibility determinations, investigating offenders, preparing
detailed reports for the purposes of justifying criminal sanctions and/or
prosecution, or coordinating with law enforcement agencies, the juvenile
justice system, community-based placements and related State agencies
regarding the preparation of parole agreements, placement, program
development, obtaining services and the legal process of assigned youth;
and
b. Ability to work in and with legal systems, including the court system and
law enforcement; and
c. Ability to learn state and federal rules, laws and guidelines relating to the
target population and to gain knowledge about community resources.
C. Eligibility Determination
Medicaid eligible recipient’s status is determined by the Department of Juvenile Parole.
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D. Service Criteria
Medicaid eligible recipient is under the care of the Department of Juvenile Parole. Services
must be in accordance with federal regulations.
E. Transitional Targeted Case Management
1. Transitional Targeted Case Management services are provided to eligible recipients
transitioning to a community setting after a period of time in a psychiatric facility or
hospital for recipients under the age of 21.
a. Transitional Targeted Case Management services are provided 180 days
prior to discharge for an institutional stay.
b. Transitional Targeted Case Management activities are coordinated with and
are not a duplication of institutional discharge planning services.
2503.8 TARGET GROUP — JUVENILE PROBATION SERVICES (JPS)
A. Juvenile Probation Services are:
1. Covered services provided to juveniles on probation (referred or under the
supervision of juvenile caseworkers) within all counties of Nevada.
2. Covered services provided to family member(s) who are Medicaid eligible whose
children are on probation.
B. Provider Qualifications
The organization providing case management services for JPS must meet the following
requirements:
1. A minimum of five years’ experience of working successfully with children and
families in the target population, including a demonstrated capacity to provide all
components of case management.
2. A minimum of five years’ experience in responding successfully to the needs of
children and families in the target population on a countywide 24 hours, seven days
a week basis.
3. A minimum of five years’ case management experience in coordinating and linking
community medical, social, educational or other resources needed by the target
population on a countywide basis.
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4. A minimum of five years working with the target population.
5. A minimum of five years’ experience in documenting and maintaining individual
case records that is in accordance with all applicable state and federal requirements.
6. A minimum of five years’ experience of demonstrated capacity in meeting the case
management service needs of the target population.
7. Demonstrated capacity to provide training and supervision to individual case
managers, including training pertaining to Medicaid-covered services.
8. Qualifications of individual case managers:
a. Bachelor’s degree in a related field; or equivalent college and field
experience; and
b. Ability to work in and with legal systems, including the court system; and
c. Ability to learn state and federal rules, laws and guidelines relating to the
target population and to gain knowledge about community resources.
C. Eligibility Determination
Medicaid eligible recipient’s status is determined by the County Department of JPS.
D. Service Criteria
Medicaid eligible recipient is under the care of the County Department of JPS. Scope of
coverage services must be in accordance with federal regulations.
E. Transitional Targeted Case Management
1. Transitional Targeted Case Management services are provided to eligible recipients
transitioning to a community setting after a period of time in a psychiatric facility or
hospital for recipients under the age of 21.
a. Transitional Targeted Case Management services are provided 180 days
prior to discharge for an institutional stay.
b. Transitional Targeted Case Management activities are coordinated with and
are not a duplication of institutional discharge planning services.
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2503.9 TARGET GROUP — PERSONS WITH INTELLECTUAL DISABILITIES OR RELATED
CONDITIONS
A. Persons with intellectual disabilities or related conditions are persons who:
1. Are significantly sub-average in general intellectual functioning (intelligence
quotient (IQ) of 70 or below) with concurrent related limitations in two or more
adaptive skill areas, such as communication, self-care, social skills, community use,
self-direction, health and safety, functional academics, leisure and work activities.
Persons with related conditions are individuals who have a severe chronic
disability. It is manifested before the person reaches age 22 and is likely to continue
indefinitely. The disability can be attributable to cerebral palsy, epilepsy or any
other condition, other than mental illness, found to be closely related to intellectual
disabilities because the condition results in impairment of general intellectual
functioning or adaptive behavior similar to that of an intellectually disabled person
and requires treatment or services similar to those required by these persons.
The related condition results in substantial functional limitations in three or more
of the following areas of major life activity:
a. Self-care.
b. Understanding and use of language.
c. Learning.
d. Mobility.
e. Self-direction.
f. Capacity for independent living.
B. Service Eligibility Determination
The determination is made by a Qualified Intellectual Disability Professional (QIDP) as
defined in 42 CFR 483.430.
C. Provider Qualifications
1. Employee or contractor of the Division of Aging and Disability Services (ADSD)
or the DCFS; and
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a. Bachelor’s level social worker licensed to practice in Nevada.
b. RN licensed in Nevada to practice professional nursing
.
c. Disabilities specialist with at least a bachelor’s degree in human sciences.
d. Psychologist licensed to practice in Nevada.
e. Child development specialist and psychology, nursing or social work
caseworker who works under the direct supervision of a person in classes (a)
through (d) above.
D. Service Criteria
1. Admission Criteria.
Meets admission criteria as addressed in Section 2503.9(A)
2. Continuing Stay Criteria.
Continues to meet admission criteria.
3. Discharge Criteria.
a. Does not meet admission criteria.
b. Recipient or family chooses not to participate in program or is non-
compliant.
c. Admission into a hospital, NF or Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID).
d. Has sufficient support system to sustain stability not requiring unnecessary
or frequent acute admissions.
4. Exclusionary Criteria
a. Does not meet admission criteria.
b. Recipient is hospitalized or resides in an ICF/IID.
c. Admission into a hospital, NF or ICF/IID.
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E. Transitional Targeted Case Management
1. Transitional Targeted Case Management services are provided to eligible recipients
transitioning to a community setting after a period of time in a psychiatric facility or
hospital for recipients under the age of 21.
a. Transitional Targeted Case Management services are provided 180 days
prior to discharge for an institutional stay.
b. Transitional Targeted Case Management activities are coordinated with and
are not a duplication of institutional discharge planning services.
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2504 HEARINGS
Please reference Medicaid Services Manual (MSM) Chapter 3100, Hearings, for hearings
procedures.
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2505 RESERVED FOR FUTURE USE
October 1, 2015 CASE MANAGEMENT Section 2505 Page 1
MEDICAID SERVICES MANUAL
TRANSNITTTALLETTER
June 25, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: TAMMI MOFFm, CHIEF OF OPERATIONS
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 2600- INTERMEDIARY SERVICE ORGANIZATION
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2600 - Intermediary Service
Organization are being proposed to add language due to the passage ofthe 21 81 Century Cures Act.
In December 2016, Congress passed H.R. 34 - 21st Century Cures Act, mandating that all States
require the use of an Electronic Visit Verification (EVV) system for all Medicaid-funded personal
care services that are provided under a State Plan or a waiver of the plan, including services
provided under Section 1915(c).
Throughout the chapter, grammar and punctuation changes were made, acronyms used and
standardized, and language reworded for clarity. Renumbering and re-arranging of sections was
necessary.
Entities Financially Affected: This proposed change affects all Medicaid-enrolled providers
delivering specific personal care services. Those provider types (PT) include but are not limited
to: Intermediary Service Organization (PT 83).
Financial Impact on Local Government Unknown at this time.
These changes are effective September 25, 2019.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL20/19 MTL21116
CHAPTER 2600 - INTERMEDIARY CHAPTER 2600 - INTERMEDIARY
SERVICE ORGANIZATION SERVICE ORGANIZATION
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
2601 AUTHORITY
Page I of 3
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
2603.1 SELF-DIRECTED Clarified that all services must be documented
PERSONAL CARE in an approved EVV system.
SERVICES (PCS)
2603.1B INITIATING SELF- Removed obsoleted form titles.
DIRECTED PERSONAL
CARE SERVICES (SD PCS)
2603.1F ELECTRONIC VISIT New section added to highlight the 21st Century
VERIFICATION (EVV) Cures Act requirements. There are two options
in the State of Nevada for use of an EVV
system: state option and data aggregator.
Various data points are required and outlined in
this section.
2603.8 PROVIDER Added the 21st Century Cures Act to the list of
RESPONSIBILITIES local, state and federal regulations that agencies
must comply with.
Added EVV language to mandate the use of an
EVV system for all.
Added language that the Intermediary Services
Organization (ISO) staff must review with the
recipient, legally responsible individual (LRI)
or personal care representative (PCR) the EVV
requirements and recipient participation to
adhere to the 21st Century Cures Act.
Added language that all personal care aides
(PCAs) must understand the EVV requirements
and expectations, including the documentation
of all personal care services in an approved
EVV system.
Removed language regarding records. All
record requirements are listed in the newly
created Section 2603.1F.
2603.9 RECIPIENT Added language to agree to utilize a Medicaid-
RESPONSIBILITIES approved EVV system and to confirm services
electronically, per requirements of the 21st
Century Cures Act.
Page 2 of 3
Manual Section Section Title Background and Explanation of Policy
Changes, Clarifications and Updates
2604.1B PROVIDER Added language to agree to utilize a Medicaid-
RESPONSIBILITIES approved EVV system and to confirm services
electronically, per requirements of the 21st
Century Cures Act.
Added EVV language to mandate the use of an
EVV system for services performed through
the independent contractor model.
Page 3 of 3
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
INTERMEDIARY SERVICE ORGANIZATION
TABLE OF CONTENTS
2600 INTRODUCTION ...........................................................................................................................1
2601 AUTHORITY ..................................................................................................................................1
2602 DEFINITIONS .................................................................................................................................1
2603 POLICY ...........................................................................................................................................1
2603.1 SELF DIRECTED PERSONAL CARE SERVICES (PCS) ...........................................................1
2603.1A ELIGIBILITY CRITERIA...............................................................................................................1
2601.1B INITIATING SELF-DIRECTED PERSONAL CARE SERVICES (SD PCS) ..............................2
2603.1C COVERAGE AND LIMITATIONS ...............................................................................................2
2603.1D AUTHORIZATION PROCESS ......................................................................................................6
2603.1E FLEXIBILITY OF SERVICE DELIVERY ..................................................................................10
2603.1F ELECTRONIC VISIT VERIFICATION (EVV)...........................................................................10
2603.1G CONFLICT OF INTEREST STANDARDS .................................................................................12
2603.2 LEGALLY RESPONSIBLE INDIVIDUAL (LRI) .......................................................................12
2603.3 PERSONAL CARE REPRESENTATIVE (PCR).........................................................................12
2603.4 SERVICES TO CHILDREN .........................................................................................................13
2603.5 PCS FOR RECIPIENTS ENROLLED IN HOSPICE ...................................................................14
2603.6 RESIDENTIAL SUPPORT SERVICES/SUPPORTED LIVING ARRANGEMENT (SLA) .....15
2603.7 SELF-DIRECTED (SD) SKILLED SERVICES ...........................................................................15
2603.7A PROGRAM ELIGIBILITY CRITERIA ........................................................................................15
2603.7B INITIATING SD SKILLED SERVICES ......................................................................................15
2603.7C COVERAGE AND LIMITATIONS .............................................................................................16
2603.7D AUTHORIZATION PROCESS ....................................................................................................19
2603.8 PROVIDER RESPONSIBILITIES ...............................................................................................19
2603.9 RECIPIENT RESPONSIBILITIES AND RIGHTS ......................................................................26
2603.10 ESCORT SERVICES ....................................................................................................................29
2603.10A COVERAGE AND LIMITATIONS .............................................................................................29
2603.10B AUTHORIZATION PROCESS ....................................................................................................30
2603.10C PROVIDER RESPONSIBILLITY ................................................................................................30
2603.11 TRANSPORTATION ....................................................................................................................30
2603.12 REIMBURSEMENT .....................................................................................................................31
2603.13 IMPROPER BILLING PRACTICES ............................................................................................31
2603.14 QUALITY ASSURANCE .............................................................................................................32
2603.15 ADVERSE ACTIONS ...................................................................................................................32
2604 PCS INDEPENDENT CONTRACTOR (IC) MODEL...................................................................1
2604.1 COVERAGE AND LIMITATIONS ...............................................................................................1
2604.1A AUTHORIZATION PROCESS ......................................................................................................1
Page 1 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
2604.1B PROVIDER RESPONSIBILITIES .................................................................................................1
2604.1C RECIPIENT RESPONSIBILITIES .................................................................................................5
2605 HEARINGS .....................................................................................................................................1
2606 CLINICAL DECISION SUPPORT GUIDE ...................................................................................1
Page 2 of 2
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Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
2600 INTRODUCTION
INTERMEDIARY SERVICE ORGANIZATION - (ISO)
An Intermediary Service Organization (ISO) is an entity acting as an intermediary between
Medicaid recipients, who elect the Self-Directed (SD) service delivery model and the Personal
Care Assistants (PCAs) who provide those services. In the SD service delivery model, the recipient
is the managing employer of the PCA and the ISO is the employer of record.
Under the SD service delivery model, Nevada Medicaid allows for the self-direction of two
services through an ISO, Personal Care Services (PCS) and Skilled Services. These services are
provided where appropriate, when medically necessary and within service limitations. Services
may be provided in settings outside the home, including employment sites.
SD PCS and Skilled Services are available to recipients, including those persons with cognitive
impairments, who have the ability and desire to manage their own care. When a recipient does not
have the ability to manage or direct their own care, a Personal Care Representative (PCR) may be
selected on the recipient’s behalf to direct the services.
SD PCS and SD Skilled Services are available to recipients who are not inpatients or residents of
a hospital, Nursing Facility (NF), Intermediate Care Facility for Individuals with Intellectual
Disabilities (ICF/IID), institutions for mental disease or other excluded settings.
This Medicaid Services Manual (MSM), Chapter 2600, contains Nevada Medicaid’s policy for the
SD service delivery model of PCS and Skilled Services provided through an ISO. For policy
pertaining to the Provider Agency service delivery model of PCS, refer to Chapter 3500.
All providers must be contracted with the Division of Health Care Financing and Policy (DHCFP)
in accordance with Chapter 100 and meet certain qualifications and criteria as discussed later in
this chapter.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), with the exception of the areas where Medicaid and NCU policies differ as
documented in the NCU Manual Chapter 1000.
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2601 AUTHORITY
Personal Care Services (PCS) are an optional Medicaid benefit under the Social Security Act
(SSA).
Regulatory oversight:
• SSA 1905(a)(24)
• Title 42, Code of Federal Regulations (CFR) Section 440.167
• Nevada State Plan Attachment 3.1-A (26)
• 21st Century Cures Act, H.R. 34, Sec. 12006 – 114th Congress
• H.R. 6042 – 115th Congress
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MEDICAID SERVICES MANUAL DEFINITIONS
2602 DEFINITIONS
Program definitions can be found in the Medicaid Services Manual (MSM) Addendum.
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2603 POLICY
Nevada Medicaid offers two services that can be self-directed by the recipient or their Personal
Care Representative (PCR) through an Intermediary Service Organization (ISO): PCS and Skilled
Services.
Legally responsible individuals (LRIs) may not be reimbursed for providing Self-Directed (SD)
PCS and/or SD Skilled Services.
2603.1 SELF-DIRECTED PERSONAL CARE SERVICES (PCS)
Self-Directed PCS provide assistance to support and maintain recipients living independently in
their homes. Services may be provided in the home, locations outside the home or wherever the
need for the service occurs. Assistance may be in the form of direct hands-on assistance or cueing
the individual to perform the task themselves, and related to the performance of Activities of Daily
Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Services are based on the
need of the recipient being served, as determined by a Functional Assessment Service Plan (FASP)
approved by the Division of Health Care Financing and Policy (DHCFP). All services must be
performed in accordance with the approved service plan, must be prior authorized and documented
in an approved Electronic Visit Verification (EVV) system. The time authorized for services is
intended to meet the recipient needs within program limits and guidelines, facilitate effective and
efficient service delivery and to augment unpaid and paid supports currently in place. Services are
not intended to replace or substitute services and/or supports currently in place, or to exchange
unpaid supports for paid services.
Services are available to recipients in need of PCS, including persons with cognitive impairments,
who have the ability and desire to manage their own care. When the recipient does not have the
ability to manage their own care, a PCR may do so on their behalf.
This option is utilized by accessing services through an ISO. The ISO is the employer of record
and the recipient is the managing employer for the PCAs that provide the services.
2603.1A ELIGIBILITY CRITERIA
1. The recipient must have ongoing Medicaid or Nevada Check Up (NCU) eligibility for
services;
2. The recipient is not in a hospital, Nursing Facility (NF), Intermediate Care Facility for
Individuals with Intellectual Disabilities (ICF/IID), an institution for the mentally ill or a
licensed residential facility for groups;
3. The recipient does not have an LRI who is available and capable of providing the necessary
care;
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4. The recipient must be able to make choices about ADLs, understand the impact of these
choices and assume responsibility for them or have a PCR who is willing to assist the
recipient in making choices and assumes responsibility for those choices;
5. The recipient or PCR must be cooperative in establishing the need for the provision of
services and comply with the approved service plan;
6. PCS must be determined to be medically necessary as defined by the DHCFP or its
designee; and
7. The recipient or PCR must be willing and capable of managing all tasks related to service
delivery including, but not limited to: recruitment, selection, scheduling, training and
directing PCAs.
2603.1B INITIATING SELF-DIRECTED PERSONAL CARE SERVICES (SD PCS)
The recipient, LRI or their PCR indicates interest in self-directing their PCS by contacting their
local DHCFP District Office or Aging and Disability Services Division (ADSD) Office directly.
1. The DHCFP District Office or local ADSD Office staff provides information to the
recipient or the PCR about the self-directed services available. If the recipient is interested
in self-direction, a list of enrolled Medicaid ISO providers is provided to the recipient to
choose and initiate contact with the ISO of his or her choice.
2. If the recipient elects to self-direct his or her own PCS, the ISO will provide, and the
recipient will sign, the Intermediary Service Organization (ISO) Self-Directed Personal
Care Services Unskilled Only Recipient Agreement.
3. If the recipient elects a PCR to direct his or her care, the ISO will provide, and the PCR
will sign, the Intermediary Service Organization (ISO) Self-Directed Personal Care
Services Unskilled Only Personal Care Representative Agreement.
A signed copy of either agreement should be given to the recipient and/or PCR and the ISO
shall retain the original for their records.
2603.1C COVERAGE AND LIMITATIONS
1. Covered Services
a. Assistance with the following ADLs is a covered service when no LRI is available
and/or capable of providing the necessary service. Services must be directed to the
individual recipient and related to their health and welfare.
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1. Bathing/dressing/grooming.
2. Toileting needs and routine care of an incontinent recipient.
3. Transferring and positioning non-ambulatory recipients from one stationary
position to another, assisting a recipient out of bed, chair or wheelchair,
including adjusting/changing recipient’s position in a bed, chair or
wheelchair.
4. Mobility/Ambulation, which is the process of moving between locations,
including walking or helping the recipient to walk with support of a walker,
cane or crutches or assisting a recipient to stand up or get to his/her
wheelchair to begin ambulating.
5. Eating, including cutting up food. Specialized feeding techniques may not
be used.
b. Assistance with the following IADLs is a covered service when no LRI is available
and/or capable of providing the necessary service. Services must be directed to the
individual recipient and related to their health and welfare. See the service
limitations section of this chapter for specific eligibility criteria to be considered
eligible to receive additional time for assistance with IADLs.
1. Meal preparation, which includes storing, preparing and serving food.
2. Laundry, which includes washing, drying and folding the recipient’s
personal laundry and linens (sheets, towels, etc.). Ironing is not a covered
service.
3. Light housekeeping, which includes changing the recipient’s bed linens,
dusting, or vacuuming the recipient’s living area.
4. Essential shopping, which includes shopping for prescribed drugs, medical
supplies, groceries, and other household items required specifically for the
health and nutrition of the recipient.
2. Service Limitations
To be considered eligible to receive additional time for assistance with IADLs, the recipient
must be eligible to receive PCS for ADLs and have deficits which directly preclude the
individual from completing IADLs. The FASP must demonstrate that the recipient meets
the following criteria:
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a. The recipient has extensive impairments, Level 2 or higher on the FASP in two or
more areas of ADLs; and
b. The recipient has at least one of the deficits listed below:
1. Mobility deficits/impairments of an extensive nature which requires the use
of an assistive device, and directly impacts the recipient’s ability to safely
perform household tasks or meal preparation independently;
2. Cognitive deficits directly impacting the recipient’s ability to safely
perform household tasks or meal preparation independently;
3. Endurance deficits directly impacting the recipient’s ability to complete a
task without experiencing substantial physical stressors;
4. Sensory deficits directly impacting the recipient’s ability to safely perform
household tasks or meal preparation independently.
Assistance with the IADLs may only be provided in conjunction with services for
ADLs, and only when no LRI is available and/or capable.
3. Non-Covered Services
Duplicative services are not considered medically necessary and will not be covered by
Nevada Medicaid. An inquiry or referral for services does not determine the medical
necessity for services.
The following are not covered under PCS and are not reimbursable:
a. A task that the DHCFP or its designee determines could reasonably be performed
by the recipient.
b. Services normally provided by an LRI.
c. Any tasks not included on the recipient’s approved service plan.
d. Services to maintain an entire household, such as cleaning areas of the house not
used solely by the recipient(s).
e. Services provided to someone other than the intended recipient.
f. Skilled care services requiring the technical or professional skill that State statute
or regulation mandates must be performed by a health care professional licensed or
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certified by the State. Services include, but are not limited to, the following:
1. Insertion and sterile irrigation of catheters;
2. Irrigation of any body cavity. This includes both sterile and non-sterile
procedures such as ear irrigation, vaginal douches, and enemas;
3. Application of dressings involving prescription medications and aseptic
techniques, including treatment of moderate or severe skin problems;
4. Administration of injections of fluids into veins, muscles, or skin;
5. Administration of medication, including, but not limited to, the insertion of
rectal suppositories, the application of prescribed skin lotions, or the
instillation of prescribed eye drops (as opposed to assisting with self-
administered medication);
6. Physical assessments;
7. Monitoring vital signs;
8. Specialized feeding techniques;
9. Rectal digital stimulation;
10. Massage;
11. Specialized range of motion (ROM);
12. Toenail cutting;
13. Medical case management, such as accompanying a recipient to a
physician’s office for the purpose of providing or receiving medical
information; and
14. Any task identified within the Nurse Practice Act as requiring skilled
nursing, including Certified Nursing Assistant (CNA) services.
g. Chore services.
h. Companion care, baby-sitting, supervision, or social visitation.
i. Care of pets except in cases where the animal is a certified service animal.
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j. Respite care intended primarily to relieve a member of the recipient’s household, a
family member or caregiver from the responsibility of caring for the recipient.
k. A task the DHCFP determines is within the scope of services provided to the
recipient as part of an assisted living contract, a supported living arrangement
contract or a foster care agreement.
l. Escort services for social, recreational or leisure activities.
m. Transportation of the recipient by the PCA.
n. Any other service not listed under Section 2603.1C.1.
2603.1D AUTHORIZATION PROCESS
PCS authorization requests must be submitted to the QIO-like vendor using the following
procedures:
1. Initial Authorization Requests
The recipient, LRI, PCR or an individual covered under the confidentiality requirements
of Health Insurance Portability and Accountability Act (HIPAA) may contact the QIO-like
vendor to request PCS. Initial requests may not be made by the PCS Agency provider.
The QIO-like vendor validates that the recipient meets PCS criteria, and if so, an enrolled
and trained physical or occupational therapist will then complete an in-home assessment
of the recipient’s functional abilities.
The physical or occupational therapist contacts the recipient to schedule an appointment
for the completion of the FASP. The recipient is responsible for keeping the scheduled
appointment.
Taking into account the physical or occupational therapists’ clinical judgment, the in-home
visit may be followed by an in-clinic visit in order to accurately evaluate the recipient’s
need for PCS.
After completion, the FASP is forwarded to the QIO-like vendor to process.
If the recipient’s request for PCS is approved, the QIO-like vendor will issue a prior
authorization number to the recipient’s chosen ISO Provider.
a. At Risk Recipient Requests
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Upon receipt of a request for an initial FASP, the QIO-like vendor will first
complete a risk assessment over the phone to identify those recipients for whom
PCS are urgent to avoid institutionalization or for whom the service need is the
result of an acute medical condition or loss of a primary caregiver or LRI. The intent
of the telephonic risk assessment is to determine if a recipient is at risk of losing or
being unable to return to a community setting because of the need for PCS.
When a recipient is determined “at risk,” the QIO-like vendor will provide a
temporary service authorization. An enrolled and trained physical or occupational
therapist will then complete an in-home assessment of the recipient’s functional
abilities.
The physical or occupational therapist contacts the recipient to schedule an
appointment for the completion of the FASP. The recipient is responsible for
keeping the scheduled appointment.
Taking into account the physical or occupational therapists’ clinical judgment, the
in-home visit may be followed by an in-clinic visit in order to accurately evaluate
the recipient’s need for PCS. After completion, the FASP is forwarded to the QIO-
like vendor to process.
The selected ISO Provider is notified when a recipient is at risk and agrees, by
accepting the case, to initiate needed services within 24 hours of case acceptance.
The approved service plan and authorization document are faxed to the provider
upon acceptance.
2. Annual Update Authorization Requests
To prevent a break in service, reassessment requests for ongoing services are recommended
to be submitted to the QIO-like vendor at least 60 days, but not greater than 90 days, prior
to the expiration date of the current authorization. The request must be submitted on the
Authorization Request for PCS form (FA-24). The form must include all required recipient
and provider information, as well as the units requested and the dates of service for the
service interval requested.
The QIO-like vendor validates that the request meets PCS criteria. An enrolled and trained
physical or occupational therapist will then complete an in-home assessment of the
recipient’s functional abilities.
The assigned physical or occupational therapist contacts the recipient to schedule an
appointment for the completion of the FASP. The recipient is responsible for keeping the
scheduled appointment.
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Taking into account the physical or occupational therapists’ clinical judgment, the in-home
visit may be followed by an in-clinic visit in order to accurately evaluate the recipient’s
need for PCS. After completion, the FASP is forwarded to the QIO-like vendor to process.
If the request is approved, the QIO-like vendor will issue a prior authorization number to
the ISO Provider submitting the request.
3. Significant Change in Condition or Circumstance Authorization Requests
Requests for reassessment due to significant change in the recipient’s condition or
circumstances must be submitted to the QIO-like vendor as soon as the significant change
is known. A request for reassessment due to significant change in the recipient’s condition
or circumstances must be submitted on the Authorization Request for PCS form (FA-24)
and must be accompanied by documentation from the recipient’s physician or health care
provider. Requesting a reassessment does not guarantee an increase in previously approved
PCS.
a. Significant change in condition may be demonstrated by, for example, an
exacerbation of a previous disabling condition resulting in a hospitalization (within
past 14 days) or a physician’s visit (within past seven days) or a new diagnosis not
expected to resolve within eight weeks.
b. Significant change in circumstances may include such circumstances as absence,
illness, or death of the primary caregiver or LRI.
c. Significant change in condition or circumstances would result in hospitalization or
other institutional placement if PCS are not reassessed to meet the recipient’s
change in service needs.
The QIO-like vendor validates that the request meets PCS criteria and if so, an
enrolled and trained physical or occupational therapist will then complete an in-
home assessment of the recipient’s functional abilities.
The physical or occupational therapist contacts the recipient to schedule an
appointment for the completion of the FASP. The recipient is responsible for
keeping the scheduled appointment.
Taking into account the physical or occupational therapists’ clinical judgment, the
in-home visit may be followed by an in-clinic visit in order to accurately evaluate
the recipient’s need for PCS. After completion, the FASP is forwarded to the QIO-
like vendor to process.
If the request is approved, the QIO-like vendor will issue a prior authorization
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number to the ISO Provider submitting the request.
4. Temporary Service Authorization Requests
When the recipient has an unexpected change in condition or circumstance which requires
short-term (less than eight weeks) modification of the current authorization, a new FASP
is not required.
Such a modification is considered when additional PCS are required for a short time as the
result of an acute medical episode or during a post-hospitalization period.
The following procedure must be followed for all short-term modifications of the approved
service plan:
a. Documentation must be maintained in the recipient’s record of the circumstances
that required the short term modification(s) of the approved authorization;
b. Documentation of the short-term modification(s) of the approved service plan must
be completed and sent to the ISO, and if applicable the appropriate home and
community-based waiver case manager. Documentation must include the
recipient’s name, Medicaid number, and the dates during which the modified
service plan will be in effect; and
c. Upon expiration of the modified service plan, the recipient’s original approved
service plan is automatically reinstated unless a new FASP is completed due to a
significant change in the recipient’s condition or circumstance.
5. One-Time Service Authorization Request
The recipient’s Provider Agency may submit a single-service authorization request, when
the recipient requires an extra visit for an unanticipated need(s), such as bowel or bladder
incontinence. The Provider Agency must document the medical necessity of the services
requested and be the designated provider for the current authorization period. The request
must be submitted to the QIO-like vendor no later than seven business days after the service
is provided. A new FASP is not required in these single-service situations.
6. Mileage Authorization Request
Mileage for travel to and from a recipient’s home or for shopping is not reimbursable to
ISO providers, except in hardship situations in remote or rural areas of the state, where
failure to reimburse mileage expenses would severely limit available providers. Mileage
authorization requests must be submitted in advance to the local DHCFP District Office
for review and may be approved on a case-by-case basis. If approved, the DHCFP District
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Office will notify the QIO-like vendor to issue an authorization number for the approved
mileage to the provider.
2603.1E FLEXIBILITY OF SERVICE DELIVERY
The total weekly authorized hours for PCS may be combined and tailored to meet the needs of the
recipient, as long as the plan does not alter medical necessity. The recipient will determine how to
use the weekly authorized hours on an ongoing basis. Any changes that do not increase the total
authorized hours can be made, for the recipient’s convenience, within a single week without an
additional authorization. Flexibility of services may not take place solely for the convenience of
the provider or PCA.
The following requirements must be met:
1. Upon receipt of an initial service plan from the QIO-like vendor, the provider must meet
with the recipient in person to determine how the total weekly authorized hours will be
provided to meet the individual’s needs.
2. Written documentation of the contact with the recipient regarding provision of services
must be maintained in the recipient’s file.
3. Any change to the approved service plan must be discussed between the provider and the
recipient. This may be done either in person or via the telephone in order to determine how
hours and tasks will be provided.
4. Changes may be requested on a daily and/or weekly basis when necessary to meet a change
in circumstance or condition.
5. The ISO provider must follow their established policies and procedures in order to meet
recipient requests for changes in service delivery in a timely manner.
6. Written documentation of the contact with the recipient regarding any change to the
approved service plan must be maintained in the recipient’s file.
2603.1F ELECTRONIC VISIT VERIFICATION (EVV)
The 21st Century Cures Act requires the use of an EVV system to document services that are
provided for all personal care services under a Medicaid State Plan or waiver program. This
mandate requires provider agencies to use an EVV system to record service delivery visit
information. Nevada Medicaid utilizes the open-system model, procuring a vendor but also allows
agencies to utilize their own EVV system if it meets the 21st Century Cures Act requirements for
documentation.
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All service information must be recorded in an electronic system that interfaces with either a
telephone or an electronic device that generates a timestamp. The provider agency must verify the
EVV record, including any visit maintenance, prior to submitting a claim associated with the EVV
record. All claims must be supported by an EVV entry into an EVV system prior to claim
submission.
Provider Agencies must ensure each Personal Care Attendant (PCA) has a unique identifier
(National Provider Identification – NPI) associated with their worker profile in the EVV system.
1. STATE OPTION
A. The EVV system electronically captures:
1. The type of service performed, based on procedure code;
2. The individual receiving the service;
3. The date of the service;
4. The location where service is provided;
5. The individual providing the service;
6. The time the service begins and ends.
B. The EVV system must utilize one or more of the following:
1. The agency/PCA’s smartphone;
2. The agency/PCA’s tablet;
3. The recipient’s landline telephone;
4. The recipient’s cellular phone (for Interactive Voice Response (IVR)
purposes only);
5. Another GPS-based device as approved by DHCFP.
2. DATA AGGREGATOR OPTION
A. All Provider Agencies that utilize a different EVV system (as approved by the
DHCFP) must comply with all documentation requirements of this chapter and
must utilize the data aggregator to report encounter or claim data.
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1. Appropriate form must be approved by the DHCFP before use of system to
ensure all data requirements are being collected to meet the 21st Century
Cures Act.
2. At a minimum, data uploads must be completed monthly into data
aggregator.
2603.1G CONFLICT OF INTEREST STANDARDS
The DHCFP assures the independence of contracted providers completing the FASPs. Physical
and occupational therapists who complete the FASPs must be an independent third party and may
not be:
1. related by blood or marriage to the individual, or to any paid caregiver of the individual;
2. financially responsible for the individual;
3. empowered to make financial or health-related decisions on behalf of the individual;
4. related by blood or marriage to the Provider who provides PCS to the individual.
The therapist completing the FASP must not have an interest in or employment by a Provider.
Note: To ensure the independence of individuals performing the FASPs, providers are prohibited
from contacting the physical or occupational therapists directly.
2603.2 LEGALLY RESPONSIBLE INDIVIDUAL (LRI)
LRI’s are individuals who are legally responsible to provide medical support. These individuals
include spouses of recipients, legal guardians, and parents of minor recipients, including
stepparents, foster parents and adoptive parents. LRI’s may not be reimbursed for providing PCS.
If the LRI is not capable of providing the necessary services/supports, he or she must provide
verification to the DHCFP’s QIO-like vendor, from a physician, that they are not capable of
providing the supports due to illness or injury. If not available, verification that they are
unavailable due to hours of employment and/or school attendance must be provided. Without this
verification, PCS will not be authorized.
Additional verification may be required on a case by case basis.
2603.3 PERSONAL CARE REPRESENTATIVE (PCR)
A recipient who is unable to direct their own care may opt to utilize a PCR. This individual is
directly involved in the day-to-day care of the recipient, is available to direct care in the home, acts
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on behalf of the recipient when the recipient is unable to direct his or her own personal care services
and assumes all medical liability associated with directing the recipient’s care. A PCR must be a
responsible adult.
For the self-directed service delivery model, the PCR is responsible to hire, manage and schedule
PCAs, assumes responsibility for training and manages all paperwork functions.
The PCR must:
1. effectuate, as much as possible, the decision the individual would make for himself/herself;
2. accommodate the individual, to the extent necessary that they can participate as fully as
possible in all decisions that affect them;
3. give due consideration to all information including the recommendations of other interested
and involved parties; embody the guiding principles of self-determination; and
4. understand that provision of services is based upon mutual responsibilities between the
PCR and the ISO.
A PCR is not eligible to receive reimbursement from Medicaid for this activity. A recipient’s paid
PCA cannot be the recipient’s PCR. The PCR must meet all criteria outlined in Section 2603.9 of
this chapter. In addition, this individual must be present for the provision of care on a consistent
basis, as well as sign daily records. For this reason, it is not allowable for individuals such as a
paid PCA, care coordinator or case manager to assume this role.
The PCR may reside outside the home if frequent contact can be made by the recipient, the ISO,
and other care providers. The PCR must be available to the recipient, the ISO and other care
providers as necessary to fulfill the regular elements of Section 2603.9 of this chapter.
Additionally, if a change in PCR becomes necessary, a new personal care representative agreement
must be completed and kept in the recipient’s provider file. Contact the ISO to make the necessary
changes and to obtain form(s).
2603.4 SERVICES TO CHILDREN
An LRI of a minor child has a duty/obligation to provide the child necessary maintenance,
health/medical care, education, supervision and support. Necessary maintenance includes, but is
not limited to, the provisions of ADLs and IADLs. Payment will not be made for the routine care,
supervision or services normally provided for the child without charge as a matter of course in the
usual relationship among members of the nuclear family.
PCS are not a substitute for natural and informal supports provided by family, friends or other
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available community resources; however, are available to supplement those support systems so the
child is able to remain in the home. LRIs may not be reimbursed by Medicaid for PCS services.
PCS for children with disabilities may be appropriate when there is no legally responsible,
available and capable parent or LRI, as defined by the DHCFP, to provide all necessary personal
care. Documentation verifying that the recipient’s parent or LRI is unavailable or incapable must
be provided upon request. In authorizing PCS services to Medicaid eligible children, the FASP
factors in the age and developmental level of the child as well as the parent or LRI’s availability
and capability to provide the child’s personal care needs.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services are available to
children under the age of 21. EPSDT may provide a vehicle for receiving medically necessary
services beyond the limitations of the PCS benefit. Services must be deemed medically necessary.
Authorization of additional services under EPSDT must take into account the responsibilities of
the LRI and age-appropriate service provision as discussed above.
Housekeeping tasks are limited directly to the provision of PCS, such as cleaning the
bathtub/shower after a bath/shower has been given. Time is allocated under the bathing task and
is not an additional service. When a recipient lives with an LRI, it is the responsibility of the LRI
to perform specific housekeeping tasks, other than those which are incidental to the performance
of Personal Care tasks. This includes, but is not limited to other housekeeping tasks, meal
preparation, essential shopping and escort services.
A child’s LRI must be present during the provision of services. If the LRI cannot be present during
the provision of services, a PCR designated by the LRI, other than the PCA, must be present during
the time services are being provided.
All other policies in this chapter apply.
2603.5 PCS FOR RECIPIENTS ENROLLED IN HOSPICE
PCS may be provided for recipients enrolled in hospice when the need for PCS is unrelated to the
terminal condition, and the personal care needs exceed the PCS provided under the hospice benefit.
If a recipient enrolls in hospice, the DHCFP or its designee will conduct an evaluation of the
individual's comprehensive personal care needs to document any needs not met by hospice and
which may be provided by the PCA. The evaluation will differentiate between personal care needs
unrelated to the terminal condition and those needs directly related to hospice, clearly documenting
the total personal care needs. PCS provided under hospice will be subtracted from the total
authorized PCS hours.
The PCS provided by a PCA to a recipient because of needs unrelated to the terminal condition
may not exceed program limits and guidelines.
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2603.6 RESIDENTIAL SUPPORT SERVICES/SUPPORTED LIVING ARRANGEMENT (SLA)
Recipients on the Home and Community Based Waiver for Individuals with Intellectual
Disabilities and receiving residential support services through a SLA may receive State Plan PCS
if the services are determined to be medically necessary and are non-duplicative of the residential
support services being provided. The FASP will be completed factoring in the residential support
services.
2603.7 SELF-DIRECTED (SD) SKILLED SERVICES
SD Skilled Services are skilled services provided to a recipient by an unlicensed personal care
assistant. This option is offered by Nevada Medicaid under the authority of NRS 629.091, where
a provider of healthcare can authorize an unlicensed personal care assistant to provide certain
specific medical, nursing or home health services, subject to a number of conditions. All skilled
services that are self-directed and provided by an unlicensed personal care assistant require a
doctor’s order and prior authorization.
2603.7A PROGRAM ELIGIBILITY CRITERIA
In addition to the requirements listed in Section 2603.1A, the following requirements must be met
to be determined eligible for SD Skilled Services:
1. The primary physician has determined the condition of the person with a disability is stable
and predictable;
2. The primary physician has determined the procedures involved in providing the services
are simple and the performance of such procedures by the personal care assistant does not
pose a substantial risk to the person with a disability;
3. A provider of healthcare has determined the personal care assistant has the knowledge,
skill and ability to perform the services competently;
4. The PCA agrees with the provider of health care to refer the person with a disability to the
primary physician in accordance with NRS 629.091;
5. Services must be provided in the presence of the LRI or PCR if the recipient is unable to
direct their own care, as in the case of a minor or a cognitively impaired adult, in
accordance with NRS 629.091.
2603.7B INITIATING SD SKILLED SERVICES
The recipient or their PCR indicates interest in the SD Skilled Services Model by contacting their
local DHCFP or ADSD Office directly.
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1. The local DHCFP or ADSD Office staff provides information to the recipient, the LRI or
the PCR about the self-directed services available. If the recipient is interested in self-
direction, a list of enrolled Medicaid ISO providers is provided to the recipient to choose
and initiate contact with the ISO of his or her choice.
2. The ISO will provide the recipient with the Authorization Request for Self-Directed Skilled
Services Authorization Form (FA-24C) for completion.
3. The ISO must fax the completed Authorization Request for Self-Directed Skilled Services
Authorization Form (FA-24C) and all necessary supporting medical documentation
specific to the request to the QIO-like vendor for processing.
2603.7C COVERAGE AND LIMITATIONS
1. COVERED SERVICES
SD Skilled Services may be approved for recipients who are chronically ill or disabled who
require skilled care to remain at home. The following criteria must be met:
a. The service(s) are medically necessary and required to maintain or improve the
recipient’s health status;
b. The service(s) performed must be one that a person without a disability usually and
customarily would personally perform without the assistance of a provider of health
care;
c. The service(s) must be sufficient in amount, duration and scope to reasonably
achieve its purpose;
d. The service(s) must have prior authorization.
2. Non-Covered Services
In addition to the non-covered services listed in Section 2603.1C3 reimbursement is not
available for:
a. Services provided in a physician’s office, clinic or other outpatient setting;
b. SD Skilled Services provided in the absence of an LRI or PCR for those individuals
who are not able to direct their own care; or
c. Services normally provided by a legally responsible individual or other willing and
capable caregiver.
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3. Medical Criteria
Services must be based on supporting documentation provided by the provider of health
care that describes the complexity of the recipient’s care and the frequency of skilled
interventions. Services must be appropriate, reasonable and necessary for the diagnosis and
treatment of the recipient’s illness or injury within the context of the recipient’s unique
medical condition and the standard of practice within the community.
a. The following criteria are used to establish the appropriate complexity of skilled
interventions. The DHCFP or its designee makes the final determination regarding
the reasonable amount of time for completion of a task based on supporting
documentation, standards of practice, and/or a home health evaluation, as indicated.
1. Limited Skilled Interventions - Interventions that when performed in
combination would not reasonably exceed four hours per week. Limited
skilled interventions include, but are not limited to: obtaining vital signs or
weights; nail care; suprapubic catheter care; attaching a colostomy bag on a
wafer or other attachment device that already adheres to the skin; weekly
bowel care; skin care, or catheter care; application of opsite, duoderm, or
similar product to an abrasion or Stage I wound; application of oxygen;
monitoring of oxygen saturation levels; nebulizer treatments performed no
more frequently than once daily; once a day glucose monitoring; medication
set up; administration of non-complex oral medications; suppositories;
enemas; subcutaneous or intramuscular injections; eye drops, nose drops,
and/or ear drops; application of a medicated patch, or application of a
prescription ointment or lotion to fewer than two body parts.
2. Routine Skilled Intervention - Intervention that by its inherent complexity
combined with the frequency in the recipient’s care routine can reasonably
be expected to exceed four hours on a weekly basis. Routine skilled
interventions include, but are not limited to: bowel care performed more
than once a week; daily pulmonary treatments; nebulizer treatments done
more than once a day; catheter changes; Stage II to IV wound care; digital
stimulation; colostomy care that includes both attaching a colostomy bag on
a wafer or other attachment device that already adheres to the skin and
changing the wafer or attachment device; multiple straight catheterizations
daily; and complex medication administration. Complex medication
administration includes, but is not limited to, administration of six or more
medications on a different frequency schedule, administration of
medications through a feeding tube, and glucose testing and insulin
administration occurring more than once a day.
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3. Highly Complex Intervention - Intervention that by its inherent complexity
combined with the frequency in the recipient’s care routine can reasonably
be expected to exceed one and one-half or more hours per day to perform.
Highly complex interventions may include but are not limited to: tube
feedings; special swallow techniques; peritoneal dialysis; Stage III or IV
wound care; or care of Stage II to Stage IV wounds in multiple locations. A
physician must provide a written rationale for the time requested to perform
this intervention.
b. Interventions performed on a monthly frequency are not included in calculating the
total number of interventions being performed unless the performance of this task
requires two or more hours and a physician has provided a written rationale to
explain this request. If authorized, this intervention will equal one routine
intervention.
c. Additional major procedures not listed here may be considered in determining the
complexity of skilled intervention. The DHCFP’s QIO-like vendor, or their
designee, should be contacted with information on what the procedure is and the
amount of skilled time needed to perform this procedure or task.
d. Clinical Decision Support Guide – See Section 2606. The Clinical Decision
Support Guide identifies the benefit limitations for individual recipients based upon
supporting documentation provided by the physician that describes the complexity
of the recipient’s care and the frequency of skilled interventions. Services must be
appropriate, reasonable and necessary for the diagnosis and treatment of the
recipient’s illness or injury within the context of the recipient’s unique medical
condition and the standard of practice within the community.
The QIO-like vendor reviews the request and supporting documentation utilizing
criteria identified in the clinical decision support guide. The QIO-like vendor will
use these criteria to review for medical necessity and utilization control procedures.
4. Crisis Override
The SD Skilled Services benefit allows, in rare crisis situations, a short-term increase of
service hours beyond standard limits. A crisis situation is one that is generally
unpredictable and puts the individual at risk of institutionalization without the provision of
additional hours.
a. Coverage and Limitations
1. Additional services may be covered up to 20% above program limits.
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2. Additional services are limited to one 60-day interval in a three-year period
(calendar years).
The provider must contact the DHCFP QIO-like vendor with information in writing
regarding the crisis situation and need for additional hours.
2603.7D AUTHORIZATION PROCESS
Prior authorization must be obtained before services can be provided. SD Skilled Services are
authorized by the DHCFP’s QIO-like vendor. Services must be requested using Code T1019 plus
a TF modifier to represent SD Skilled Services If the TF modifier is not requested, reimbursement
for SD Skilled Services will not be approved and subsequent claims will be denied.
1. The ISO must fax the completed Authorization Request for Self-Directed Skilled Services
Authorization Form (FA-24C) and all necessary supporting medical documentation
specific to the request to the QIO-like vendor for processing.
2. The QIO-like vendor reviews the request and supporting documentation utilizing criteria
identified in the Clinical Decision Support Guide. The QIO-like vendor will use these
criteria to review for medical necessity and utilization control procedures.
3. Prior authorizations are specific to the recipient, a provider, specific services, established
quantity of units and for specific dates of service.
4. Prior authorization is not a guarantee of payment for the service; payment is contingent
upon passing all edits contained with the claims payment process; the recipient’s continued
Medicaid eligibility; and the ongoing medical necessity for the service being provided.
2603.8 PROVIDER RESPONSIBILITIES
ISO providers shall ensure that services to Medicaid and NCU recipients are provided in
accordance to the individual recipient’s approved service plan and in accordance with the
conditions specified in this chapter and the Medicaid Provider Contract.
Additionally, all ISO providers have the following responsibilities:
1. Certification and/or Licensure
In order to enroll as a Nevada Medicaid ISO provider, all providers must be certified and/or
licensed by the DPBH as an ISO or an Agency to Provide Personal Care in the Home and
certified as an ISO.
Providers must comply with licensing requirements and maintain an active certification
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and/or license at all times.
2. Provider Enrollment
To become a Nevada Medicaid ISO provider, the provider must enroll with the QIO-like
vendor as an Intermediary Service Organization (PT 83).
The provider must meet the conditions of participation as stated in the MSM Chapter 100.
The provider must comply with all local, state and federal regulations and applicable
statutes, including but not limited to Nevada Revised Statutes Chapters 449 and 629, the
Internal Revenue Service (IRS), Federal Insurance Contributions Act (FICA),
Occupational Safety and Health Act (OSHA), the Health Insurance Portability and
Accountability Act (HIPAA) and the 21st Century Cures Act.
3. Employer of Record
The ISO is the employer of record for the PCAs providing services to a Medicaid recipient
who chooses the Self-Directed service delivery model. The ISO shall not serve as the
managing employer of the PCA.
4. Electronic Visit Verification (EVV)
Utilize an EVV system that meets the requirements of the 21st Century Cures Act, to
electronically document the PCS provided to Medicaid recipients served by a Medicaid
provider.
5. Recipient Education
The ISO may initiate education of the recipient or PCR in the skills required to act as the
managing employer and self-direct care. This may include training on how to recruit,
interview, select, manage, evaluate, dismiss and direct the PCA in the delivery of
authorized services. Education must begin with an accepted recipient referral and continue
throughout the duration of the service provision. Verification of recipient education must
be maintained in the recipient’s file.
6. Personal Care Assistant (PCA) List
The ISO may, upon request, provide a list of PCAs to recipients, their LRI or their PCR.
The recipient, their LRI or PCR may reference this list in recruiting potential PCAs.
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7. Backup List
The ISO shall maintain and make available to the recipient, their LRI or PCR, on request,
a list of qualified PCAs that may be able to provide back-up services. The ISO is not
responsible for arranging or ensuring back-up care is provided as this is the responsibility
of the recipient, their LRI or PCR.
8. Backup Plan
The ISO may, upon request, assist the recipient in developing a written back-up plan to
address personal care service needs in the event that care is interrupted. This may include
providing a current list of PCAs available to assist in providing appropriate back-up
services. The ISO is responsible for documenting the back-up plan that is developed but is
not responsible for arranging or ensuring back-up care is provided, as this is the
responsibility of the recipient, their LRI or PCR.
9. Medicaid and Nevada Check Up (NCU) Eligibility
Verification of Medicaid or NCU eligibility on a monthly basis is the responsibility of the
ISO.
10. Prior Authorization
The ISO shall obtain prior authorization for services prior to the provision of services. All
initial and ongoing services must be prior authorized by the DHCFP’s QIO-like vendor.
Services which have not been prior authorized will not be reimbursed.
11. Service Initiation
Prior to the start of services, the ISO staff must review and document with the recipient,
their LRI or PCR all components of the MSM Chapter 2600 and the following items:
a. The ISO may initiate education of the recipient or PCR in the skills required to act
as managing employer and self-direct care. This may include training on how to
recruit, interview, select, manage, evaluate, dismiss and direct the PCAs in the
delivery of authorized services. Documentation of this must be maintained in the
recipient’s file.
b. The ISO must review with the recipient, their LRI or PCR the approved service
plan, weekly hours, tasks to be provided and EVV requirements and recipient
participation.
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c. The ISO must review with the recipient, their LRI or PCR his or her responsibility
to establish the PCA’s schedule and to establish his or her own back-up plan.
d. The ISO provider must review with the recipient, their LRI or PCR the differences
between the Agency and the SD Service Delivery Model.
12. PCS Not Permitted
The following are some of the activities that are not within the scope of PCS and are not
permitted. This is not an all-inclusive list.
a. Skilled Care Services requiring the technical or professional skill that State statute
or regulation mandates must be performed by a health care professional licensed or
certified by the State. PCS services must never be confused with services of a higher
level that must be performed by persons with professional training and credentials;
b. Increasing and/or decreasing time authorized on the approved service plan;
c. Accepting or carrying keys to the recipient’s home;
d. Purchasing alcoholic beverages for use by the recipient or others in the home unless
prescribed by the recipient’s physician;
e. Making personal long-distance telephone calls from the recipient’s home;
f. Performing tasks not identified on the approved service plan;
g. Providing services that maintain an entire household;
h. Loaning, borrowing, or accepting gifts of money or personal items from the
recipient;
i. Accepting or retaining money or gratuities for any reason other than that needed
for the purchase of groceries or medications for the recipient; and
j. Care of pets, except in the case where the animal is a certified service animal.
13. Supervision
The ISO must review with the recipient, their LRI or PCR, the recipient’s approved service
plan. This must be done each time a new service plan is approved. The ISO must clarify
with the recipient, their LRI or PCR, the recipient’s needs and the tasks to be performed.
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Documentation of the approved service plan review must be maintained in the recipient’s
record.
All PCAs must understand the EVV requirements and expectations, including the
documentation of all personal care services in an approved EVV system.
14. Provider Liability
Provider liability responsibilities are included in the Medicaid and NCU Provider Contract.
15. Notification of Suspected Abuse or Neglect
State law requires that persons employed in certain capacities make a report to a child
protective service agency, an aging and disability services agency or law enforcement
agency immediately, but in no event later than 24 hours after there is reasonable cause to
believe that a child, adult or older person has been abused, neglected, exploited, isolated or
abandoned.
For recipients under the age of 18, the Division of Child and Family Services (DCFS) or
the appropriate county agency accepts reports of suspected child abuse and neglect. For
adults’ age 60 and over, the Aging and Disability Services Division (ADSD) accepts
reports of suspected abuse, neglect or self-neglect, exploitation or isolation. For all other
individuals (other age groups) contact local law enforcement.
The DHCFP expects that all providers be in compliance with the intent of all applicable
laws.
16. Serious Occurrences
The ISO must report all serious occurrences involving the recipient, the PCA, or affecting
the provider’s ability to deliver services. The Nevada DHCFP Serious Occurrence Report
must be completed within 24 hours of discovery and submitted to the local DHCFP District
Office. If the recipient is on a Home and Community Based Waiver (HCBW), the
notification shall be made directly to the HCBW case manager’s ADSD office.
Reportable serious occurrences involving either the recipient or PCA include, but are not
limited to the following:
a. Suspected physical or verbal abuse;
b. Unplanned hospitalization or ER visit;
c. Neglect of the recipient;
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d. Exploitation;
e. Sexual harassment or sexual abuse;
f. Injuries or falls requiring medical intervention;
g. An unsafe working environment;
h. Any event which is reported to Child or Elder Protective Services or law
enforcement agencies;
i. Death of the recipient;
j. Loss of contact with the recipient for three consecutive scheduled days;
k. Medication errors;
l. Theft;
m. Medical Emergency; or
n. Suicide Threats or Attempts.
17. Health Insurance Portability and Accountability Act (HIPAA), Privacy and Confidentiality
Information on HIPAA, privacy and confidentiality of recipient records and other protected
health information is found in MSM Chapter 100.
18. Direct Marketing
Providers shall not engage in any unsolicited direct marketing practices with any current
or potential Medicaid PCS recipient or their LRI. All marketing activities conducted must
be limited to the general education of the public or health care providers about the benefits
of PCS. Such literature may be printed with the company’s logo and contact information,
however, this literature may not be distributed, unsolicited, to any current or potential
Medicaid PCS recipient(s)or their LRI. The provider may not, directly or indirectly, engage
in door-to-door, telephone, direct mail, email or other cold-call marketing activities.
The provider must ensure that marketing, including plans and materials, are accurate and
do not mislead, confuse or defraud current or potential recipients. Statements considered
inaccurate, false or misleading include, but are not limited to, any assertion or statement
that:
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a. the recipient must enroll with the provider in order to obtain benefits or in order not
to lose benefits; or
b. the provider is endorsed, certified or licensed by the DHCFP. Compensation or
incentives of any kind which encourage a specific recipient to transfer from one
provider to another are strictly prohibited.
19. Records
The provider must maintain medical and financial records, supporting documents, and all
other records relating to services provided. The provider must retain records for a period
pursuant to the State records retention policy, which is currently six years from the date of
payment for the specified service.
a. If any litigation, claim or audit is started before the expiration of the retention period
provided by the DHCFP, records must be retained until all litigation, claims or audit
findings have been finally determined.
1. The Provider must maintain all required records for each PCA employed by
the agency, regardless of the length of employment.
2. The Provider must maintain the required record for each recipient who has
been provided services, regardless of length of the service period.
b. The PCA’s supervisor (or other designated agency representative) must review and
approve all service delivery records completed by the PCA. The provider will only
be paid for the hours and tasks authorized on the approved service plan, which are
clearly documented as being provided on the service delivery records. This includes
electronic service delivery records.
20. Documentation Requirements
In addition to all of the above responsibilities, if Self-Directed Skilled Services are
provided it is the responsibility of the ISO to ensure all requirements of NRS 629.091 are
met in order to receive reimbursement for these services. All required documentation must
be made available to the DHCFP or its designee immediately upon request.
In order to ensure the safety and well-being of the recipient, documentation specific to this
option is required and must be signed by all applicable individuals as identified on each
form and updated annually with any significant change in condition. Documentation must
be maintained in the recipient’s file.
All service delivery records completed by the PCA must be reviewed. The provider will
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only be paid for the hours and tasks which are provided according to the approved service
plan and are documented on the service delivery records. This includes electronic service
delivery records.
21. Discontinuation of Provider Agreement
a. In the event that a Provider decides to discontinue providing PCS to any of their
service areas, the Provider shall:
1. provide all current Medicaid recipients with written notice at least 30
calendar days in advance of service discontinuation advising the recipient
will need to transfer to a Medicaid contracted PCS provider. A current list
of Medicaid contracted PCS providers must be obtained from the QIO-like
vendor and included with the notification;
2. provide the DHCFP with a copy of the written notice of intent to discontinue
services, including a list of the affected recipients, at least 30 calendar days
in advance of service discontinuation; and
3. continue to provide services through the notice period or until all recipients
are receiving services through another Provider, whichever occurs sooner.
b. In the event that the DHCFP discontinues the contractual relationship with a
Provider, for any reason, the Provider shall:
1. within five calendar days of receipt of the DHCFP notification to terminate
the contractual relationship, send written notification to all their current
Medicaid recipients advising the recipient will need to transfer services to a
Medicaid contracted PCS provider. A current list of Medicaid contracted
PCS providers must be obtained from the QIO-like vendor and be included
in this notification.
2. provide reasonable assistance to recipients in transferring services to
another provider.
Providers who fail to satisfactorily meet the requirements discussed above shall be
prohibited from participation in a new application for any other PCS provider
agreement for a period of not less than one year.
2603.9 RECIPIENT RESPONSIBILITIES AND RIGHTS
1. Recipient Responsibilities
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Participation in the SD service delivery option is completely voluntary and failure to
comply with any of the responsibilities listed below may result in termination of the
recipient’s participation in this service delivery option.
The recipient, their LRI or PCR will:
a. notify the provider of changes in Medicaid or NCU eligibility.
b. notify the provider of current insurance information, including the carrier of other
insurance coverage, such as Medicare.
c. notify the provider of changes in medical status, service needs, address and location
or in changes of status of legally responsible individual(s) or PCR.
d. treat all staff appropriately.
e. agree to utilize an approved EVV system for the Medicaid services being received
from the ISO.
f. confirm services were provided by electronically signing or initialing, as
appropriate per service plan, the EVV record that reflects the service rendered. If
IVR is utilized, a vocal confirmation is required.
g. establish a backup plan in case a PCA is unable to provide services at the scheduled
time.
h. not request a PCA to work more than the hours authorized on the approved service
plan.
i. not request a PCA to work or clean for non-recipients.
j. not request a PCA to provide services not on the approved service plan.
k. comply with all Medicaid policies and procedures as outlined in the MSM, all
relevant chapters, including Chapters 100 and 3300.
l. recruit, interview, select, schedule, direct and dismiss PCAs.
m. develop a backup plan in the event of failure to maintain continuous coverage of
regularly scheduled PCAs.
n. Verify services were provided according to the approved service plan and/or
doctor’s orders by, whenever possible, signing or initialing the PCA documentation
of the exact date and time the PCA was in attendance and providing services.
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o. inform the PCA of the existence of advance directive documents, if these are
available, and provide a copy to the ISO, if appropriate.
p. notify the ISO and the recipient’s case manager, if applicable, or the local DHCFP
District Office when the recipient, their LRI or PCR no longer wish to self-direct
their services and request care be provided through a provider agency.
q. cooperate with the DHCFP or its designee in conducting compliance reviews,
investigations or audits.
r. specify any and all specialized training requirements of the PCA and assure that the
specified training has been received.
s. obtain re-certification for continued services according to policy. This may require
that a FASP and/or a new authorization request for Self-Directed Skilled Services
Form be completed.
In addition to the responsibilities identified above, the following requirements are
applicable to all recipients that opt to self-direct their Skilled Services.
t. The recipient, LRI and/or PCR are responsible to cooperate fully with the physician
and other healthcare providers in order to establish compliance with the
requirements set forth in NRS 629.091.
u. When the recipient desires to provide specialized training and is able to state and
convey his/her own needs and preferences to the PCA, information must be
documented in the recipient’s file identifying the specific training the recipient has
provided.
v. The authorization request for Self-Directed Skilled Services Form is required and
must be completed by a qualified provider for each personal care assistant who will
perform the skilled services.
2. Recipient Rights
Every Medicaid and NCU recipient receiving PCS or SD Skilled Services, their LRI or
PCR, has the right to:
a. request a change in service delivery model from the Self-Directed model provided
through an ISO to the Provider Agency model for their PCS or a Home Health
Agency for their skilled services;
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b. receive considerate and respectful care that recognizes the inherent worth and
dignity of each individual;
c. participate in the development process and receive an explanation of authorized
services;
d. receive a copy of the approved service plan;
e. contact the local DHCFP District Office, with questions, complaints, or for
additional information;
f. receive assurance that privacy and confidentiality about one's health, social,
domestic and financial circumstances will be maintained pursuant to applicable
statutes and regulations;
g. know that all communications and records will be treated confidentially;
h. expect all providers, within the limits set by the approved service plan and within
program criteria, to respond in good faith to the recipient's reasonable requests for
assistance;
i. receive information upon request regarding the DHCFP’s policies and procedures,
including information on charges, reimbursements, FASP determinations and the
opportunity for fair a hearing;
j. request a change of provider;
k. have access, upon request, to his or her Medicaid recipient files;
l. request a Fair Hearing if there is disagreement with the DHCFP’s action(s) to deny,
terminate, reduce or suspend services; and
m. receive upon request the telephone number of the Office for Consumer Health
Assistance.
2603.10 ESCORT SERVICES
Escort services may be authorized in certain situation for recipients who require a PCA to perform
an approved PCS task en route to or while obtaining Medicaid reimbursable services.
2603.10A COVERAGE AND LIMITATIONS
Escort services may be authorized as a separate billable service when all the following conditions
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are met:
1. The needed PCS is currently an authorized task on the approved service plan and
will be provided during the course of the visit.
2. The PCS required are an integral part of the visit. Covered personal care tasks
would include undressing/dressing, toileting, transferring/positioning, ambulation
and eating. For example, transferring a recipient on and off an examination table is
an integral part of a physician visit.
3. An LRI is unavailable or incapable of providing the personal care task en route to
or during the appointment.
4. Staff at the site of the visit (surgery center, physician’s office, clinic setting,
outpatient therapy site or other Medicaid reimbursable setting) is unable to assist
with the needed personal care task.
2603.10B AUTHORIZATION PROCESS
1. The provider must contact the QIO-like vendor for prior authorization for escort services.
2. Service should be requested as a single service authorization request. The provider must
document the medical necessity of the services.
3. A new FASP is not required in this situation.
2603.10C PROVIDER RESPONSIBILITY
1. The provider must verify that all conditions above are met when asking for an escort
services authorization.
2. The provider must include all the above information when submitting the prior
authorization request, including the date of service and the amount of time requested. The
provider must comply with all other policies in Section 2603.1D of this chapter.
2603.11 TRANSPORTATION
Transportation of the recipient in a provider’s vehicle, or the PCA’s private vehicle or any other
vehicle is not a covered service and is not reimbursable by the DHCFP. Recipients who choose to
be transported by the PCA do so at their own risk.
Refer to MSM Chapter 1900, Transportation Services, for requirements of the DHCFP medical
transportation program. Medicaid may reimburse for necessary and essential medical
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transportation to and from medical providers.
2603.12 REIMBURSEMENT
Medicaid reimbursement is made directly to the Provider Agency for services billed using Service
Code T1019 for PCS or T1019TF for SD Skilled. The reimbursement rate is based on a contracted
rate which takes into consideration and includes the costs associated with doing business.
Consequently, separate reimbursement is not available for the following: Time spent completing
administrative functions such as supervisory visits, scheduling, chart audits, surveys, review of
service delivery records and personnel consultant;
A. The cost of criminal background checks and TB testing;
B. Travel time to and between recipients’ home;
C. The cost of basic training, in-service requirements and the CPR and First Aid requirement;
D. Routine supplies customarily used during the course of visits, including but not limited to
non-sterile gloves.
2603.13 IMPROPER BILLING PRACTICES
Providers must bill only for the dates when services were actually provided, in accordance with
the appropriate billing manual.
Any provider found by the State or its agent(s) to have engaged in improper billing practices,
without limitations, may be subject to sanctions including recoupment, denial or termination from
participation in Nevada Medicaid.
The findings and conclusions of any investigation or audit by the DHCFP shall not be construed
as prohibiting any criminal or civil investigations, actions or other claims for relief that may be
available to any party under applicable federal, state or local laws.
Improper billing practices may include, but are not limited to:
A. submitting claims for unauthorized visits;
B. submitting claims for services not provided, for example billing a visit when the recipient
was not at home but the PCA was at the recipient’s residence;
C. submitting claims for visits without documentation to support the claims billed.
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1. Acceptable documentation for each visit billed shall include the nature and extent
of services, the care provider’s signature, the recipient’s signature, the month, day,
year and time in and out of the recipient’s home. Providers shall submit or produce
such documentation upon request by the DHCFP staff;
D. submitting claims for unnecessary visits or visits that are in excess of amount, scope and
duration necessary to reasonably achieve its purpose;
E. billing for the full authorized number of units when they exceed the actual amount of service
units provided; or submitting claims for PCS provided by an unqualified paid PCA.
F. submitting claims for PCS provided by an unqualified paid PCA.
Any PCS or other provider who improperly bills the DHCFP for services rendered is subject to all
administrative and corrective sanctions and recoupments listed in the MSM Chapter 3300. All
Medicaid overpayments are subject to recoupment.
Any such action taken against a provider by the DHCFP has no bearing on any criminal liability
of the provider.
2603.14 QUALITY ASSURANCE
The DHCFP and/or ADSD may conduct reviews, announced or unannounced, to evaluate the
provider’s compliance with this chapter and any other regulatory requirement.
These reviews may consist of, but are not limited to, a desk review by the DHCFP and/or ADSD
staff and/or an onsite review. Providers must cooperate with the review process. Additionally,
reviews may be conducted to verify that providers meet requirements established for each service,
to ensure services are being provided and billed for accordingly and that claims for those services
are paid in accordance with the State Plan, this chapter and all federal and state regulations.
Reviews may also be conducted to ensure the health and welfare, service satisfaction and freedom
of choice of the recipients receiving PCS and/or Skilled Services.
2603.15 ADVERSE ACTIONS
An adverse action refers to a denial, termination, reduction or suspension of an applicant or
recipient’s request for services or eligibility determination.
For the purposes of this Chapter, the DHCFP or their designee may take adverse action when:
A. the recipient is not eligible for Medicaid;
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B. the recipient does not meet the PCS eligibility criteria;
C. the recipient, their LRI or the PCR refuses services or is non-cooperative in the
establishment or delivery of services;
D. the recipient, their LRI or the PCR refuses to accept services in accordance with the
approved service plan;
E. all or some services are no longer necessary as demonstrated by the FASP;
F. the recipient’s needs can be met by an LRI;
G. the recipient’s parent and/or legal guardian is responsible for the maintenance, health care,
education and support of their child;
H. services requested exceed service limits;
I. services requested are non-covered benefits (refer to 2603.1C.3);
J. another agency or program provides or could provide the services.
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2604 PCS INDEPENDENT CONTRACTOR (IC) MODEL
An individual may independently contract with the DHCFP to provide SD Skilled Services and
PCS in a recipient’s residence or in a location outside the home, except as excluded per 1905(a)(24)
of the Social Security Act. An individual may only apply to the DHCFP to become a PCS IC when
the need and preference for SD Skilled Services exists, where no PCS Agency or ISO is available
and when the absence of an IC would constitute a hardship for an eligible recipient. A hardship
situation is one in which the recipient is considered to be “at risk.”
An application to become an IC with Nevada Medicaid is made through the local DHCFP District
Office. Each IC providing PCS must comply with all PCS program criteria. The local DHCFP
District Office will inform the potential IC of program criteria, training requirements, etc. The
local DHCFP District Office will assist in processing the IC’s application which must be submitted
to the QIO-like vendor. Once the IC is approved, the local DHCFP District Office will notify the
appropriate ADSD case manager who will provide the IC with the recipient’s service plan and
authorized service hours.
2604.1 COVERAGE AND LIMITATIONS
All of the policies discussed in the Section 2603.1C and 2603.7C of this chapter apply to the IC
option.
2604.1A AUTHORIZATION PROCESS
Prior authorization must be obtained before services can be provided. PCS is authorized by the
ADSD case manager. The IC shall contact the recipient’s ADSD case manager to obtain prior
authorization for services.
2604.1B PROVIDER RESPONSIBILITIES
The IC must assist eligible Medicaid recipients with ADLs and IADLs, as identified on the
individual recipient’s service plan and in accordance with the conditions specified in this Chapter
and the Medicaid Provider Contract, as well as SD Skilled Services pursuant to NRS 629.091.
In order to ensure the safety and well-being of the recipient, documentation specific to the SD
Skilled Services option of the program is required and must be signed by all applicable individuals
as identified on each form, and updated annually and/or with any significant change in condition.
Current forms are available upon request from the DHCFP or the QIO-like vendor.
1. Provider Enrollment.
To become a Nevada Medicaid provider, the IC must enroll with the QIO-like vendor as
a PT 58, Specialty 189.
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2. Electronic Visit Verification (EVV)
Utilize an EVV system that meets the requirements of the 21st Century Cures Act, to
electronically document the PCS provided to Medicaid recipients served by a Medicaid
provider.
3. The following policies apply to the IC option:
a. The IC must verify Medicaid Eligibility monthly.
b. The Provider shall provide PCS in ADLs and IADLs which are medically necessary
and approved on the service plan. The services provided must not exceed the PCA
scope of services or limitations defined elsewhere in the MSM.
c. The IC must review the recipient's service plan with the recipient or their PCR prior
to the initiation of services. The IC shall review all allowable tasks, excluded
activities and recipient back up plan. Documentation must be maintained in the
recipient’s file that this requirement has been met.
d. 24-Hour Accessibility.
The IC should have reasonable phone access either through a cell phone or home
telephone for contact by the recipient or PCR. The IC is not required to maintain
24-hour phone accessibility.
e. Backup Mechanism.
The IC has no responsibility to establish a back-up mechanism in the event of an
unanticipated, unscheduled absence because this is a recipient or PCR
responsibility. The IC must notify the recipient at least two weeks in advance of
anticipated time off (vacation, elective surgery etc.).
f. Referral Source Agreement.
The IC has no responsibility to establish a referral source agreement as there are no
provider agencies within the immediate geographical area.
g. Administrative Functions
The IC is responsible for complying with all state regulations regarding
independent contractors.
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h. Service Initiation.
Prior to initiation of services and periodically as needed, the IC must review with
the recipient or PCR, the following:
1. Advanced Directive, including their right to make decisions about their
health care, and the right to execute a living will or grant power of attorney
to another individual. Refer to MSM Chapter 100 for further information.
2. Procedure to be followed when a PCA does not appear at a scheduled visit
or when an additional visit is required.
3. The non-covered service/tasks of the PCS program.
4. The procedure and form used to verify PCA attendance.
5. The recipient’s service plan or any changes in the service plan, including
the following:
a. Authorized service hours;
b. PCA’s schedule;
c. PCA’s assigned tasks and pertinent care provided by informal
supports; and
6. EVV requirements and recipient participation.
i. Supervision
The IC is not required to meet the supervisory requirement of the PCS agency. As
an IC the provider is required to perform all PCA services and document all services
in an approved EVV system.
j. Training
The IC may be required to obtain training in the following areas, if directed to do
so by the recipient.
1. Basic Training - Basic training shall involve community resources, such as
public health nurses, home economists, physical therapists and social
workers. An outline of content of each subject shall be maintained by the
IC.
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Basic training shall be a minimum of 16 hours in length. Basic training may
include content in the following areas:
a. Orientation to the service plan, community and the DHCFP medical
assistance program services;
b. Body mechanics and transfer techniques;
c. Bathing, basic grooming and mobility techniques, including simple
non-prescribed range of motion;
d. Personal care skills, including PCS permitted and not permitted
(refer to Sections 2603.1C and 2603.8);
e. Care of the home and personal belongings;
f. Infection control, including information on common communicable
diseases, blood borne pathogens, infection control procedures,
universal precautions and applicable Occupation Safety Hazard Act
(OSHA) requirements;
g. Household safety and accident prevention, including information on
general household safety and how to prevent accidents, poisoning,
fires etc. and minimizing the risk of falls;
h. Food, nutrition and meal preparation, including information on a
well-balanced diet, special dietary needs and the proper handling
and storage of food;
i. Bowel and bladder care, including routine care associated with
toileting, routine maintenance of indwelling catheter drainage
system (emptying bag, positioning, etc.), routine care of colostomies
(emptying bag, changing bag), signs and symptoms of urinary tract
infections and common bowel problems, such as constipation and
diarrhea;
j. Skin care, including interventions to prevent pressure sores,
(repositioning, use of moisturizers, etc.), routine inspections of skin,
and reporting skin redness, discoloration or breakdown to the
recipient or caregiver;
k. Health oriented record keeping, including written documentation of
services provided and time verification records;
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l. Recipient's rights, including confidentiality pursuant to state and
federal regulations and consumer rights;
m. Communication skills, including basic listening and verbal
communication skills, problem solving and conflict resolution
skills, as well as alternative modes of communication techniques for
individuals with communication or sensory impairments;
n. Information including overview of aging and disability (sensory,
physical and cognitive) regarding changes related to the aging
process, sensitivity training towards aged and disabled individuals,
recognition of cultural diversity and insights into dealing with
behavioral issues;
o. Directives, including information regarding the purpose of an
advance directive and implications for the PCA.
k. Records
The IC must maintain medical and financial records, supporting documents, and all
other records relating to PCS provided. The provider must retain records for a
period pursuant to the State records retention policy, which is currently six years
from the date of payment for the specified service.
l. HIPAA, Privacy and Confidentiality
Refer to MSM Chapter 100 for information on HIPAA, privacy and confidentiality
of recipient records and other protected health information.
m. Notification of Suspected Abuse or Neglect
Reference Section 2603.8 of this chapter.
2604.1C RECIPIENT RESPONSIBILITIES
All of the policies discussed in the Section 2603.9 of this chapter apply to the IC model.
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MEDICAID SERVICES MANUAL HEARINGS
2605 HEARINGS
Reference MSM Chapter 3100, Hearings, for Medicaid recipient hearing procedures and Medicaid
provider hearing procedures.
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Subject:
MEDICAID SERVICES MANUAL CLINICAL DECISION SUPPORT
GUIDE
2606 SELF DIRECTED (SD) SKILLED SERVICES – CLINICAL DECISION SUPPORT GUIDE
Level I Level II Level III Level IV Level V
Not to exceed
Not to exceed10 Not to exceed 22 Not to exceed 30 Not to exceed 40
four hours a
hours a week hours a week hours a week hours a week
week
+ Limited skilled ++One or two Three to five Four to six routine Seven routine skilled
interventions routine skilled routine skilled skilled interventions, interventions, with or
interventions, interventions, with or with or without without limited
with or without without limited limited skilled skilled interventions;
limited skilled skilled interventions; interventions; or or
interventions. or
+++One highly One highly complex One highly complex
complex skilled and skilled intervention skilled intervention
one to two routine and three to four and five to six
skilled routine skilled routine skilled
intervention(s), with intervention(s), with interventions, with or
or without limited or without limited without limited
skilled interventions; skilled interventions; skilled interventions;
or or or
Two complex Two highly complex Two highly complex
skilled interventions, skilled interventions, skilled intervention
with or without with either routine and two to five
limited skilled skilled interventions routine skilled
services. or limited skilled interventions, with or
interventions. without limited
skilled interventions;
or
Three highly
complex skilled
interventions, with or
without additional
routine skilled
interventions or
limited skilled
interventions.
September 8, 2016 INTERMEDIARY SERVICES ORGANIZATION Section 2606 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
January 28, 2020
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: CODY L. PHINNEY, DEPUTY ADMINISTRATOR /Cody L. Phinney/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 2700 – CERTIFIED COMMUNITY
BEHAVIORAL HEALTH CENTER SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2700 – Certified Community Behavioral
Health Center Services are being proposed to update language throughout the chapter based on
integration of the Certified Community Behavioral Health Center (CCBHC) model within state
plan authority. The CCBHC was previously only under the authority of Section 223(a)(2)(F) of
Protecting Access to Medicare Act (PAMA). The proposed revisions also include additions to the
chapter to clarify an access site and guidance for CCBHCs dually enrolled as Federally Qualified
Health Centers (FQHC). Additionally, the proposed revisions include the removal of non-state
plan covered services, including Family Peer Support, Supported Employment and Targeted Case
Management for individuals with Substance Use Disorder.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: This proposed change affects all Medicaid-enrolled providers
delivering services under the Certified Community Behavioral Health Center model, Provider
Type 17 Specialty 188.
Financial Impact on Local Government: Unknown at this time.
These changes are effective January 29, 2020.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 03/20 MTL 12/17
Chapter 2700 – Certified Community Chapter 2700 – Certified Community
Behavioral Health Center Services Behavioral Health Center Services
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Throughout Throughout Certified Community Behavioral Health Clinic has
Chapter 2700 Chapter 2700 been changed to Certified Community Behavioral
Health Center.
Throughout Throughout Changed CCBHC demonstration to CCBHC
Chapter 2700 Chapter 2700 program.
2701 AUTHORITY Added language to clarify the demonstration
authority has been extended.
Added Nevada State Plan 4.19-A and Nevada State
Plan 3.1-A.
Added CMS 2261-P, Centers for Medicare and
Medicaid Services (CMS).
2702(B) DEFINITIONS Added language to include authority of state plan.
2702(F)(4)(c) Remove Supported Employment.
2702(F)(6)(b) Remove Family Support Services.
2702(H) Remove Family Support Services definition.
2702(I) Remove Family Support Specialist definition.
2702(S) Remove Supported Employment definition.
2703.3(A)(12) GENERAL Clarifying language related to timeline submission of
PROVISIONS cost report.
2703.7(A)(3)(a-b) ACCESS TO CARE Added clarifying language for an access site.
2703.11 SUPERVISION Adding language to describe source of supervision
STANDARDS requirement.
2703.16 SERVICES Removed link to Allowable Services grid and
described where to find it.
2703.16(B)(3)(k)(1) Removed requirement to include the Child Abuse and
Neglect Systems (CANS) in comprehensive
assessment.
2703.16(H) Removed Family Support Services.
2703.16(K) Removed Supported Employment.
Page 2 of 3
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2703.16(L) Removed Co-occurring Disorders (COD) and
recipients with Substance Use Disorders (SUD).
2703.18(C) UTILIZATION Removed language of the Health Care Guidance
MANAGEMENT Program since it is no longer a program.
2703.22 FEDERALLY Added clarifying language.
QUALIFIED
HEALTH
CENTERS
DUALLY
ENROLLED AS A
CCBHC
Page 3 of 3
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
CERTIFIED COMMUNITY BEHAVIORAL HEALTH CENTER SERVICES
2700 INTRODUCTION ........................................................................................................................1
2701 AUTHORITY ...............................................................................................................................1
2702 DEFINITIONS ..............................................................................................................................1
2703 POLICY ........................................................................................................................................1
2703.1 CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINIC (CCBHC) DELIVERY
MODEL ........................................................................................................................................1
2703.2 PROVIDER STANDARDS..........................................................................................................1
2703.3 GENERAL PROVISIONS ...........................................................................................................2
2703.4 RECIPIENTS IN THE U.S. MILITARY OR VETERANS .........................................................3
2703.5 STAFF COMPETENCIES ...........................................................................................................3
2703.6 CARE COORDINATION ............................................................................................................4
2703.7 ACCESS TO CARE .....................................................................................................................6
2703.8 HEALTH INFORMATION TECHNOLOGY (HIT) ...................................................................7
2703.9 QUALITY ASSURANCE ............................................................................................................7
2703.10 BOARD OF DIRECTORS ...........................................................................................................8
2703.11 SUPERVISION STANDARDS ...................................................................................................8
2703.12 RECIPIENT SATISFACTION OF CARE ...................................................................................8
2703.13 PROVIDER QUALIFICATIONS ................................................................................................9
2703.14 TARGET POPULATIONS ..........................................................................................................9
2703.15 RECIPIENT ELIGIBILITY..........................................................................................................9
2703.16 SERVICES ....................................................................................................................................9
2703.17 DOCUMENTATION REQUIREMENTS..................................................................................15
2703.18 UTILIZATION MANAGEMENT .............................................................................................16
2703.19 COVERAGE AND LIMITATIONS ..........................................................................................16
2703.20 NON-COVERED SERVICES ....................................................................................................16
2703.21 PROVIDER RESPONSIBILITIES ............................................................................................17
2703.22 FEDERALLY QUALIFIED HEALTH
CENTERS……………………………………………………………………………………...17
2703.23 RECIPIENT AND/OR FAMILY RESPONSIBILITIES ...........................................................17
2703.24 AUTHORIZATION PROCESS .................................................................................................18
2704 HEARINGS ..................................................................................................................................1
1
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Section:
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Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
CERTIFIED COMMUNITY BEHAVIORAL HEALTH CENTER SERVICES
2700 INTRODUCTION
Nevada Medicaid reimburses for the Certified Community Behavioral Health CENTER (CCBHC)
model for children and adults under a combination of mental health rehabilitation, medical/clinical
and institutional authority. The intent of the CCBHC model is to increase access to high quality,
coordinated and integrated care that is outcomes-based across the continuum of care. The services
must be recommended by a physician or other licensed practitioner of the healing arts working
within their scope of practice under state law. Services are provided for the maximum reduction
of a physical and mental disability and to restore the recipient to the best possible functioning
level. The services are provided in the least restrictive, most normative setting possible and must
be delivered in a CCBHC delivery model. The CCBHC provides developmentally appropriate
services that are recovery-oriented, person- and family-centered, strengths-based and trauma-
informed in a culturally and linguistically competent manner. The CCBHC delivery model ensures
recipient participation in shared decision-making regarding their individualized treatment and
recovery plans and engages recipients and their families in active participation in their care. The
provision of services occurs within community settings, using a welcoming approach that
encourages and supports treatment to occur “beyond the four walls” of a traditional treatment
setting, increasing availability and accessibility of care.
CCBHCs meet the psychosocial and physical health needs of the recipient through the provision
of direct services and through effective case management and care coordination. CCBHCs may
collaborate with a Designated Collaborating Organization (DCO) that is an extension of the
CCBHC delivery model. This innovative and flexible delivery model provides whole person
responsive and preventative care to best meet the needs of the recipient. Services assist recipients
to develop, enhance and/or retain behavioral and physical health, social integration skills, personal
adjustment and/or independent living competencies in order to experience success and satisfaction
in environments of their choice and to function as independently as possible. Interventions occur
concurrently and begin as soon as clinically possible.
CCBHC providers must ensure that all services are coordinated across the continuum of care and
provided under this chapter and according to most recent edition of the relevant Medicaid Services
Manuals (MSM) sections to include, but not limited to, Chapters 100, 400, 600, 1700, 1900, 2500,
3400, 3800 and the MSM Addendum. Providers must ensure all services are evidenced-based and
accepted as best practices based on the Substance Abuse and Mental Health Services
Administration (SAMHSA) Evidenced-Based Practices Guide (reference:
https://www.samhsa.gov/ebp-web-guide).
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MEDICAID SERVICES MANUAL AUTHORITY
2701 AUTHORITY
In 1965, the 89th Congress added Title XIX of the Social Security Act (SSA) authorizing varying
percentages of Federal Financial Participation (FFP) for states that elected to offer medical
programs. States must offer the 11 basic required medical services. Two of these are inpatient
hospital services (42 Code of Federal Regulations (CFR) 440.10) and outpatient hospital services
(42 CFR 440.20). All other mental health and substance abuse services provided in a setting other
than an inpatient or outpatient hospital are covered by Medicaid as optional services. Additionally,
state Medicaid programs are required to correct or ameliorate defects and physical and mental
illnesses and conditions discovered as the result of an Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) screening for children 21 years or younger, whether or not such services are
covered under the state plan (Section 1905(a) of the SSA).
Other authorities include:
• Nevada Medicaid Inpatient Psychiatric and Substance Abuse Policy, Procedures and
Requirements. The Joint Commission Restraint and seclusion Standards for Behavioral
Health.
Health and Human Services (HHS) Sections 2701 through 2763, 2791 and 2792 of the
Public Health Service (PHS) Act (42 USC 300gg through 300gg–63, 300gg–91 and 300gg–
92), as amended.
(Reference:https://www.gpo.gov/fdsys/pkg/FR-2013-11-13/pdf/2013-27086.pdf).
• Section 223(a)(2)(F) of Protecting Access to Medicare Act (PAMA). This demonstration
authority has been extended.
• Section 2402(a) of the Patient Protection and Affordable Care Act (ACA).
• Section 2403(a) of the ACA: Standards for Person-Centered Planning and Self-Direction
in Home and Community-Based Services Programs.
• Nevada State Plan Section 4.19-A.
• Nevada State Plan Section 3.1-A.
• CMS 2261-P, Centers for Medicare and Medicaid Services (CMS) (Medicaid Program;
Coverage for Rehabilitative Services).
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MEDICAID SERVICES MANUAL DEFINITIONS
2702 DEFINITIONS
The following definitions are listed for the purpose of this demonstration program only and are
specific to the CCBHC delivery model. All other relevant definitions can be found in the
appropriate MSM Chapter and the MSM Addendum.
A. CARE COORDINATION: Deliberately organizing, facilitating and managing a CCBHC
recipient’s care. This includes coordinating all behavioral/mental and physical health
activities regardless if the care is provided directly by the CCBHC and it’s DCO or through
referral or other affiliation outside of the CCBHC delivery model. Care coordination
includes:
1. Ensuring access to high-quality physical health care (both acute and chronic) and
behavioral health care, as well as social services, housing, educational systems and
employment opportunities as necessary to facilitate wellness and recovery of the
whole person. This may include the use of telehealth services.
2. Having policies and procedures in place that comply with Health Insurance
Portability and Accountability Act (HIPAA) and 42 CFR Part 2 requirements
specific to adults and children, and other privacy and confidentiality requirements
of state or federal law to facilitate care coordination.
3. Having policies and procedures in place to encourage participation by family
members and others important to the recipient to achieve effective care
coordination, subject to privacy and confidentiality requirements and recipient
consent.
4. Having policies and procedures in place to assist recipients and families of children
and adolescents in obtaining appointments and keeping the appointments when
there is a referral to a provider outside the CCBHC delivery model, subject to
privacy and confidentiality requirements and consistent with the recipient’s and
their family’s preference and need.
B. CERTIFIED COMMUNITY BEHAVIORAL HEALTH CENTER (CCBHC): An entity
that meets criteria as established by the Substance Abuse and Mental Health Services
Administration (SAMHSA) demonstration program and is certified in the State of Nevada
by the Division of Public and Behavioral Health’s (DPBH) Health Care Quality and
Compliance (HCQC) bureau. CCBHCs provide and contract with DCOs that provide
services in accordance with the Protecting Access to Medicare Act of 2014 (PAMA) if
providing service through this authority and with state plan.
C. CLINICAL SUPERVISOR: A licensed behavioral health professional operating within the
scope of their practice under state law who has specific education, experience, training,
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credentials and licensure to coordinate and oversee an array of behavioral health services
and ensure clinical compliance with the requirements of a CCBHC delivery model. The
Clinical Supervisor has administrative and clinical oversight of the program and must
ensure that services provided are medically necessary, and clinically, developmentally,
culturally and linguistically appropriate, and follow an evidence-based model.
D. CO-OCCURRING BEHAVIORAL HEALTH DISORDER (COD): Recipients with co-
occurring disorders are those who currently, or at any time in the past year (12 continuous
month period), have had a diagnosable substance use and a mental health disorder that
meets the coding and definition criteria specified in the most current International
Classification of Diseases (ICD), that has resulted in a functional impairment which
substantially interferes with or limits one or more major life activity. This impairment also
hinders their ability to function successfully in several areas including social, occupational
and/or educational environments, or substantially interferes with or limits them from
achieving or maintaining housing, employment, education, relationships or safety.
E. DESIGNATED COLLABORATING ORGANIZATION (DCO): A distinct entity that is
not under the direct supervision of a CCBHC, but has a formal contractual relationship
with a CCBHC to provide an authorized CCBHC service. The CCBHC must ensure the
DCO provides the same quality of care as those required by the CCBHC program. The
CCBHC maintains ultimate clinical responsibility for the services provided to CCBHC
recipients by the DCO under this agreement. To the extent that services are required that
cannot be provided by either the CCBHC directly or by a DCO, referrals may be made to
other providers or entities. The CCBHC retains responsibility for the overall coordination
of a recipient’s care including services provide by the DCO or those to which it refers a
recipient.
F. EVIDENCED-BASED PRACTICE (EBP): Services that have specific fidelity measures
for proven effectiveness. CCBHCs and DCOs must provide EBP services that meet criteria
as best practices and approaches for the purpose of the CCBHC program. The following
required EBPs are meant to meet the needs of the broader focus of recipients served
throughout their lifespan and set the minimum standard of practice in the application of
EBPs. The CCBHC may select more population-specific EBPs listed in the SAMHSAs
Evidenced-Based Practices Guide to reflect the unique needs of their communities.
1. Crisis Behavioral Health Services
a. Collaborative Management and Assessment of Suicidality
b. Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA/CIWA-
Ar)
c. Clinical Opiate Withdrawal Scale (COWS)
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d. Targeted Case Management (TCM)
e. Solution-Focused, Brief Psychotherapy (SFBT)
f. Wellness Recovery Action Plans (WRAP)
2. Screening, Assessment and Diagnostic Services
a. Achenbach Children’s Behavioral Checklists
b. Ages and Stages Questionnaire-Social Emotional
c. CRAFIT Screening Test
d. Patient Health Questionnaire-9 (PHQ-9)
e. DSM-5 Level 1 and 2 Cross-Cutting Symptom
f. Child and Adolescent Needs and Strengths (CANS)
g. Children’s Uniform Mental Health Assessment (CUMHA)
h. Child and Adolescent Services Intensity Instrument (CASII)
i. Level of Care Utilization System (LOCUS)
j. American Society of Addiction Medicine – Patient Placement Criteria
(ASAM)
k. World Health Organization Disability Assessment Scale Version 2
(WHODAS 2.0)
3. Outpatient Mental Health and Substance Use Treatment
a. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
b. Cognitive Behavioral Therapies (CBT) including Dialectical Behavior
Therapy (DBT) and Acceptance and Commitment Therapy (ACT)
c. Family Check-Up and Everyday Parenting
d. Motivational Interviewing
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e. Integrated Dual Diagnosis Treatment; Life Skills Training
f. Illness Management and Recovery (IMR)
g. Medication Management
h. Body Mass Index
i. Metabolic Monitoring with Atypical Antipsychotics
4. Psychiatric Rehabilitation Services
a. Basic Skills Training and Psychosocial Rehabilitation
b. Life Skills Curriculum
c. Assertive Community Treatment
5. Behavior Change and Counseling Risk Factors
a. Screening, Brief Intervention and Referral to Treatment (SBIRT)
b. Nursing Quit-Line
c. Chronic Disease Management
6. Peer Support, Counselor Services and Family Supports
a. Peer Support Services
G. FAMILY-CENTERED: An approach to the planning, delivery and evaluation of care
based on active participation and input from a recipient’s family and the CCBHC. Family-
centered care recognizes families as the ultimate decision-makers for their child, with the
child encouraged to gradually take on more and more of the decision-making. Services
are culturally, linguistically and developmentally appropriate and youth-guided and not
only meet the behavioral, mental, emotional, developmental, physical and social needs of
the child, but also support the family’s relationship with the child’s health care providers.
H. INTENSIVE FAMILY INTERVENTION SERVICES: A comprehensive interdisciplinary
array of flexible CCBHC services that are expected to improve or maintain a family system
to support the recipient’s recovery and functioning level and to prevent an exacerbation of
symptoms. Intensive Family Intervention Services provide support to the family to connect
them to resources, provide mentoring or coaching and assist them with setting recovery
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goals and developing and implementing recovery action plans. These services also help
families to solve problems directly related to recovery, including finding sober housing,
developing appropriate social interactions, occupying free time, improving job skills or, if
needed, assisting the family in traversing criminal or juvenile justice systems.
I. LINGUISTIC COMPETENCE: Meaningful access to services that allow the recipient with
Limited English Proficiency (LEP) or language-based disabilities to fully understand and
participate in CCBHC services. Linguistic competence includes the use of
interpretation/translation services (provided by individuals trained in a medical setting),
bilingual providers, auxiliary aids and services that are ADA compliant. Linguistic
competence also includes having written forms and signage at the appropriate literacy level
for recipients and/or their families and that are available in alternate formats as needed for
recipients with disabilities to accommodate functional limitations. CCBHCs and DCOs
must also ensure outgoing phone messages/recordings reflect linguistic competence.
J. PEER SUPPORT SPECIALIST: An individual who meets the provider qualifications in
MSM Chapter 400 and uses their lived experience of recovery from mental or substance
use disorders to deliver Peer Support Services. A Peer Support Specialist is an individual
who is currently or was previously diagnosed with a mental and/or behavioral health
disorder and who possesses the skills and abilities to work collaboratively with and under
the clinical and direct supervision of a CCBHC. A Peer Support Specialist cannot be the
legal guardian, spouse or parent.
K. PERSON-CENTERED: Person-centered care involves the recipient to the maximum
extent possible and also includes family members, legal guardians, friends, caregivers and
others whom the recipient wishes to include. The recipient directs their care and the
provider supports the recipient’s goals and wishes in their treatment and their health care
goals, objectives and approaches used.
L. PERSON-CENTERED PLANNING: An approach that focuses on the recipient’s goals,
desires, strengths and needs for support in the development of an effective plan for
treatment and in the provision of services. Services are individualized in partnership with
the recipient served to ensure that they and their families (when appropriate) can select and
direct meaningful and informed interventions. Services are matched to treatment needs, are
outcome-based and designed to maximize each recipient’s independence, capabilities and
satisfaction. (Also reference Person-Centered Treatment Planning in the MSM
Addendum).
M. PRINCIPAL BEHAVIORAL HEALTH PROVIDER (PBHP): A CCBHC clinician
assigned to each recipient. The PBHP must ensure that:
1. Regular contact is maintained with the recipient as clinically indicated and as long
as ongoing care is required;
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2. A psychiatrist reviews and reconciles the recipient’s psychiatric medications on a
regular basis;
3. Coordination and development of the treatment plan incorporates input from the
recipient (and, when appropriate, the family with the recipient’s consent when the
recipient possesses adequate decision-making capacity or with the recipient’s
surrogate decision-maker’s consent when the recipient does not have adequate
decision-making capacity);
4. Effective communication occurs with the recipient and addresses any of the
recipient’s problems or concerns about their care. This includes discussion
regarding future mental health care for recipients who are at high risk of losing
decision-making capacity;
5. For a recipient who lacks the capacity to make a decision about their integrated
treatment plan, that the recipient’s decision-making capacity is formally assessed
and documented; and
6. For a PBHP providing services to a veteran recipient (in the case that the Veterans
Health Administration (VHA) has not already assigned a PBHP), the PBHP must
also:
a. Follow the most recent edition of the VHA Handbook; and
b. Ensure that collaboration occurs with the Veterans Administration (VA)
Suicide Prevention Coordinator (SPC) at the nearest VA facility to support
the identification of those who have survived suicide attempts and others at
high risk, and to ensure that they are provided with increased monitoring
and enhanced care.
N. RECOVERY: A process of change through which individuals improve their health and
wellness, live a self-directed life and strive to reach their full potential. CCBHC and DCO
providers must utilize SAMHSAs working definition, dimensions and guiding principles
of recovery from mental health disorders and substance use disorders in their clinical
decisions. Reference http://www.samhsa.gov/ for the latest best practices.
O. RECOVERY-ORIENTED: The recipient’s care is designed to promote and sustain their
recovery from a behavioral health condition. Services are strengths-based and support the
recipient to optimal functioning and community integration.
P. SUBSTANCE USE DISORDER (SUD): An individual with a substance use disorder
(SUD) is a person who currently, or at the any time in the past year (12 continuous month
period), has had a diagnosable substance use disorder that meets the coding and definition
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criteria specified in the most current ICD that has resulted in a functional impairment which
substantially interferes with, or limits, one or more major life activity in several areas such
as social, occupational or educational.
Q. TRAUMA-INFORMED: An approach to care which “realizes the widespread impact of
trauma and understands potential paths for recovery; recognizes the signs and symptoms
of trauma in clients, families, staff and others involved in the system; and responds by fully
integrating knowledge about trauma into policies, procedures and practices, and seeks to
actively resist re-traumatization.” The six key principles of a trauma-informed approach
include: safety; trustworthiness and transparency; peer support; collaboration and
mutuality; empowerment, voice and choice; and cultural, historical and gender issues
(SAMHSA (2014)).
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2703 POLICY
2703.1 CERTIFIED COMMUNITY BEHAVIORAL HEALTH CENTER (CCBHC) DELIVERY
MODEL
A. The CCBHC delivery model incorporates the provision of expanded and non-traditional
biopsychosocial services in a behavioral health clinic. Services focus on whole person,
integrated care and the coordination of quality care for improved health outcomes for
recipients with behavioral health disorders. The CCBHC delivery model is designed to
increase provider flexibility and improve the responsiveness of services to meet the needs
of recipients served.
B. CCBHCs and DCOs must ensure that services are evidenced-based, address multiple
domains, are provided in the least restrictive environment, and involve family members,
caregivers and informal supports when considered appropriate per the recipient and/or their
legal guardian. CCBHC and DCO providers must collaborate and facilitate full
participation from the recipient’s team members including the recipient and their family
(when appropriate), to address the quality and progress of the individualized treatment
plan. CCBHCs must continuously work to improve services in order to ensure overall
efficacy of the recipient’s care.
C. In the case of child recipients, CCBHC and DCO providers must deliver youth-guided and
family-driven effective/comprehensive services and monitor child and family outcomes
through the utilization of Child and Family Team meetings. CCBHC and DCO providers
must also coordinate care for any child recipient under the jurisdiction of a state or county
child welfare agency with the relevant agency. The CCBHC must document this specific
coordination in the child recipient’s medical record.
D. Recipients receiving services from a CCBHC and/or DCO may receive services in
conjunction with or independent of other services. Services are based on an on-going
review of admission, continuing stay and discharge criteria. All services must be provided
according to the Federal requirements of a CCBHC as prescribed by SAMHSA.
2703.2 PROVIDER STANDARDS
CCBHC providers must be certified by the following DPBH bureaus: HCQC and Substance Abuse
Prevention and Treatment Agency (SAPTA). CCBHC providers must ensure timely access to
integrated, coordinated and responsive care, treatment, interventions and services under an
established CCBHC delivery model. This model is based on an integrated system of care that meets
the individually assessed biopsychosocial needs of recipients served. The provision of services is
based on medical necessity, clinical appropriateness and the emergent, urgent and stabilization
needs of each recipient in conjunction with their goals and choices. Individuals must be offered
entry into any service needed, regardless of the point of contact. All services must be coordinated
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across the continuum of care and provided under this chapter and according to all relevant MSM
Chapters and Addendum.
2703.3 GENERAL PROVISIONS
A. CCBHC providers must:
1. Continuously meet HCQC certification criteria;
2. Ensure recipient’s rights and freedom to choose providers;
3. Ensure recipients have access to the CCBHC grievance procedures outlined in the
certification criteria, including CCBHC services provided by a DCO;
4. Address specific sub-populations within their Medicaid populations. These sub-
populations include, but are not limited to, recipients involved in the
juvenile/criminal justice systems, children in child welfare, recipients at-risk for
hospitalization, recipients transitioning from inpatient stays and recipients with co-
morbid chronic health conditions;
5. Assign a PBHP to each recipient;
6. Ensure locations are accessible and recipients have a safe and functional
environment;
7. Ensure outpatient clinic hours include night and weekend hours to meet the needs
of recipients in crisis. This includes informing recipients of these services and how
to access suicide/crisis hotlines and warm lines;
8. Provide outreach and engagement activities to assist recipients and their families in
accessing services;
9. Coordinate access to transportation through Nevada Medicaid’s non-emergency
transportation vendor;
10. Have adequate continuity of operations and disaster plans in place;
11. Maintain records and documentation as required by the CCBHC program to include
the monitoring and reporting of the fidelity to selected core EBPs;
12. Submit a cost report at the end of the first year of doing business, or until a rebase
is required by the DHCFP;
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13. Submit quarterly reports on the CCBHC and State led measures;
14. Submit ad hoc reports as requested;
15. Ensure all DCO services are evidenced-based and there are formal agreements with
their DCOs to obtain access to data needed to fulfill the reporting obligations for
the CCBHC program;
16. Comply with requests from the Qualified Improvement Organization (QIO)-like
vendor; and
17. Comply with the DHCFP’s polices and agency review processes.
2703.4 RECIPIENTS IN THE U.S. MILITARY OR VETERANS
A. CCBHCs must ensure services to U.S. Military and Veterans. CCBHCs must ask all
recipients inquiring about or requesting services whether they have ever served in the U.S.
Military. For those individuals who respond positively, the CCBHC must:
1. Either direct them to care or provide the needed care;
2. Offer assistance enrolling in the VHA programs;
3. Ensure veterans and active duty military receive the required CCBHC services;
4. Assign a PBHP with specific cultural competence in military and veteran’s culture
to every veteran, unless the VHA has already assigned a PBHP;
5. Provide care and services for veterans that are recovery-oriented, and adhere to the
guiding principles of recovery as defined by the VHA and other VHA guidelines;
6. Ensure all staff who work with military or veteran recipients are trained in cultural
competence, and specifically military and veteran’s culture; and
7. Ensure the individualized treatment plan complies with VHA requirements.
2703.5 STAFF COMPETENCIES
A. CCBHCs and DCOs must ensure staff are competent and capable to provide CCBHC
services that are developmentally, culturally and linguistically appropriate as documented
by:
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1. Written policies and procedures to describe the methods used for assessing the
skills and competencies of providers;
2. A list of in-service trainings and educational programs provided that includes
documentation of the qualifications of the in-service trainers for each training topic
as evidenced by their education, training and experience; and
3. Documentation of the completion of training and demonstration of competencies
to provide CCBHC services within each staff’s personnel record.
a. This documentation must include verification to show that each staff has
completed the trainings required under the CCBHC program.
2703.6 CARE COORDINATION
A. CCBHCs and DCOs must work on behalf of recipients in the coordination and management
of their care to ensure effective outcomes. This includes all providers of behavioral/mental
and physical health care and other agencies serving a joint recipient.
CCBHCs must have policies that ensure:
1. Coordination of care for recipients who present to the local emergency department
(ED) or who are involved with law enforcement when in a crisis;
2. A reduction in any delays in the initiation of services during and after a recipient
has experienced a psychiatric crisis;
3. Coordination with all State of Nevada Department of Health and Human Services
programs to maximize benefits to recipients served, eliminate duplication of efforts,
streamline processes and improve access to available community supports; and
4. Effective and timely care coordination by having appropriate consents in place that
meet HIPAA and 42 CFR Part 2 requirements.
B. To ensure effective and timely care coordination, CCBHCs must also have agreements in
place which describe the mutual expectations and responsibilities related to care
coordination for each of the following providers unless the service is provided directly by
the CCBHC:
1. Federally Qualified Health Centers (FQHCs);
2. Rural Health Clinics (RHCs), when relevant;
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3. The recipient’s primary care provider and other recipient providers of health care
to ensure physical health care needs are addressed;
4. Ambulatory detoxification, medical detoxification, post detoxification step-down
services and residential program(s) to include the ability to track the recipient’s
admission and discharge to these facilities;
5. Emergency departments which includes having protocols for transitioning
recipients from emergency departments and other emergency settings to a safe
community setting, including the transfer of medical records, prescriptions, active
follow-up, a plan for suicide and homicide prevention and safety, where
appropriate, and the provision of peer services;
6. Acute-care and psychiatric hospitals, including, outpatient clinics and urgent care
centers;
7. Local law enforcement, criminal justice agencies and facilities including drug,
mental health, veterans and other specialty courts;
8. Indian Health Services (IHS) and tribal programs;
9. Specialty providers of medications for treatment of opioid and alcohol disorders;
10. Homeless shelters/housing agencies;
11. Employment services systems;
12. Services for children e.g., schools, child welfare agencies, juvenile justice
programs, youth regional treatment centers and state licensed and nationally
accredited child placement agencies for therapeutic foster care service, when
relevant;
13. Services for older adults, such as Aging and Disability Services Division (ADSD);
14. The nearest Department of Veterans Affairs’ medical center, independent clinic,
drop-in center or other VA facility; and
15. Local human services programs (e.g., domestic violence centers, pastoral services,
grief counseling, ACA navigators, food and transportation programs and other
social and human services programs as identified by the recipient and/or their
family as integral to their stabilization and/or recovery success).
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2703.7 ACCESS TO CARE
A. CCBHC and DCO providers must ensure access to high quality behavioral and physical
health care. This includes having policies in place that ensure:
1. Services cannot be refused due to the recipient’s residence which include protocols
to address services for those living out of state;
2. Initial services will not be denied to those who do not live in the CCBHC catchment
area (where applicable), including the provision of crisis services and other
services, and coordination and follow-up with providers in the recipient’s
catchment area. Telehealth services may be provided;
3. Services are available for recipients living in the CCBHC catchment area including
those residing in remote areas of the CCBHC’s location;
a. An access site (or point) is a location where a CCBHC recipient can receive
CCBHC services within the current service area. However, an access point
is not intended to provide all of the required services under the CCBHC
model.
b. A CCBHC offering more than four of the required services at this facility
would be classified as a “satellite clinic” and would need to be certified as
a CCBHC.
4. Communication is made to the public of the availability of CCBHC services; and
5. For access to higher levels of care, CCBHCs must:
a. Have procedures and services for transitioning recipients from emergency
departments and these other settings to CCBHC care, for shortened lag time
between assessment and treatment, and for transfer of medical records,
prescriptions and active follow-up;
b. Have provisions for tracking recipients admitted to and discharged from
these facilities (unless there is a formal transfer of care from the CCBHC);
c. Have care coordination agreements for recipients presenting to the facility
at risk of harm to themselves or others which includes the coordination of
consent for follow-up within 24 hours and continuing until the recipient is
linked to services or is assessed as being no longer at risk; and
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d. Have in place procedures that make and document reasonable attempts to
contact all recipients discharged from these facilities within 24 hours of
discharge.
2703.8 HEALTH INFORMATION TECHNOLOGY (HIT)
A. CCBHC providers must have HIT systems in place that:
1. Include Electronic Health Records (EHRs);
2. Capture demographic information, diagnoses and medications lists;
3. Provide clinical decision support;
4. Electronically transmit prescriptions to the pharmacy;
5. Allow reporting on data and quality measures required by the CCBHC program;
6. Allow the system to conduct activities such as population health management,
quality improvement, disparity reduction, outreach and research; and
7. If the HIT is newly established, can also send and receive the full common data set
for all summary of care records to support capabilities including transitions of care,
privacy and security and to meet the Patient List Creation criterion (45 CFR
170.314(a)(14)) established by the Office of the National Coordinator (ONC) for
ONC’s Health IT Certification Program.
2703.9 QUALITY ASSURANCE
A. CCBHCs must have in place a HCQC approved written Continuous Quality Improvement
(CQI) Plan. CCBHCs must:
1. Comply with this plan and all other HCQC requirements to ensure on-going quality
care;
2. Ensure the plan includes a description of how the public is made aware of the
availability of CCBHC services;
3. Submit all required and requested data, quality and fidelity measures reports to
comply with the requirements of the CCBHC program timely; and
4. Provide oversight and monitoring of all their DCOs to ensure services provided
meet the requirements of the CQI plan; they are enrolled as an Ordering,
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Prescribing or Referring (OPR) provider, if relevant; they are compliant with the
requirements of this chapter and all relevant MSM Chapters and Addendum; and
the DCOs submit all required data reports timely which includes both CCBHC and
State led measures.
2703.10 BOARD OF DIRECTORS
A. CCBHCs must operate under established bylaws and have board members that are
representatives of the individuals being served in terms of demographic factors such as
geographic area, race, ethnicity, sex, gender identity, disability, age and sexual orientation.
In terms of representation of behavioral health disorders, CCBHCs must incorporate
meaningful participation by adult consumers with mental illness, adults recovering from
substance use disorders and family members of CCBHC consumers i.e., 51 % of the board
are families, consumers or people in recovery from behavioral health conditions to provide
meaningful input to the board about the CCBHC’s policies, processes and services.
B. CCBHCs must provide the board:
1. An annual financial audit and correction plan with the relevant management letter
to address any deficiencies; and
2. The following reports to verify timely access to care:
a. Recipients seeking an appointment for routine needs are provided an initial
evaluation within 10 business days of the request;
b. Recipients seeking an appointment for an urgent need are seen and initial
evaluation completed within one business day; and
c. Recipients with an emergency or crisis need receive immediate and
appropriate action.
2703.11 SUPERVISION STANDARDS
CCBHC providers must ensure all services are provided under medical and clinical supervision as
prescribed by this chapter and within CCBHC certification criteria. Non-compliance will result in
the DHCFP provider termination and/or suspension without cause.
2703.12 RECIPIENT SATISFACTION OF CARE
CCBHC and DCO providers must demonstrate satisfaction of care by their recipients under the
CCBHC delivery model by ensuring this satisfaction is measured and any dissatisfaction is
responded to. This includes a satisfaction survey and the review of recipient responses by their
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Board of Directors. The review is to be the foundation for opportunities to improve performance
by the CCBHC and perception by the recipients.
2703.13 PROVIDER QUALIFICATIONS
A. CCBHC services are provided by qualified individuals in an interdisciplinary treatment
team approach. The CCBHC treatment team is comprised of individuals who meet the
qualifications of direct care providers under the relevant MSM chapter and who collaborate
to provide and coordinate medical, psychosocial, emotional, therapeutic and recovery
support services to the recipients served. All direct care providers of CCBHC services must
be able to provide services under the CCBHC delivery model and meet the qualification as
specified in the relevant MSM chapter.
B. CCBHCs must also ensure all DCO providers are qualified and compliant with the
requirements of the CCBHC program, this chapter and all relevant MSM Chapters and the
Addendum.
2703.14 TARGET POPULATIONS
The CCBHC target populations are the primary populations of focus. These groups include: COD,
Seriously Emotionally Disturbed (SED)/Non-SED, Severely Mentally Ill (SMI)/Non-SMI and
SUD. SED/Non-SED and SMI/Non-SMI are defined in the MSM Addendum. COD and SUD are
defined above.
2703.15 RECIPIENT ELIGIBILITY
A. Admission Criteria: To be eligible for CCBHC services, a recipient must meet criteria for
one of the six target groups.
B. Continuing Stay Criteria: The recipient continues to meet admission criteria and needs
restoration for the best possible functioning or is at risk of relapse and a higher level of
care.
C. Discharge Criteria: The recipient no longer meets admission and continuing stay criteria;
no longer wishes to receive services; or their care has been transferred, the discharge
summary has been provided and the coordination of care has been completed with the new
provider.
2703.16 SERVICES
This CCBHC program allows for the expansion of existing services and the provision of integrated
health care services. CCBHCs must provide the following required services under this program:
Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention
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services and crisis stabilization; screening, assessment and diagnosis, including risk assessment;
patient-centered treatment planning or similar processes, including risk assessment and crisis
planning; outpatient mental health and substance use services; outpatient clinic primary care
screening and monitoring of key health indicators and health risk; targeted case management;
psychiatric rehabilitation services; peer support and counselor services and family supports;
intensive, community-based mental health care for members of the armed forces and veterans,
particularly those members and veterans located in rural areas, provided the care is consistent with
minimum clinical mental health guidelines promulgated by the VHA, including clinical guidelines
contained in the “Uniform Mental Health Services Handbook of such Administration.” In addition
to the required services, CCBHCs are allowed to provide additional services identified on the
Allowable Services grid located with the CCBHC billing guide.
CCBHC treatment and services are based on the individually assessed biopsychosocial needs of
the recipient and prescribed on a person- and family-centered integrated treatment plan. Services
must be provided under the philosophy of recovery and be informed by best practices for working
with individuals from diverse cultural and linguistic backgrounds. The treatment plan guides the
prescribed treatment and services and must reflect collaboration with and endorsement by the
recipient and their family, when appropriate. The treatment plan identifies the recipient’s needs,
strengths, abilities and preferences and includes the recipient’s goal(s) that is expressed in a
manner that captures their own words or ideas and, for children, those of their family/caregiver. In
addition, the treatment plan must indicate the recipient’s advance wishes related to treatment and
crisis management or reflects their decision not to discuss those preferences.
CCBHC services are projected to reduce the number of behavioral health emergency room (ER)
visits in communities, increase positive outcomes of treatment and reduce the negative impacts of
social determinants of health on recovery. Nevada Medicaid reimburses for the following services
provided under a CCBHC delivery model in accordance with this chapter, MSM Chapter 100,
MSM Addendum and all relevant MSM Chapters. The services describe below include criteria
specific to the CCBHC delivery model. Additional requirements are specified in the relevant MSM
Chapter and Addendum.
A. CRISIS BEHAVIORAL HEALTH SERVICES:
CCBHCs must provide through an existing state-sanctioned, certified or licensed system
or network, rapid crisis response to address immediate needs, triage, stabilization and/or
appropriate transfer to a higher level of care. Crisis behavioral health services include but
are not limited to:
1. 24-hour mobile crisis to include evaluations, interventions and stabilization;
2. Telephonic crisis services. The CCBHC must ensure, once the emergency has been
resolved, the recipient is seen in-person at the next encounter and the initial
evaluation is reviewed;
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3. Comprehensive suicide assessments and interventions using the Collaborative
Management and Assessment of Suicidality to identify and address the immediate
safety needs of the recipient;
4. Identifying and managing recipients who may be at-risk of or are currently
experiencing withdrawal and determining the level of care needed to safely manage
the severity of the withdrawal. When clinically indicated, recipients must be
assessed for signs and symptoms of withdrawal using the Clinical Institute
Withdrawal Assessment of Alcohol Scale (CIWA/CIWA-Ar) and the Clinical
Opiate Withdrawal Scale (COWS);
5. Ambulatory withdrawal management for recipients who can be managed in the
community and coordinated referral for recipients who require higher levels of
withdrawal management;
6. Targeted Case Management (TCM), links to community resources to address social
determinates of health, such as access to safe housing, food and basic health care.
When the TCM provider is working with children and their families, community
resources must also be leveraged to provide wrap-around supports to increase
family resiliency and reduce the risk of further crisis;
7. Brief, solution-focused interventions to assist recipients and/or their families in
finding strength-based ways to address their needs and ameliorate further crisis.
These interventions include Solution-Focused, Brief Psychotherapy (SFBT) and
the use of Wellness Recovery Action Plans (WRAP) for the development of a crisis
plan to support recipients in advocating for their own preferences for care; and/or
8. Care coordination and discharge planning for recipients needing referrals to higher
levels of care.
B. SCREENING, ASSESSMENT AND DIAGNOSTIC SERVICES
CCBHCs must appropriately screen, assess and diagnose recipients with behavioral health
disorders for their optimal success and to provide the foundation for treatment and services.
CCBHCs must also utilize standardized, validated evidenced-based screening and
assessment tools with developmentally, culturally and linguistically appropriate measures,
and, where appropriate, motivational interviewing techniques.
1. SCREENING
CCBHCs must:
a. Ensure all new recipients receive a preliminary screening and risk
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assessment to determine acuity of needs;
b. Upon completion of a screen, provide further diagnostic assessment/
evaluation services when clinically indicated; and
c. Ensure immediate, appropriate action, including any necessary subsequent
outpatient follow-up if the screening or other evaluation identifies an
emergency or crisis need.
2. ASSESSMENT AND DIAGNOSIS
All CCBHC services must be based on a comprehensive person- and family-
centered diagnostic and treatment planning evaluation. This biopsychosocial
assessment must be completed with the recipient and in consultation with the
primary care provider, if any, within 60 calendar days of the first request for
services.
Standardized and evidence-based biopsychosocial assessments help guide the
clinician, in collaboration with the recipient and/or their families, to make informed
decisions on their treatment and recovery support options. Assessments include
aspects of motivational interviewing and treatment matching options and consider
a recipient’s or family’s preferences and stages of treatment engagement. To ensure
continuity of care, avoid duplication of services and to reduce frustration on the
part of the recipient and/or their family due to repetitious disclosure, the CCBHC
must make every effort to obtain and update the most recent comprehensive
assessment available.
3. The initial evaluation must include:
a. Preliminary diagnoses and severity rating;
b. Source of referral;
c. Reason for seeking care, as stated by the recipient or other individuals who
are significantly involved;
d. Identification of the recipient’s immediate clinical needs related to the
behavioral health diagnosis(es);
e. List of current prescriptions and over-the-counter medications, as well as
other substances the recipient may be taking;
f. Assessment of whether the recipient is a risk to self or others, including
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suicide risk factors;
g. Assessment of whether the recipient has other concerns for their safety;
h. Assessment of the need for medical care (with referral and follow-up as
required);
i. Determination of whether the recipient presently is or ever has been a
member of the U.S. Military;
j. Assessment and documentation of COD, SED/Non-SED, SMI/Non-SMI or
SUD status; and in addition;
k. For children, a comprehensive assessment must include:
1. The Children’s Uniform Mental Health Assessment (CUMHA) and
the Child and Adolescent Service Intensity Instrument (CASII); and
2. Other age appropriate screening and prevention interventions
including, where appropriate, assessment of learning disabilities.
l. For adults, the comprehensive assessments must include:
1. Level of Care Utilization System (LOCUS); or
2. American Society of Addiction Medicine-Patient Placement
Criteria (ASAM); and
3. World Health Organization Disability Assessment Scale Version 2
(WHODAS 2.0).
C. CHRONIC DISEASE MANAGEMENT: Recipients with chronic health conditions must
receive specific documented approaches intended to manage and monitor their disease(s).
This includes coordinating care to reduce the impact on their overall physical health care
and behavioral health recovery. Chronic disease management includes recipient and/or
family education, support and assistance for self-management.
D. INTENSIVE FAMILY INTERVENTION SERVICES: Family-centered and family-
driven services that are based on the strengths of the recipient’s family and include family
support services. The focus of these services is to preserve and empower families by
finding solutions that best meet their needs through home-based interventions, education
and skills building. These services include assisting families to get their basic needs met
(e.g., food, housing, transportation and/or childcare).
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E. INTENSIVE COMMUNITY-BASED BEHAVIORAL HEALTH CARE FOR
MEMBERS OF THE U.S. MILITARY AND VETERANS: Care that is consistent with the
minimum clinical mental health guidelines promulgated by the VHA and the VHA’s
Uniform Mental Health Services Handbook. These integrated and coordinated care
services are provided by the CCBHC to:
1. U.S. Military members located 50 miles are more (or one hour’s drive time) from
a Military Treatment Facility; and
2. Veterans living 40 miles or more (driving distance) from a VA medical facility, or
as otherwise required by federal law.
F. PRIMARY CARE SCREENING AND MONITORING SERVICES: Basic preventive
health services for recipients to improve overall health outcomes. These services are
considered to have high value in the prevention and intervention of preventable health and
chronic health conditions and include family planning, vaccinations and well-visits.
Primary care services include outpatient primary care screening and monitoring. This
service monitors key health indicators and health risks and identifies the need for the
coordination of care. CCBHCs must provide, collect, report, monitor and document the
following services on the integrated treatment plan:
1. Adult body mass index (BMI) screening and follow-up;
2. Adult major depressive disorder suicide risk assessment;
3. Child and adolescent major depressive disorder suicide risk assessment;
4. Diabetes screening for people with schizophrenia or bipolar disorder who are using
antipsychotic medications;
5. Screening for clinical depression and follow-up plan;
6. Tobacco use, screening and cessation intervention;
7. Unhealthy alcohol use, screening and brief counseling; and
8. Weight assessment and counseling for nutrition and physical activity for children
and adolescents.
G. OCCUPATIONAL THERAPY: Services provided by an Occupational Therapist licensed
in the State that are designed to restore self-care, work and leisure skills to eligible
recipients with functional impairments in order to increase their ability to perform tasks of
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daily living. Services must meet medical necessity and comply with the requirements of
MSM Chapter 1700 – Therapy.
H. PEER SUPPORT SERVICES: Services to improve recipient engagement by providing
them support from individuals with lived experience to bring meaningful insights into the
journey of recovery.
I. PSYCHIATRIC REHABILITATION: Recovery supports that are rehabilitative in nature
and are behavioral health services/interventions designed to engage recipients in regaining
skills and abilities necessary to live independent and self-directed lives.
J. SMOKING CESSATION: Evidence-based strategies to assist the recipient in quitting
smoking to include referral to the Nevada Tobacco Quit Line and health education classes
aimed at providing support information and needed encouragement.
K. TARGETED CASE MANAGEMENT (TCM): Services that assist CCBHC recipients in
gaining access to needed medical, social, educational and other support services including
housing and transportation needs; however, they do not include the direct delivery of
medical, clinical or other services. Components of TCM services include case management
assessment, care planning, referral/linkage and monitoring/follow-up.
All TCM services provided must comply with MSM Chapter 2500, Case Management.
Target groups for the CCBHC include those listed under MSM Chapter 2500, Non-
Seriously Mentally Ill (Non-SMI) Adults, Serious Mental Illness Adult, Non-Severely
Emotionally Disturbed (Non-SED Children and Adolescents), Severe Emotional
Disturbance (SED) Children and Adolescents
2703.17 DOCUMENTATION REQUIREMENTS
A. CCBHCs must comply with the MSM Chapter 400 documentation requirements and must
also document:
1. The medical necessity and clinical appropriateness of services prescribed on an
integrated and individualized person- and family-centered treatment plan;
2. The coordination of care for recipients with all providers of behavioral and physical
health care and, when relevant, with the VHA;
3. How services are individualized and developmentally, culturally and linguistically
competent for each recipient; and
4. The tracking of and response to recipient’s accessing higher levels of care which
includes discharge planning, implementation and coordination.
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2703.18 UTILIZATION MANAGEMENT
A. The CCBHC delivery model expands access to crisis evaluation, ambulatory detoxification
services and outpatient stabilization for recipients who are appropriate for such services.
For recipients with needs that exceed outpatient treatment, CCBHCs are required to
provide coordinated referrals to higher levels of care in the community.
B. The role of the CCBHC includes follow-up after hospitalization for behavioral/mental
health issues within seven and 30 days. CCBHCs are required to focus care coordination
efforts towards recipients transitioning from inpatient behavioral health care to outpatient
community treatment settings.
C. The CCBHC must provide utilization management and oversight of all services performed
by a DCO.
2703.19 COVERAGE AND LIMITATIONS
A. Nevada Medicaid reimburses for all CCBHC services listed in this chapter based on the
prospective payment system (PPS) rate methodology.
B. The CCBHC is responsible for submission of claims including those on behalf of the DCO.
Payments for DCO services will be made directly to the CCBHC.
2703.20 NON-COVERED SERVICES
A. The following services are not covered under the CCBHC program for Nevada Medicaid
and Nevada Check Up (NCU):
1. Services under this chapter for a recipient who does not have a covered, current
ICD diagnosis;
2. Therapy for marital problems without a covered, current ICD diagnosis;
3. Therapy for parenting skills without a covered, current ICD diagnosis;
4. Therapy for gambling disorders without a covered, current ICD diagnosis;
5. Custodial services, including room and board;
6. Social model support group services (Peer Support Services are based on a medical
model);
7. More than one provider seeing the recipient in the same therapy session; and
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8. Respite.
2703.21 PROVIDER RESPONSIBILITIES
A. CCBHCs must ensure recipients are informed of services, choices and their rights and
responsibilities prior to the provision of services.
B. Providers are also responsible for:
1. Verifying Medicaid eligibility on a monthly basis.
2. Submitting appropriate billing reflecting accurate procedure and code usage.
2703.22 FEDERALLY QUALIFIED HEALTH CENTERS DUALLY ENROLLED AS A CCBHC
A. FQHCs dually enrolled as a CCBHC should determine the appropriate model to bill
medically appropriate rendered services. The FQHC and the CCBHC must have internal
policies regarding the appropriate placement for treatment for their respective recipients.
Medical necessity and clinical appropriateness as determined by the clinical professionals,
under care coordination are required and should be taken into consideration when services
overlap both within the FQHC and/or the CCBHC scope of services. This is to determine
which encounter (FQHC or CCBHC) is appropriate to request reimbursement. Care
coordination is required to prevent duplicative billing for the same service occurring at the
same time.
B. Services that are covered under the CCBHC model are identified on the services grid
located in the CCBHC billing guide. Recipients that are accessing services that are
primarily CCBHC and not an exclusively FQHC service will bill the CCBHC PPS rate.
Services that are primarily FQHC specific and not exclusively CCBHC services will bill
the FQHC encounter rate.
C. The Medicaid Surveillance and Utilization Review unit (SUR) will monitor in a
retrospective review for any duplication of billing between the two delivery models.
2703.23 RECIPIENT AND/OR FAMILY RESPONSIBILITIES
A. Recipients or their legal guardians (when applicable) must:
1. Participate in the development and implementation of their individualized
treatment plan;
2. Inform their Medicaid providers of any changes to their Medicaid eligibility; and
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3. Provide their Medicaid card to their service providers.
2703.24 AUTHORIZATION PROCESS
A. Prior Authorizations are not required under the CCBHC model.
B. The CCBHC has the ultimate clinical responsibility for all services including those
provided by the DCO and must ensure the medical necessity and clinical appropriateness
of the services.
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2704 HEARINGS
Please reference MSM Chapter – 3100, Hearings, for hearings procedures.
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TRANSMITTAL LETTER
March 24, 2020
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: CODY L. PHINNEY, DEPUTY ADMINISTRATOR /Cody L. Phinney/
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 2800 – SCHOOL HEALTH SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2800 – School Health Services (SHS) are
being proposed to remove the Individualized Education Program (IEP) limitations and align the
policy with the Centers for Medicare and Medicaid Services’ (CMS’) State Medicaid Director’s
Letter (SMD #14-006) which reversed the CMS guidance on reimbursement for services provided
free of charge to all students in a school setting.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: School Health Services (SHS) – Provider Type (PT) 60.
Financial Impact on Local Government: No financial impact is anticipated for local government.
These changes are effective March 1, 2020.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 15/20 MTL 45/10, 25/08
MSM Chapter 2800 – School Health MSM Chapter 2800 – School Based Child
Services Health Services
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2800 Introduction Changed the name of services from School Based
Child Health Services (SBCHS) to School Health
Services (SHS). Added language to allow both Local
Education Agencies (LEAs) and State Education
Agencies (SEAs) to be able to provide medical
services in schools. Removed IEP limitation and
Page 1 of 8
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
replaced it with requirement that services be
screening/diagnostic or in a Plan of Care (POC).
Removed Individuals with Disabilities Education
Act (IDEA) language. Updated Nevada Check Up
(NCU) citation.
2801 Authority Removed list of services and replaced it with more
general language. Split regulations into Federal and
State. Added several Code of Federal Regulations
(CFRs) and Nevada Revised Statutes (NRSs).
Updated State Plan Amendment (SPA) page(s).
2802 Definitions Added definitions of 504 Accommodation Plan,
Activities of Daily Living (ADLs), Applied Behavior
Analysis (ABA), Autism Spectrum Disorder (ASD),
By or Under Direction Of, Fetal Alcohol Spectrum
Disorder (FASD), Individual Family Service Plan
(IFSP), Instrumental Activities of Daily Living
(IADLs), Legally Responsible Individual (LRI),
Medical Necessity, Medical Team Conference (with
interdisciplinary team), Personal Care Assistant
(PCA), Personal Care Services (PCS), Plan of Care
(POC), School Functional Assessment Service Plan
(SFASP), Screening and Diagnostic Services, State
Education Agency (SEA), Third Party Liability
(TPL) and Treatment Services. Removed definitions
of Counseling Services, Disability, Multidisciplinary
Conference (MDC) replaced by Medical Team
Conference, Parent (replaced by LRI), Present Levels
of Educational Performance, Progress Monitoring,
Related Services, Review and Revision of IEP,
Special Education and Support Services. Revised
definitions of Assistive Communication Device
(ACD), Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT), Local Education Agency
(LEA), and Short-term Objectives/Benchmark.
2803.1 Policy Overview Added POC language. Added the categories
Screening and Diagnostic Services, and Treatment
Services.
2803.1A Screening and Added new section that refers to Chapter 1500 –
Diagnostic Services Healthy Kids Program services that will now be
covered in School Health Services (SHS).
Page 2 of 8
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2803.1B Treatment Services Added new section that includes all SHS except those
in Screening and Diagnostic Services.
2803.1C Coverage and Previously Section 2803.1A. IEP development
Limitations meeting changed to medical team conference. Added
the language to “Section 2803.1C(3) Covered
Services” to make it more inclusive of screening and
diagnostic services. Rearranged services to match
order they are described later in the chapter. Updated
MSM sections referenced. Added screening,
diagnostic, and treatment services; mental health and
alcohol/substance abuse services (replaced
psychological counseling); PCS; ABA services;
dental services; optometry services; case
management; and services delivered by telehealth to
covered services. Added medical necessity and
Ordering, Prescribing, Referring (OPR) section to the
non-covered services. Removed dental or related
services, treatment of obesity, and any examination
and laboratory tests for preventable diseases from the
non-covered services.
2803.1D Provider Previously Section 2803.1B. Replace “Medical or
Responsibility Treatment Services” section with newly drafted
“Ordering, Prescribing and Referring (OPR)” section.
Added table to “By or Under the Direction Of”
section to clarify who can practice under the direction
of another provider. Replaced “Reserved for Future
Use” section with newly drafted “Plan of Care
(POC)” section. Replaced “Individualized Education
Program (IEP)” section with “Medical Team
Conference (with Interdisciplinary Team)” section.
Removed IEP Assessment/Evaluation and
Assessment sections. Added statement that
documentation must be completed as appropriate for
the service being provided as detailed in the
corresponding MSM chapter to the Records section.
Made Non-Discrimination section more general and
reference back to MSM 100. Added language to the
Third Party Liability (TPL) section to state that Pay
& Chase will only apply to IEP services. Replaced
Parental Notification and Consent section with Katie
Beckett Recipients section. Removed parental
notification and consent as it is a Family Educational
Page 3 of 8
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
Rights and Privacy Act (FERPA) regulation not a
Medicaid regulation.
2803.1F Authorization Previously Section 2803.1D. Added language that
Process POC serves as prior authorization. Added reference to
the OPR section.
2803.2 Provider Licensed replaced with qualified as not all services
Qualifications require a licensed provider.
2803.2A Physician, Added provider qualifications.
Physician’s
Assistant, &
Advanced Nurse
Practitioner
Qualification
2803.2B Mental Health and Added provider qualifications.
Substance Abuse
Services
Qualifications
2803.2C Nursing Added provider qualifications.
Qualifications
2803.2D Physical Therapy Added provider qualifications.
Qualifications
2803.2E Occupational Added provider qualifications.
Therapy
Qualifications
2803.2F Speech Therapy and Added provider qualifications.
Audiology
Qualifications
2803.2G PCS Qualifications Added provider qualifications.
2803.2H Applied Behavior Added provider qualifications.
Analysis (ABA)
Qualifications
2803.2I Dental Added provider qualifications.
Qualifications
Page 4 of 8
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2803.2J Optometry Added provider qualifications.
Qualifications
2803.2K Case Management Added provider qualifications.
Qualifications
2803.2L Telehealth Added provider qualifications.
Qualifications
2803.3 Screening, Added new section that refers to Chapter 1500 –
Diagnostic Services, Healthy Kids Program services that will now be
and Treatment covered in School Health Services (SHS).
2803.3A Coverage and Added new section with coverage and limitations of
Limitations screening, diagnostic and treatment services.
2803.3B Covered Services Added new section with covered services for
screening, diagnostic and treatment services.
2803.3C Limitations Added new section with limitations for screening,
diagnostic and treatment services.
2803.4 Physician, Previously Section 2803.3. Added APRNs.
Physician’s
Assistant &
Advanced Nurse
Practitioner
Services
2803.4A Covered Services Defined the list of covered services as examples, not
an exhaustive list.
2803.4B Limitations Added new section with limitations for physician,
physician’s assistant & advanced nurse practitioner
services.
2803.5 Mental Health and Renamed section from psychological counseling.
Alcohol/Substance Added language to more closely resemble the
Abuse Services language in MSM, Chapter 400.
2803.5A Covered Services Added neuro-cognitive, psychological and mental
status testing; mental health therapies; medication
management; medication training & support,
rehabilitative mental health services; outpatient
Page 5 of 8
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
alcohol and substance abuse services; and medical
team conference participation as covered services.
2803.5B Limitations Added new section with limitations for Mental Health
and Alcohol/Substance Abuse Services.
2803.6 Nursing Services Added language that nursing services must be under
the order and direction of a physician or APRN.
Removed statement that services considered
observational or stand-by in nature are not covered.
2803.6A Covered Services Clarified who Registered Nurses (RNs) may
supervise. Changed IEP/IFSP meeting to Medical
Team Conference.
2803.6B Limitations Added new section with limitations for Nursing
Services.
2803.7A Covered Services Changed IEP/IFSP meeting to Medical Team
Conference.
2803.7B Limitations Added new section with limitations for Physical
Therapy Services.
2803.8A Covered Services Changed IEP/IFSP meeting to Medical Team
Conference.
2803.8B Limitations Added new section with limitations for Occupational
Therapy Services.
2803.9A Covered Services Changed IEP/IFSP meeting to Medical Team
Conference.
2803.9B Limitation Added new section with limitations for Speech
Therapy and Audiology Services.
2803.10 Audiological Replaced IEP with POC.
Supplies,
Equipment, Medical
Supplies and Other
Durable Medical
Equipment (DME)
Page 6 of 8
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2803.10B Limitations Added new section with limitations for Audiological
Supplies, Equipment, Medical Supplies and other
DME.
2803.11 Personal Care Added new section on how PCS can be provided in a
Services (PCS) in school setting.
School Setting
2803.11A Covered Services Added new section on what is covered under PCS in
a school setting.
2803.11B Service Limitations Added new section with service limitations for PCS
in a school setting.
2803.11C Non-Covered Added new section on non-covered services for PCS
Services in a school setting.
2803.11D Authorization Added new section on authorization process for PCS
Process in a school setting.
2803.11E Flexibility of Added new section on flexibility of PCS services
Services Delivery delivered in a school setting.
2803.11F Supervision Added new section on supervision of Personal Care
Assistant (PCA) providing services in a school
setting.
2803.11G Records Added new section on documentation of PCS services
in a school setting.
2803.12 Applied Behavior Added new section on how ABA services can be
Analysis (ABA) provided.
2803.12A Covered Services Added new section on covered services for ABA in a
school setting.
2803.12B Limitations Added new section on limitations of ABA services in
a school setting.
2803.13 Dental Added new section on dental services covered in a
school setting.
2803.13A Covered Services Added new section on what dental services are
covered in the school setting.
Page 7 of 8
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
2803.13B Limitations Added new section on limitations of dental services
in a school setting.
2803.14 Optometry Added new section on optometry services provided in
a school setting.
2803.14A Covered Services Added new section on optometry services covered in
a school setting.
2803.14B Limitations Added new section on limitations of optometry
services covered in a school setting.
2803.15 Case Management Added new section on case management services
provided in a school setting.
2803.15A Covered Services Added new section on case management services
covered in a school setting.
2803.15B Limitation Added new section on limitations of case
management services covered in a school setting.
2803.16 Telehealth Added new section on services provided by telehealth
in a school setting.
2803.16A Coverage and Added new section on coverage and limitations of
Limitations telehealth in a school setting.
2804 Reserved for Future Added new section for future use.
Use
2805 Hearings Previously section 2804.
2806 References and Previously section 2805.
Cross References
2806.1 Provider Specific Added MSM, Chapters 1000, 1100, 2500, 3400, and
Information 3700 to the references.
2805.3 Contracted QIO- Removed section.
Like Vendor and
Fiscal Agent
Attachment A Qualified Nevada Removed section.
Medicaid Providers
Page 8 of 8
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
SCHOOL BASED CHILD HEALTH SERVICES
2800 INTRODUCTION ............................................................................................................................ 1
2801 AUTHORITY ................................................................................................................................... 1
2802 DEFINITIONS .................................................................................................................................. 1
2803 POLICY ............................................................................................................................................ 1
2803.1 POLICY OVERVIEW ...................................................................................................................... 1
2803.1A SCREENING AND DIAGNOSTIC SERVICES ..............................................................................1
2803.1B TREATMENT SERVICES .............................................................................................................. 2
2803.1C COVERAGE AND LIMITATIONS ................................................................................................ 2
2803.1D PROVIDER RESPONSIBILITY...................................................................................................... 5
2803.1E RECIPIENT RESPONSIBILITIES ................................................................................................ 14
2803.1F AUTHORIZATION PROCESS ..................................................................................................... 14
2803.2 PROVIDER QUALIFICATIONS .................................................................................................. 15
2803.2A PHYSICIAN, PHYSICIAN’S ASSISTANT & ADVANCED NURSE PRACTITIONER
QUALIFICATIONS ....................................................................................................................... 15
2803.2B MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES QUALIFICATIONS................. 16
2803.2C NURSING QUALIFICATIONS .................................................................................................... 16
2803.2D PHYSICAL THERAPY QUALIFICATIONS ............................................................................... 16
2803.2E OCCUPATIONAL THERAPY QUALIFICATIONS .................................................................... 16
2803.2F SPEECH THERAPY AND AUDIOLOGY QUALIFICATIONS ................................................. 16
2803.2G PCS QUALIFICATIONS ............................................................................................................... 16
2803.2H APPLIED BEHAVIOR ANALYSIS (ABA) QUALIFICATIONS ............................................... 19
2803.2I DENTAL QUALIFICATIONS ...................................................................................................... 19
2803.2J OPTOMETRY QUALIFICATIONS .............................................................................................. 19
2803.2K CASE MANAGEMENT QUALIFICATIONS .............................................................................. 20
2803.2L TELEHEALTH QUALIFICATIONS ............................................................................................ 20
2803.3 SCREENING AND DIAGNOSTIC SERVICES ........................................................................... 20
2803.3A COVERAGE AND LIMITATIONS .............................................................................................. 20
2803.3B COVERED SERVICES .................................................................................................................. 20
2803.3C LIMITATIONS ............................................................................................................................... 21
2803.4 PHYSICIAN, PHYSICIAN’S ASSISTANT & ADVANCED NURSE PRACTITIONER
SERVICES ...................................................................................................................................... 22
2803.4A COVERED SERVICES .................................................................................................................. 22
2803.4B LIMITATIONS ............................................................................................................................... 22
2803.5 MENTAL HEALTH AND ALCOHOL/SUBSTANCE ABUSE SERVICES............................... 22
2803.5A COVERED SERVICES .................................................................................................................. 23
2803.5B LIMITATIONS ............................................................................................................................... 23
2803.6 NURSING SERVICES ................................................................................................................... 24
2803.6A COVERED SERVICES .................................................................................................................. 24
2803.6B LIMITATIONS ............................................................................................................................... 25
2803.7 PHYSICAL THERAPY SERVICES .............................................................................................. 25
Page 1 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
2803.7A COVERED SERVICES .................................................................................................................. 25
2803.7B LIMITATIONS ............................................................................................................................... 26
2803.8 OCCUPATIONAL THERAPY SERVICES .................................................................................. 26
2803.8A COVERED SERVICES .................................................................................................................. 26
2803.8B LIMITATIONS ............................................................................................................................... 27
2803.9 SPEECH THERAPY AND AUDIOLOGY SERVICES................................................................ 27
2803.9A COVERED SERVICES .................................................................................................................. 27
2803.9B LIMITATION ................................................................................................................................. 27
2803.10 AUDIOLOGICAL SUPPLIES, EQUIPMENT, MEDICAL SUPPLIES AND OTHER
DURABLE MEDICAL EQUIPMENT (DME) .............................................................................. 28
2803.10A COVERED SERVICES .................................................................................................................. 28
2803.10B LIMITATIONS ............................................................................................................................... 28
2803.11 PERSONAL CARE SERVICES (PCS) IN SCHOOL SETTING.................................................. 28
2803.11A COVERED SERVICES .................................................................................................................. 29
2803.11B SERVICE LIMITATIONS ............................................................................................................. 29
2803.11C NON-COVERED SERVICES ........................................................................................................ 29
2803.11D AUTHORIZATIONS PROCESS ................................................................................................... 31
2803.11E FLEXIBILITY OF SERVICES ...................................................................................................... 31
2803.11F SUPERVISION............................................................................................................................... 32
2803.11G RECORDS ...................................................................................................................................... 32
2803.12 APPLIED BEHAVIOR ANALYSIS (ABA).................................................................................. 33
2803.12A COVERED SERVICES .................................................................................................................. 33
2803.12B LIMITATIONS ............................................................................................................................... 33
2803.13 DENTAL......................................................................................................................................... 34
2803.13A COVERED SERVICES .................................................................................................................. 34
2803.13B LIMITATIONS ............................................................................................................................... 34
2803.14 OPTOMETRY ................................................................................................................................ 34
2803.14A COVERED SERVICES .................................................................................................................. 35
2803.14B LIMITATIONS ............................................................................................................................... 35
2803.15 CASE MANAGEMENT ................................................................................................................ 35
2803.15A COVERED SERVICES .................................................................................................................. 35
2803.15B LIMITATIONS ............................................................................................................................... 36
2803.16 TELEHEALTH ............................................................................................................................... 36
2803.16A COVERAGE AND LIMITATIONS .............................................................................................. 36
2804 RESERVED FOR FUTURE USE .................................................................................................... 1
2805 HEARINGS ...................................................................................................................................... 1
2806 REFERENCES AND CROSS REFERENCES ................................................................................ 1
2806.1 PROVIDER SPECIFIC INFORMATION ....................................................................................... 1
Page 2 of 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2800
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
SCHOOL HEALTH SERVICES
2800 INTRODUCTION
School Health Services (SHS) are medical services provided by a Local Education Agency (LEA)
or State Education Agency (SEA) for children who attend public schools in Nevada. SHS are
provided to Medicaid eligible students. SHS are medically necessary services listed in the student’s
Plan of Care (POC), and/or preventive services that are coverable under Early Periodic Screening,
Diagnostic, and Treatment (EPSDT) as defined in 42 Code of Federal Regulations (CFR)
440.40(b). Services listed in a POC are designed to meet the health needs of a child and work
towards the reduction of a physical or mental impairment and restoration of the child to the best
possible functional level.
All Medicaid policies and requirements (such as prior authorization (PA), etc.) are the same for
Nevada Check Up (NCU) recipients, with the exception of the areas where Medicaid and NCU
policies differ as documented in the NCU Manual Chapter 1000.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2801
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
2801 AUTHORITY
SHS contain an element of early detection and preventive service delivery. EPSDT is a mandatory
benefit authorized by 1905(a) and 1903(4)(c) of the Social Security Act.
SHS also contains a rehabilitative element of service delivery. These services are optional benefits
under the program and include services authorized in the Nevada Medicaid State Plan.
Federal regulations governing SHS are:
• Social Security Act Section 1903(c)
• Social Security Act Section 1902(a)(30)(A)
• 42 CFR 441.58.c.
• 42 CFR 440.110, 440.130.d and 440.170
• 42 CFR 440.40(b)
• 42 CFR 440 Subpart A
• 42 CFR 447.201
• 42 CFR 431.53
• 42 CFR 435
• 42 CFR 455.410 and 455.440
• 34 CFR 300.154(d)(2)(iv)
• 34 CFR 300.300
State regulations governing SHS are:
• Nevada Administrative Code (NAC) 640A.020
• NAC 640.001 to 006
• State Plan Amendment 3.1-A
• Nevada Revised Statutes (NRS) 603
March 1, 2020 SCHOOL HEALTH SERVICES Section 2801 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2801
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
• NRS 630
• NRS 632
• NRS 633
• NRS 636
• NRS 637
• NRS 637B
• NRS 640
• NRS 640A
March 1, 2020 SCHOOL HEALTH SERVICES Section 2801 Page 2
MTL 15/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2802
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
2802 DEFINITIONS
504 ACCOMODATION PLAN
A plan developed to ensure that a child who has a disability identified under the law and is
attending an elementary or secondary educational institution receives accommodations that will
ensure their academic success and access to the learning environment.
ACTIVITIES OF DAILY LIVING (ADLs)
Self-care activities routinely performed on a daily basis, such as bathing, dressing, grooming,
toileting, transferring, mobility/ambulation and eating.
APPLIED BEHAVIOR ANALYSIS (ABA)
The design, implementation, and evaluation of environmental modifications using behavioral
stimuli and consequences to produce socially significant improvement in human behavior,
including the use of direct observation, measurement, and functional analysis of the relations
between environment and behavior.
ASSISTIVE COMMUNICATION DEVICE (ACD)
A Durable Medical Equipment (DME) which helps speech, hearing and verbally impaired
individuals communicate.
AUDIOLOGY TESTING
Audiology testing is evaluation/testing performed by an audiologist licensed by the appropriate
licensure board of the state to determine extent of hearing impairments that affect the student's
ability to access education. Audiology testing includes hearing and/or hearing aid evaluations,
hearing aid fitting or reevaluation and audiograms.
AUTISM SPECTRUM DISORDER (ASD)
A group of developmental disabilities that can cause significant social, communication, and
behavioral challenges.
BY OR UNDER DIRECTION OF
“By or under the direction of” means that the Medicaid qualified staff providing direction is a
licensed practitioner of the healing arts qualified under state law and federal regulations to diagnose
and treat individuals with the disability or functional limitations, is operating within their scope of
practice defined in Nevada State law, and is supervising each individual’s care.
March 1, 2020 SCHOOL HEALTH SERVICES Section 2802 Page 1
MTL 15/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2802
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT)
A preventive health care program, the goal of which is to provide to Medicaid eligible children
under the age of 21 the most effective, preventive health care through the use of periodic
examinations, standard vaccinations, diagnostic and treatment services which are medically
necessary and designed to correct or ameliorate defects in physical or mental illnesses or
conditions. 42 United States Code (USC) Section 1396.d (a)(4)(B). Nevada’s program is named
Healthy Kids.
FETAL ALCOHOL SPECTRUM DISORDERS (FASD)
A group of developmental conditions resulting from maternal alcohol use during pregnancy.
FREE APPROPRIATE PUBLIC EDUCATION (FAPE)
A federal statutory requirement that children and youth with disabilities receive a public education
appropriate to their needs at no cost to their families.
INDIVIDUAL FAMILY SERVICE PLAN (IFSP)
A plan for special services for young children from birth to three years of age with disabilities.
The goals that are put into place within an IFSP are targeted toward the family versus the goals
within an Individualized Education Program (IEP) which are targeted specifically towards the
student.
INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA)
The federal law that mandates that a free and appropriate public education is available to all school-
age children with disabilities.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
A written plan for every student receiving special education services that contain information such
as the student’s special learning needs and the specific education services required for the student.
The document is periodically reviewed and updated at least annually.
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)
Activities related to independent living including meal preparation, laundry, light housekeeping
and essential shopping.
March 1, 2020 SCHOOL HEALTH SERVICES Section 2802 Page 1
MTL 15/20
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2802
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
LEGALLY RESPONSIBLE INDIVIDUAL (LRI)
Individuals who are legally responsible to provide medical support. These individuals include legal
guardians and parents of minor recipients, including stepparents, foster parents, and adoptive
parents. LRIs may not be reimbursed for providing Personal Care Services (PCS). For this
chapter’s purpose LRI does not include the State if the child is a ward of the State and an LRI can
be any person, individual acting in the place of a natural or adoptive parent including a grandparent,
or other relative with whom the child lives.
LOCAL EDUCATION AGENCY (LEA)
A public board of education or other public authority legally constituted for administrative control
or direction of a public elementary or secondary schools in a city, county, township, school district,
or for a combination of school districts or counties as are recognized in a state as an administrative
agency for its public elementary schools or secondary schools
MEDICAL NECESSITY
Reference Medicaid Services Manual (MSM) Chapter 100 for Nevada’s definition of medical
necessity.
MEDICAL TEAM CONFERENCE (WITH INTERDISCIPLINARY TEAM)
A conference with an interdisciplinary team to determine a student's need for further testing. The
required composition of the team is defined in MSM Section 2803.1D(6) of this Chapter, Provider
Responsibility - Medical Team Conference (with Interdisciplinary Team). Other professional staff
such as physical therapists, occupational therapists, speech therapists, and behavior analysts, etc.
may provide input, as well as audiology, vision, health, education and the student’s LRI. As a result
of this process, a POC will be established outlining treatment modalities.
PERSONAL CARE ASSISTANT (PCA)
A trained but unlicensed individual who provides PCS to individuals with disabilities and/or
conditions which causes them barriers to independently performing ADLs and IADLs.
PERSONAL CARE SERVICES (PCS)
A range of human assistance provided to a student with disabilities and chronic conditions, which
enables accomplishment of tasks that they would normally do for themselves if they did not have
a disability or chronic condition. Assistance may be in the form of direct hands-on assistance or
cueing the student to perform the task themselves and related to the performance of ADLs and
IADLs.
March 1, 2020 SCHOOL HEALTH SERVICES Section 2802 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2802
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
PLAN OF CARE (POC)
For the purpose of this chapter POC is defined as a medical document developed after an
assessment by a qualified health professional acting within their scope of practice. Serves as
documentation of medical necessity for all services being provided to the student. Must include all
elements outlined in MSM 2803.1D(5) of this chapter.
SCHOOL FUNCTIONAL ASSESSMENT SERVICE PLAN (SFASP)
An assessment tool used by a trained physical or occupational therapist, to complete an in-person
assessment, to identify the ability/inability of a student to perform ADLs and IADLs. This
assessment identifies a student’s unmet needs and provides a mechanism for determining the
appropriate amount of PCS hours, based on the student’s needs and functional ability. The SFASP
also evaluates the environment in which services are provided.
SCREENING AND DIAGNOSTIC SERVICES
A child’s health is assessed as early as possible in the child’s life, in order to prevent or find
potential diseases and disabilities in their early stages, when they are most effectively treated.
Assessment of a child’s health at regularly scheduled intervals assures that a condition, illness or
injury is not developing or present. Screening services provide physical, mental, developmental,
dental, hearing, vision, and other screening tests to detect potential problems. Diagnostic services
or tests are performed to follow up when a risk is identified.
SHORT-TERM OBJECTIVES/BENCHMARK
A POC must contain a statement of annual goals, including a description of short-term objectives
or benchmarks that are measurable and outcome oriented. Goals should be related to the child’s
unique needs to enable the child with a disability to participate and function in the general
curriculum.
STATE EDUCATION AGENCY (SEA)
The State board of education or other agency responsible for the State supervision of public
elementary schools and secondary schools.
THIRD PARTY LIABILITY (TPL)
The legal obligation of third parties (ie. any individual, entity or program) that may be liable to
pay all or part of the expenditures for medical assistance furnished under a State Medicaid Plan
including NCU. By law, all other third party resources must meet their legal obligation to pay
claims before the Medicaid program pays for the care of an individual eligible for Medicaid.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2802
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
TREATMENT SERVICES
Treatment services are those available to correct or improve diagnosed physical and/or mental
illnesses. Treatment must be medically necessary and does not include educational interventions.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2803
Subject:
MEDICAID SERVICES MANUAL POLICY
2803 POLICY
2803.1 POLICY OVERVIEW
It is the policy of the Division of Health Care Financing and Policy (DHCFP) to support the unique
health needs of Medicaid eligible students Medicaid covers School Health Services (SHS) when
they are primarily medical and not educational in nature. This chapter establishes a Medicaid
provision for medically necessary health care services a LEA/SEA may provide to students.
For a LEA/SEA to receive reimbursement for services through the Medicaid SHS Program, each
Medicaid eligible student must have a POC that documents the medical necessity of the service to
be provided and/or preventive services that are coverable under EPSDT. This documentation needs
to specify the services required to treat the student’s identified medical condition(s) as specified
in MSM Section 2803.1D of this chapter.
The DHCFP recognizes two categories of services that can be provided in SHS. These categories
are:
a. Screening and Diagnostic Services, and
b. Treatment Services.
2803.1A SCREENING AND DIAGNOSTIC SERVICES
LEAs/SEAs are encouraged to provide screening and diagnostic services as defined in MSM
Chapter 1500 – Healthy Kids Program. These services can be covered without a POC as long as
the screening and diagnostic services:
1. Follow the periodicity schedule as established in the Healthy Kids Program, MSM Chapter
1500;
2. Are determined to be a medically necessary screening when it falls outside the periodicity
schedule; and
3. Are documented in medical records with the assessments and significant positive and
negative findings, and referrals made for diagnosis, treatment or other medically necessary
health services for any conditions identified.
A child’s health is assessed as early as possible in the child’s life, in order to prevent or find
potential diseases and disabilities in their early stages, when they are most effectively treated.
Assessment of a child’s health at regularly scheduled intervals assures that a condition, illness or
injury is not developing or present.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2803
Subject:
MEDICAID SERVICES MANUAL POLICY
2803.1B TREATMENT SERVICES
Treatment services are those available to correct or improve defects and physical and mental
illnesses. Treatment must be medically necessary and does not include educational interventions.
Treatment services must be documented appropriately for the service that is being provided in a
POC as described in MSM Section 2803.1D(5) of this chapter, Provider Responsibility – Plan of
Care (POC).
2803.1C COVERAGE AND LIMITATIONS
1. PROGRAM ELIGIBILITY CRITERIA
Only those services listed in MSM Sections 2803.3 – Preventive Health Screenings and
Treatment through 2803.16 – Telehealth of this chapter are covered benefits.
a. SHS are available for eligible Medicaid and NCU children between three years of
age and under the age of 21, in both Fee-for-Service (FFS) and Medicaid Managed
Care. SHS for children who are enrolled in Medicaid Managed Care are covered
and reimbursed under the FFS Medicaid. The student must be Medicaid eligible
when services are provided;
b. The DHCFP does not reimburse for any services considered educational or
recreational in nature;
c. Any Medicaid eligible child requiring SHS services may receive these services
from the LEA/SEA provided:
1. All SHS relate to a medical diagnosis and are medically necessary;
2. The service performed is within the scope of the profession of the healthcare
practitioner performing the service;
3. All services including the scope, amount, frequency and duration of service
are documented as part of the child’s school record, including the name(s)
of the health practitioner(s) actually providing the service(s);
4. The treatment services are a part of the recipient’s written POC; or an
assessment, evaluation, or screening for the purpose of early identification
of health concerns. This documentation must be kept on file with the
LEA/SEA. The plan/documentation may be subject to review by authorized
DHCFP personnel; and
March 1, 2020 SCHOOL HEALTH SERVICES Section 2803 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2803
Subject:
MEDICAID SERVICES MANUAL POLICY
5. All applicable federal and state Medicaid regulations are followed,
including those for provider qualifications, comparability of services and
the amount, duration and scope of provisions.
2. LIMITATIONS
The Nevada Medicaid Program pays for SHS services conforming to accepted methods of
diagnosis and treatment directly related to the recipient’s diagnosis, symptoms or medical
history. Limitations are:
a. Only qualified health care providers will be reimbursed for their participation in the
POC development for medical related services concerning each specific discipline.
Nevada Medicaid reimbursement for the participation time in the Medical Team
Conference is only allowed for medical related services, not educational process
and goals.
b. Services are limited to medical and related services described throughout this
Chapter and procedure codes listed on the DHCFP website Provider Type (PT) 60
SHS Fee Schedule at http://dhcfp.nv.gov/RatesUnit.htm.
c. Services may not be provided to students under the age of three years old or students
age of 21 years and older.
3. COVERED SERVICES
SHS are medically necessary diagnostic, evaluative, and direct medical services to detect,
correct, or ameliorate any physical or mental diagnosis that meet the medical needs of
Medicaid eligible students. The services are provided by a LEA/SEA to meet the health
needs of a student. The services are 1) directed at early detection of a physical or mental
health impairment, or 2) the reduction of a physical or mental impairment and restoration
of the child to his/her best possible functioning level.
SHS Covered Services include:
a. Screening, diagnostic and treatment services when provided as described in MSM
Section 2803.3 of this chapter.
b. Physician services when provided as described in MSM Sections 2803.2A and
2803.4 of this chapter.
c. Mental health and alcohol/substance abuse services when provided as described in
MSM Sections 2803.2B and 2803.5 of this chapter.
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d. Nursing services when provided as described in MSM Sections 2803.2C and
2803.6 of this chapter.
e. Physical therapy services when provided as described in MSM Sections 2803.2D
and 2803.7 of this chapter.
f. Occupational therapy services when provided as described in MSM Sections
2803.2E and 2803.8of this chapter.
g. Speech therapy services when provided as described in MSM Sections 2803.2F and
2803.9 of this chapter.
h. ACD, audiological supplies and disposable medical supplies provided to serve a
medical purpose, intervention to maintain or improve the student’s health status.
Refer to MSM Section 2803.10 of this chapter.
i. PCS when provided as described in MSM Sections 2803.2G and 2803.11 of this
chapter.
j. ABA services when provided as described in MSM Sections 2803.2H and 2803.12
of this chapter.
k. Dental services when provided as described in MSM Sections 2803.2I and 2803.13
of this chapter.
l. Optometry services when provided as described in MSM Sections 2803.2J and
2803.14 of this chapter.
m. Case management services when provided as described in MSM Sections 2803.2K
and 2803.15 of this chapter.
n. Telehealth services when clinically appropriate and within the health care
professional’s scope of practice as established by its licensing agency. Refer to
MSM Sections 2803.2L and 2803.16 of this chapter.
4. NON-COVERED SERVICES
a. Medical care that does not meet the medical necessity definition in MSM Chapter
100, e.g. health education classes and first aid classes;
b. Evaluation and/or direct medical service performed by providers who do not meet
Medicaid provider qualifications;
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c. Information furnished by the provider to the recipient over the telephone;
d. Services which are educational, vocational, or career oriented;
e. Speech services involving non-diagnostic, non-therapeutic, routine, repetitive, and
reinforced procedures or services for the child’s general good and welfare; e.g., the
practicing of word drills. Such services do not constitute speech pathology services
for Medicaid purposes and are not to be covered since they do not require
performance by a licensed qualified health care provider;
f. When maximum benefits from any treatment program are reached, the service is
no longer covered;
g. Any vaccinations, biological products and other products available free of charge
from the State Division of Public and Behavioral Health (DPBH);
h. Any services recreational in nature, including those services provided by an
adaptive specialist or assistant;
i. Textbooks or other such items that are educational in nature and do not constitute
medical necessity;
j. Transportation of school aged children to and from school, including specialized
transportation for Medicaid eligible children on days when they receive Medicaid
covered services at school;
k. Covered medical service(s) listed in a POC for those dates of service when the POC
has expired; and
l. Covered medical or treatment service(s) which require a referral/prescription (as
detailed in MSM Section 2803.1D(3) of this chapter, Provider Responsibility –
OPR) from a qualified professional working within their scope of practice pursuant
to Nevada State Law and are being provided without the referral or prescription
from a qualified professional.
2803.1D PROVIDER RESPONSIBILITY
1. GENERAL INFORMATION
The provider shall furnish screening, diagnostic, and treatment services as medically
necessary and identified in the POC.
As a condition of participation in the Nevada Medicaid Program, all service providers must
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abide by the policies of the DHCFP, state and federal laws and regulations, including but
not limited to, the United States CFRs governing the Medicaid Program, and all state laws
and rules governing the Department of Education and the DHCFP. All providers must meet
the requirements established for being a Medicaid provider. This includes the LEA/SEA’s
subcontractors who must meet all qualifications as Nevada Medicaid providers for the
services they are providing. Department of Education Certification is not sufficient under
federal regulations to meet Medicaid provider requirements.
All staff providing services to recipients under the SHS Program must be qualified as
detailed in MSM Section 2803.2 of this chapter (Provider Qualifications) and provide
services within their scope of practice.
2. ENROLLMENT PROCEDURES AND REQUIREMENTS
To be enrolled in the Nevada Medicaid Program as a SHS (PT 60), a LEA/SEA must enter
into an Inter-Local Agreement, signed by the LEA or SEA and the DHCFP. Participating
providers must comply with Medicaid regulations, procedures, and terms of the contract.
The provider must allow, upon request of proper representatives of the DHCFP, access to
all records which pertain to Medicaid recipients for regular review, audit, or utilization
review. Refer to the MSM Chapter 100 for medical and fiscal record retention timeframes.
3. ORDERING, PRESCRIBING AND REFERRING (OPR)
In the school setting, if the service being provided is one in which reimbursement is
dependent on the presence of an order, prescription or referral, then the claims for those
services must comply with the Ordering, Prescribing, and Referring (OPR) requirements
found at 42 CFR 455.410 and 455.440. The OPR requirements for services are based on
the federal regulations at 42 CFR 440 Subpart A and what the state has defined in the
Nevada Medicaid State Plan.
The referral/prescription services must be renewed at least annually and/or when the scope,
amount and frequency, or duration of service(s) has changed. A POC that includes the
required components of a referral/prescription for a service that has been reviewed and
signed by a Medicaid qualified provider operating within their scope of practice pursuant
to state law may serve as the referral/prescription for service(s).
For Medicaid to reimburse for services or medical supplies resulting from a practitioner’s
order, prescription, or referral, the OPR provider must be enrolled in Medicaid. Physicians
or other eligible professionals who are already enrolled in Nevada Medicaid as a
participating provider and who submit claims to Medicaid are not required to enroll
separately as an OPR.
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The table below shows each category of service that can be provided in SHS and if that
service requires an order or prescription prior to being provided. Additionally, if the service
does require an order or prescription, it states what level of professional is able to make
that order/prescription.
Service Ordering, Ordering/Referring Qualifications
Prescribing,
Referring (OPR)
Required
Physician Services No No OPR requirement
Mental Health and No No OPR requirement
Alcohol/Substance Abuse
Services
Nursing Services Yes Physician, M.D.; Osteopath, D.O.;
Advanced Practice Registered Nurse
(APRN); Physician’s Assistant (PA)
Therapies (Physical, Yes Physician, M.D.; Osteopath, D.O.;
Occupational, and Speech) APRN; PA
Durable Medical Equipment Yes Physician, M.D.; Osteopath, D.O.;
(DME) Disposable Supplies and APRN; PA
Supplements
Audiology Services No No OPR requirement
Hearing Aid Dispenser & Yes Audiologist; Physician, M.D.;
Related Supplies Osteopath, D.O.; APRN; PA
Laboratory Services Yes Physician, M.D.; Osteopath, D.O.;
APRN; PA
Personal Care Services (PCS) Yes Occupational Therapist; Physical
Therapist; Physician, M.D.; Osteopath,
D.O.; APRN; PA
Applied Behavior Analysis Yes Clinical Psychologist;
(ABA) services Neuropsychologist; Physician, M.D.;
Osteopath, D.O.; APRN; PA
Dental No No OPR requirement
Ocular Services No No OPR requirement
Case Management No No OPR requirement
Treatment services may also be provided by a community-based private practitioner
performing within the scope of his/her practice as defined by state law. In providing SHS
at a location other than the school campus, the LEA or SEA may contract with community-
based licensed health professionals and clinics.
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4. BY OR UNDER THE DIRECTION OF
“By or under the direction of” means that the Medicaid qualified staff providing direction
is a licensed practitioner of the healing arts qualified under state law and federal regulations
to diagnose and treat individuals with a disability or functional limitations and is operating
within their scope of practice defined in Nevada State law and is supervising each
individual’s care.
The supervision must include, at a minimum, face-to-face contact with the individual
provider being supervised initially and periodically as needed, prescribing the services
provided and reviewing the need for continued services throughout the course of treatment.
The Medicaid qualified supervisor must also assume professional responsibility for the
services provided and ensure that the services are medically necessary. The Medicaid
qualified supervisor must spend as much time as necessary directly supervising the services
to ensure the student(s) are receiving services in a safe and efficient manner and in
accordance with accepted standards of practice. Documentation must be kept supporting
the supervision of services and ongoing involvement in the treatment.
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Qualified Nevada Medicaid Providers Supervisor Supervisee
Bill “Under the
Direction of a
Supervisor”
PHYSICIAN AND NURSING SERVICES
Physician licensed by the Nevada State Board of Medical Examiners or the X
Nevada State Board of Osteopathic Medical Examiners acting within their
scope of practice.
Physician Assistant licensed by the Nevada State Board of Medical Examiners X
or certification by the Nevada State Board of Osteopathic Medicine to perform
medical services supervised by a licensed physician in accordance with
professional standards.
Advanced Practice Registered Nurse (APRN) licensed by the Nevada State X
Board of Nursing acting within their scope of practice.
A Registered Nurse (RN) licensed by the Nevada State Board of Nursing acting X X
within their scope of practice. (LPNs/CNAs (M.D., D.O., or
only) APRN)
A licensed Practical Nurse licensed by the Nevada State Board of Nursing. X
Supervised by a licensed APRN or RN in accordance with professional
standards.
A Nursing Assistant certified by the Nevada State Board of Nursing. X
Supervised by a licensed APRN or RN in accordance with professional
standards.
MENTAL HEALTH AND ALCOHOL/SUBSTANCE ABUSE
SERVICES
A Doctorate Degree in Psychology and licensed by the State of Nevada Board X
of Psychological Examiners acting within their scope of practice.
Psychological Assistants registered with the State of Nevada Board of X
Psychological Examiners and supervised by a licensed psychologist in
accordance with professional standards.
Psychological Interns registered with the State of Nevada Board of X
Psychological Examiners and supervised by a licensed psychologist in
accordance with professional standards.
Psychological Trainees registered with the State of Nevada Board of X
Psychological Examiners and supervised by a licensed psychologist in
accordance with professional standards.
Licensed Clinical Social Workers (LCSW) licensed by the Nevada Board of X
Examiners for Social Workers acting within their scope of practice.
Licensed Marriage and Family Therapists (LMFT) licensed by the Nevada X
Board of Examiners for Marriage and Family Therapists and Clinical
Professional Counselors acting within their scope of practice.
Clinical Professional Counselors (CPC) licensed by the Nevada Board of X
Examiners for Marriage and Family Therapists and Clinical Professional
Counselors acting within their scope of practice.
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Qualified Nevada Medicaid Providers Supervisor Supervisee
Bill “Under the
Direction of a
Supervisor”
Qualified Mental Health Professionals (QMHPs) as defined in MSM, Chapter X
400, excluding Interns, operating within the scope of their practice under state
law.
LCSW interns licensed by the Nevada Board of Examiners for Social Workers X
and supervised by a LCSW, LMFT, CPC, or QMHP acting within their scope
of practice.
LMFT interns licensed by the Nevada Board of Examiners for Marriage and X
Family Therapists and Clinical Professional Counselors and supervised by a
LCSW, LMFT, CPC, or QMHP acting within their scope of practice.
CPC intern licensed by the Nevada Board of Examiners for Marriage and X
Family Therapists and Clinical Professional Counselors and supervised by a
LCSW, LMFT, CPC, or QMHP acting within their scope of practice.
Qualified Mental Health Associates (QMHAs) as defined in MSM, Chapter X
400, and supervised by a LCSW, LMFT, CPC, or QMHP acting within their
scope of practice.
Qualified Behavioral Aids (QBAs) as defined in MSM, Chapter 400, and X
supervised by a LCSW, LMFT, CPC, or QMHP acting within their scope of
practice.
OCCUPATIONAL THERAPY SERVICES
An Occupational Therapist licensed by the State of Nevada Board of X
Occupational Therapy acting within their scope of practice.
An Occupational Therapy Assistant certified by the State of Nevada Board of X
Occupational Board of Therapy. Supervised by a Licensed Occupational
Therapist in accordance with professional standards.
PHYSICAL THERAPY SERVICES
A Physical Therapist licensed by the State of Nevada Physical Therapy X
Examiners Board.
A Physical Therapist Assistant licensed by the State of Nevada Physical X
Therapy Examiners Board. Supervised by a licensed Physical Therapist in
accordance with professional standards.
SPEECH PATHOLOGIST SERVICES
Licensed Speech-Language Pathologist by the Nevada Speech-Language
Pathology, Audiology, and Hearing Aid Dispensing Board and has Certificate X
of Clinical Competence (CCC) from the American Speech and Hearing
Association (ASHA).
Licensed Speech-Language Pathologist by the Nevada Speech-Language
Pathology, Audiology, and Hearing Aid Dispensing Board with no CCC but X
holds a Master’s or doctoral degree from an accredited institution.
Speech-Language Pathologist clinical fellow with a provisional license from X
the Nevada Speech-Language Pathology, Audiology, and Hearing Aid
Dispensing Board and supervised by a licensed Speech-Language Pathologist
in accordance with professional standards.
Qualified Speech-Language endorsed by the Department of Education as
detailed in NAC 391.370 2(a), (c), (d), (e) and supervised by a licensed Speech- X
Language Pathologist in accordance with professional standards.
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5. PLAN OF CARE
A POC is a medical document developed after an assessment by a qualified health
professional acting within their scope of practice. A POC must meet the following
guidelines:
a. The POC must identify a health condition/diagnosis that requires treatment.
b. The POC must identify the type of treatment to be provided and the frequency it
will be provided.
c. The POC must identify the short-term objectives of the treatment interventions.
d. The POC must include a time frame for evaluation of progress.
e. Each POC must have a start and end date. Treatment is only authorized during the
time period as written in the POC.
f. POCs can be written for no longer than a year.
g. POCs can be reviewed and renewed annually or more often as is medically
necessary.
h. IEPs and 504 Accommodation Plans may act as a POC and an additional plan is
not required if they meet all requirements of a POC and document medical necessity
of the services being provided.
i. Not all POCs are required to be IEPs or 504 Accommodation Plans as LEAs/SEAs
may have the need for shorter and less formal plans for lower acuity health
conditions.
j. Multiple conditions can be documented in the same POC for a student who has
multiple health conditions/diagnoses, however each service is to be documented in
a specific service area.
The POC serves as a medical summary of progress documentation. The POC also serves as
a PA for services that require PA.
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6. MEDICAL TEAM CONFERENCE (WITH INTERDISCIPLINARY TEAM)
A medical team conference with an interdisciplinary team is completed with a team
consisting of a minimum of a:
a. Physician, M.D.; Osteopath, D.O.; APRN; PA; or Clinical Psychologist;
b. Registered Nurse; and
c. Special Education Teacher
to determine a student's medical needs. Other professional staff such as physical therapists,
occupational therapists, speech therapists, behavior analysts, etc. may provide input, as well
as audiology, vision, health, education, and the student’s LRI. As a result of this process, a
POC will be established outlining treatment modalities. For simplicity, we will refer to this
as a Medical Team Conference for the remainder of this MSM Chapter.
7. ELIGIBILITY VERIFICATION
Medicaid recipient eligibility is determined on a monthly basis. Therefore, it is important
to verify the student’s eligibility on a monthly basis. Payments can only be made for
covered services rendered to eligible students. If the student was not eligible on the date
the service was rendered, payment will be denied.
Eligibility can be verified by accessing the Automated Response System (ARS) or the
Electronic Verification System (EVS) or using Health Insurance Portability Accountability
Act (HIPAA) compliant electronic transaction. Refer to our Quality Improvement
Organization (QIO)-like vendor’s website for additional information.
8. RECORDS
The evaluative and diagnostic services which determine the need for treatment and the
POC which defines the treatment needs must be documented as part of the student’s
medical record at the school, including the name(s) of the health practitioner(s) actually
providing the service(s). The written POC must be on file with the participating LEA/SEA.
All medical and financial records which reflect services provided must be maintained by
the LEA/SEA and furnished on request to the Department of Health and Human Services
(DHHS) or its authorized representative. A LEA/SEA must keep organized and
confidential records that detail all student specific information regarding all services
rendered for each student receiving of services and retain those records for review.
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LEAs/SEAs must maintain appropriate records to document the student’s progress in
meeting the goals of the treatment. SHS encompasses services from several disciplines, as
such all documentation must be completed as appropriate for the service that is being
provided as detailed in the MSM Chapter corresponding to the service being provided.
Nevada Medicaid reserves the right to review the student’s records to assure the treatment
is restorative and rehabilitative.
9. NON-DISCRIMINATION
LEAs/SEAs must follow all federal rules and regulations and the DHCFP rules and
regulations regarding discrimination against recipients on the basis of protected status(es)
as detailed in MSM Chapter 100.
10. THIRD PARTY LIABILITY (TPL)
In 1988, as a result of the Medicare Catastrophic Coverage Act, Medicaid was authorized
by Congress to reimburse for IDEA related medically necessary services for eligible
children before IDEA funds are used. Medicaid reimbursement is available for those
services under Social Security Act, Section 1903(c) to be the primary payer to the other
resources as an exception. Federal legislation requires Medicaid to be the primary payer
for Medicaid services provided to eligible recipients under IDEA, Children with Special
Health Care Needs, Women’s Infants and Children (WIC) Program, Title V Programs,
Indian Health Services (IHS), or Victims of Crimes Act 1984.
Although Medicaid must pay for services before (or primary to) the U.S. Department of
Education (School Districts), it pays secondary to all other sources of payment. As such,
Medicaid is referred to as the “payer of last resort.”
Medicaid statutory provisions for TPL preclude Medicaid from paying for services
provided to Medicaid recipients if another payer (e.g. health insurer or other state or federal
programs) is legally liable and responsible for providing and paying for services.
The Medicaid Program is generally the payer of last resort; exceptions to this principle are
IEP and related services, Title V, and WIC, as mentioned previously.
Medicaid is required to take all reasonable measures to ascertain the legal liability of third
parties to pay for care and services available under the Nevada Medicaid State Plan. If a
state has determined that probable liability exists at the time a claim for reimbursement is
filed, it generally must reject the claim and return it to the provider for a determination of
the amount of TPL (referred to as “cost avoidance”). If probable liability has not been
established or the third party is not available to pay the individual’s medical expenses, the
state must pay the claim and then attempt to recover the amount paid (referred to as “pay
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and chase”). Nevada Medicaid has elected to pay and chase for SHS found to have TPL
for IEP services only.
11. KATIE BECKETT RECIPIENTS
In order for children to remain eligible under the Katie Beckett eligibility category,
Medicaid must assure the Centers for Medicare and Medicaid Services (CMS) that the per
capita expenditures under this eligibility category will not exceed the per capita
expenditures for the institutional level of care under the state plan. LRIs with children
eligible under the Katie Beckett category may not want the SHS to be billed to Nevada
Medicaid as this may impact the child’s eligibility or may result in a cost to the LRI for
services outside of the school arena. LRIs with a child eligible under this category are
encouraged to work closely with their Medicaid District Office (DO) case manager to
assure services do not impact their eligibility status.
12. NOTIFICATION OF SUSPECTED ABUSE/NEGLECT
The DHCFP expects that all Medicaid providers will be in compliance with all laws
relating to incidents of abuse, neglect, or exploitation as it relates to students.
2803.1E RECIPIENT RESPONSIBILITIES
The recipient or authorized representative shall:
1. Provide the LEA/SEA with a valid Medicaid card at the LEA’s/SEA’s request.
2. Provide the LEA/SEA with accurate and current medical information, including diagnosis,
attending physician, medication, etc.
3. Notify the LEA/SEA of all insurance information, including the name of other third party
insurance coverage.
4. Participate in the Medical Team Conference(s).
5. Every student and their LRI is entitled to receive a statement of students or parent/guardian
rights from their LEA/SEA. The student and their LRI should review and sign this
document.
2803.1F AUTHORIZATION PROCESS
1. Prior authorizations are not required for any SHS that may be reimbursed for a Medicaid-
eligible student even when the MSM chapter referenced for that service requires a prior
authorization as the POC serves as the prior authorization. Refer to MSM Section 2803.1C
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in this chapter outlining service coverage and limitations. Services must be deemed
medically necessary and appropriate as defined in this chapter. The treatment services must
be documented as defined in this chapter and substantiated that the services are medically
necessary by a signature by a qualified provider working within the scope of their practice.
Refer to MSM Section 2803.1D(3) in this chapter for more details on OPR requirements.
A referral and signature do not constitute medical necessity. Refer to MSM Chapter 100
for the definition of medical necessity. Proper documentation is required to show the
referral/recommendation for services.
As a method of protecting the integrity of the SHS Program, Medicaid will perform retro-
review activities on claims data to evaluate medical necessity and billing procedures.
Services that have been reimbursed but are shown not to have been documented in the POC
and a progress note(s) of the student, as outlined in this chapter, may be subject to
recoupment.
Refer to the DHCFP website for billable codes http://dhcfp.nv.gov/RatesUnit.htm. The
SHS billing manual PT 60 can be found at our QIO-like vendor’s website.
2. MISCELLANEOUS PROVISIONS
a. All payments for SHS are made to the LEA/SEA. Separate payment will not be
made to those individual practitioners who rendered the services.
b. The LEA/SEA can submit claims for reimbursement on a monthly basis
maintaining adherence to Medicaid’s timely filing requirements. Refer to MSM,
Chapter 100, Eligibility, Coverage and Limitations.
2803.2 PROVIDER QUALIFICATIONS
In order to be reimbursed by Nevada Medicaid, all SHS must be provided by a qualified health
care provider working within their scope of practice under state and federal regulations.
It is the responsibility of the LEA/SEA to assure all billed Medicaid covered services are rendered
by the appropriately credentialed providers. Each LEA/SEA must maintain documentation of each
rendering practitioner’s license, certifications, registration, or credentials to practice in Nevada.
All documentation must be available, if requested by state or federal agencies.
2803.2A PHYSICIAN, PHYSICIAN’S ASSISTANT & ADVANCED NURSE PRACTITIONER
QUALIFICATIONS
Providers must meet qualifications as detailed in at least one of the following NRS Chapters:
1. NRS Chapter 630 Physicians and Physician Assistants and Practitioners of Respiratory
Care, or
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2. NRS Chapter 633 Osteopathic Medicine, or
3. NRS Chapter 632 Nursing as an advanced practice registered nurse as detailed in NRS
632.140 through 632.240.
2803.2B MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES QUALIFICATIONS
Providers must meet qualifications as detailed in MSM Chapter 400.
2803.2C NURSING QUALIFICATIONS
Providers must meet qualifications as detailed in NRS Chapter 632 Nursing.
2803.2D PHYSICAL THERAPY QUALIFICATIONS
Providers must meet qualifications as detailed in NRS Chapter 640 Physical Therapy.
2803.2E OCCUPATIONAL THERAPY QUALIFICATIONS
Providers must meet qualifications as detailed in NRS Chapter 640A Occupational Therapy.
2803.2F SPEECH THERAPY AND AUDIOLOGY QUALIFICATIONS
Providers must meet qualifications as detailed in NRS Chapter 637B Audiologists and Speech
Pathologist.
2803.2G PCS QUALIFICATIONS
1. PCS Supervisor must meet the following documented minimum qualifications:
a. Is at least 18 years of age;
b. Has a high school diploma or its equivalent;
c. Is responsible and mature and exhibits empathy, listening skills, and other personal
qualities which will enable the PCS Supervisor to understand the problems of
persons with disabilities;
d. Has demonstrated the ability to read, write, speak, and understand the English
language; and
e. Meets all qualifications of a Personal Care Assistant (PCA) as detailed below.
2. The PCS Supervisor shall oversee the daily operations of the PCS being delivered in the
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school. The PCS Supervisor shall appoint another qualified employee to assume the
responsibilities of the PCS Supervisor in the case of their absence. The responsibilities of
the PCS Supervisor include, without limitation:
a. Ensuring that all PCAs under their supervision are qualified and properly trained;
b. Ensuring that the initial SFASP of each student is completed and that the PCA to
provide the PCS to the student is capable of providing the services necessary to
meet those needs;
c. Providing oversight and direction for PCAs as necessary to ensuring that the
students receive needed PCS, each PCA must receive at least one hour of direct
supervision a year; and
d. Ensure that:
1. Students are not abused, neglected, or exploited by a PCA or another
member of the staff of the LEA/SEA; and
2. Suspected cases of abuse, neglect, or exploitation of a student are reported
in the manner prescribed in NRS 432B.220.
3. Personal Care Assistant (PCA) must meet the following documented minimum
qualifications:
a. Be at least 18 years of age;
b. Maintain records and provide to the DHCFP, upon request, documentation that the
PCA is in compliance with the tuberculosis (TB) testing requirements of NAC
441A.375.
c. Be responsible, mature, exhibit empathy, listening skills, and other personal
qualities which will enable the PCA to understand the problems of persons with
disabilities;
d. Demonstrate the ability to read, write, speak, and communicate effectively in the
language of the student receiving the PCS.
e. Demonstrate the ability to meet the needs of the students of the LEA/SEA by having
the ability and skills for all tasks listed in the SFASP; and
f. Within the 90 days immediately preceding the date on which the PCA begins
providing the services to a student and at least annually thereafter, complete not
less than eight hours of training related to providing for the needs of the students of
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the LEA/SEA and limitation on the PCS provided by the LEA/SEA. The training
must include, without limitation, training concerning:
1. Duties and responsibilities of PCA and the appropriate techniques for
providing PCS including the written documentation of PCS provided;
2. Recognizing and responding to emergencies, including, without limitation,
fires and medical emergencies;
3. Dealing with the adverse behaviors of the student;
4. Nutrition and hydration, including, without limitation, special diets and
meal preparation and service;
5. Bowel and bladder care, including, without limitation, routine care
associated with toileting, routine maintenance of an indwelling catheter
drainage system such as emptying the bag and positioning of the system,
routine care of colostomies such as emptying and changing the colostomy
bag, signs and symptoms of urinary tract infections and common bowel
problems, including without limitation, constipation and diarrhea;
6. Methods for preventing skin breakdown, contractures and falls;
7. Handwashing and infection control;
8. Basic body mechanics, mobility and techniques for transferring students;
9. The rights of the student and methods to protect the confidentiality of
information concerning the student as required by federal and state law and
regulations;
10. The special needs of persons with disabilities;
11. Maintenance of a clean and safe environment;
12. Recognizing the signs of child abuse and mandated reporting; and
13. First aid and cardiopulmonary resuscitation (CPR). A certificate in first aid
and CPR issued to the PCA by the American Red Cross or an equivalent
certificate will be accepted as proof of that training.
14. Communication skills, including without limitation, active listening,
problem solving, conflict resolution, and techniques for communicating
through alternative modes with persons with communication or sensory
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impairments.
g. PCAs must participate in and complete a training program before independently
providing PCS to the students of the LEA/SEA. The training program must include
an opportunity for the PCA to receive on-the-job instruction provided to students
of the LEA/SEA, as long as the PCS Supervisor provides supervision during this
instruction to determine whether the PCA is able to provide the PCS successfully
and independently to the student.
4. Each PCA at a LEA/SEA must be evaluated and determined to be competent by the
LEA/SEA in the required areas of training set forth in MSM Section 2803.2G of this
chapter.
5. Each PCA at a LEA/SEA must have evidence of successful completion of a training
program that includes the areas of training set forth in MSM Section 2803.2G of this
chapter within 90 days immediately preceding the date on which the PCA begins providing
PCS to a student.
2803.2H APPLIED BEHAVIOR ANALYSIS (ABA) QUALIFICATIONS
Providers must meet qualifications as detailed in MSM Chapter 3700.
2803.2I DENTAL QUALIFICATIONS
Any dental provider, who undertakes dental treatment, as covered by Nevada Medicaid, must be
qualified by training and experience in accordance with the Nevada State Board of Dental
Examiners rules and regulations.
All materials and therapeutic agents used or prescribed must meet the minimum specifications of
the American Dental Association (ADA).
2803.2J OPTOMETRY QUALIFICATIONS
Providers must meet qualifications as set forth by one of the following and be working within their
scope of practice;
1. NRS Chapter 630.375 – Physicians,
2. NRS Chapter 636 – Optometry, or
3. NRS Chapter 637 – Dispensing Opticians.
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2803.2K CASE MANAGEMENT QUALIFICATIONS
Providers must meet qualifications as detailed in MSM Chapter 2500.
2803.2L TELEHEALTH QUALIFICATIONS
Services provided via telehealth must be clinically appropriate and within the health care
professional’s scope of practice as established by its licensing agency.
2803.3 SCREENING AND DIAGNOSTIC SERVICES
Screening and diagnostic services refers to health care that focuses on disease (or injury)
prevention. Screening and diagnostic services also assists the provider in identifying a patient’s
current or possible future health care risks through assessments, lab work, and other diagnostic
studies.
LEAs/SEAs are encouraged to provide screening and diagnostic services as defined in MSM
Chapter 1500 – Healthy Kids Program.
A child’s health is assessed as early as possible in the child’s life, in order to prevent or find
potential diseases and disabilities in their early stages, when they are most effectively treated.
Assessment of a child’s health at regularly scheduled intervals assures that a condition, illness, or
injury is not developing or present.
2803.3A COVERAGE AND LIMITATIONS
Screening and diagnostic services can be covered without a POC as long as they:
1. Follow the periodicity schedule as established in MSM, Chapter 1500 – Healthy Kids
Program;
2. Are determined to be a medically necessary screening when it falls outside the periodicity
schedule; and
3. Are documented in medical records with the assessments and significant positive and
negative findings, and referrals made for diagnosis, treatment or other medically necessary
health services for any conditions that were identified.
2803.3B COVERED SERVICES
1. American Academy of Pediatrics (AAP) recommended screenings and diagnostics as
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detailed in MSM Chapter 1500 – Healthy Kids Program.
2. Dental services are outline in MSM Chapter 1000 – Dental. Dental services can occur at
intervals outside the established periodicity schedule when indicated as medically
necessary to determine the existence of a suspected illness or condition.
3. Vision services are outlined in MSM Chapter 1100 – Ocular Services. Vision services can
occur at intervals outside the established periodicity schedule when indicated as medically
necessary to determine the existence of a suspected illness or condition.
4. Hearing services are outlined in MSM Chapter 2000 – Audiology. Hearing services can
occur at intervals outside the established periodicity schedule when indicated as medically
necessary to determine the existence of a suspected illness or condition.
5. Vaccinations are outlined in MSM Chapter 1500 – Healthy Kids Program. Nevada
Medicaid will reimburse for appropriate immunizations that are due and administered
during the screening visit and according to the schedule established by the Advisory
Committee on Immunization Practices (ACIP) for pediatric vaccines:
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html. Nevada Medicaid will
only reimburse for administration fees if the vaccination is available through the DPBH as
part of the Vaccines for Children (VFC) Program.
6. Laboratory procedures are outlined in MSM Chapter 800 – Laboratory Services. Nevada
Medicaid will reimburse for age-appropriate laboratory procedures performed at intervals
in accordance with the Healthy Kids periodicity schedule. These include blood lead level
assessment appropriate to age and risk, urinalysis, Tuberculin Skin Test (TST), Sickle-cell,
hemoglobin or hematocrit and other tests and procedures that are age-appropriate and
medically necessary.
7. Interperiodic Screenings – Healthy Kids screenings are provided to all eligible persons
under the age of 21, which may include medically necessary intervals that are outside an
established periodicity schedule, also known as interperiodic screenings.
2803.3C LIMITATIONS
Refer to MSM Chapter 1500 – Healthy Kids Program for limitations.
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2803.4 PHYSICIAN, PHYSICIAN’S ASSISTANT & ADVANCED NURSE PRACTITIONER
SERVICES
Nevada Medicaid reimburses for covered medical services that are reasonable and medically
necessary, performed by a physician, APRN or under the personal supervision of a physician and
that are within the scope of practice as defined by Nevada State Law. Services must be performed
by the physician, APRN or by a licensed professional working under the personal supervision of
the physician.
2803.4A COVERED SERVICES
Physician and APRN services may include, but are not limited to:
1. Evaluation and consultations with providers of covered services for diagnostic and
preventive services including participation in a multi-disciplinary team assessment;
2. Record review for diagnostic and prescriptive services;
3. Diagnostic and evaluation services to determine a student’s medically related condition
that results in the student’s need for medical services;
4. New and established patient visits as described in MSM Chapter 600 – Physician Services;
and
4.5. Medical Team Conference participation time for the development of medical related
services in the POC. Payment is excluded for participation time of POC development for
educational processes and goals.
2803.4B LIMITATIONS
Refer to MSM Chapter 600 – Physician Services for limitations.
2803.5 MENTAL HEALTH AND ALCOHOL/SUBSTANCE ABUSE SERVICES
Nevada Medicaid reimburses LEAs/SEAs for community-based mental health services to students
under a combination of mental health rehabilitation and medical/clinical authority. The services
must be recommended by a physician or other licensed practitioner of the healing arts, within their
scope of practice under Nevada State law for the maximum reduction of a physical or mental
disability and to restore the individual to the best possible functioning level.
Mental health rehabilitation assists individuals to develop, enhance and/or retain psychiatric
stability, social integration skills, personal adjustment and/or independent living competencies in
order to experience success and satisfaction in environments of their choice and to function as
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independently as possible. Interventions occur concurrently with clinical treatment and begin as
soon as clinically possible.
Alcohol and substance abuse treatment and services are aimed to achieve the mental and physical
restoration of alcohol and drug abusers. Medicaid only reimburses LEAs/SEAs for services
delivered in an outpatient setting and they must constitute a medical-model service delivery
system.
Nevada Medicaid’s philosophy assumes that behavioral health services shall be person-centered
and/or family driven. All services shall be culturally competent, community supportive, and
strength based. The services shall address multiple domains, be in the least restrictive environment,
and involve family members, caregivers, and informal supports when considered appropriate per
the recipient or legal guardian. Service providers shall collaborate and facilitate full participation
from team members including the individual and their family to address the quality and progress
of the individualized care plan and tailor services to meet the recipient’s need.
2803.5A COVERED SERVICES
The following services are covered when provided as described in MSM Chapter 400 – Mental
Health and Alcohol/Substance Abuse Services:
1. Mental Health Assessments;
2. Neuro-Cognitive, Psychological and Mental Status Testing;
3. Mental Health Therapies;
4. Medication Management;
5. Medication Training and Support;
6. Rehabilitative Mental Health Services;
7. Outpatient Alcohol and Substance Abuse Services; and
8. Medical Team Conference participation time for the development of medical related
services in the POC. Payment is excluded for participation time of development for
educational processes and goals.
2803.5B LIMITATIONS
1. Mental Health and Alcohol/Substance Abuse Services not listed above in covered services.
2. All limitations listed in MSM Chapter 400 for the related services.
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2803.6 NURSING SERVICES
Skilled nursing refers to assessments, judgments, interventions, and evaluation of interventions
which require the education, training and experience of a licensed nurse to complete. Services must
be based on an assessment and supporting documentation that describes the complexity and
intensity of the student’s care and the frequency of skilled nursing interventions.
All nursing services must be under the order and direction of a physician or APRN. Skilled nursing
services are a covered service when provided by a registered nurse (RN) or a licensed practical
nurse (LPN) under the supervision of an RN in accordance with the POC. An LPN may participate
in the implementation of the POC for providing care to students under the supervision of a licensed
RN, physician or APRN that meet the federal requirements of 42 CFR 440.166. Nursing services
are provided to an individual on a direct, one-to-one basis, on site within the school setting.
2803.6A COVERED SERVICES
Nursing services are provided by a licensed RN, or an LPN under the supervision of an RN, or a
CNA under the direction and supervision of an RN. RNs, LPNs and CNAs must be licensed by
the Nevada State Board of Nursing and acting within their scope of practice. These services may
include, but are not limited to:
1. Evaluations and assessments (RN only);
2. Care and maintenance of tracheotomies;
3. Catheterization or catheter care;
4. Oral or tracheal suctioning;
5. Oxygen administration;
6. Prescription medication administration that is part of the POC;
7. Tube feedings;
8. Ventilator Care; or
9. Medical Team Conference participation time for the development of medical related
services in the POC. Payment is excluded for participation time of POC development for
educational processes and goals. (RN only)
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2803.6B LIMITATIONS
1. Nursing services must be provided within the scope of work for the level of licensure of
the nurse providing the service(s).
2. Service(s) provided without an OPR from a qualified health professional working within
their scope of practice are not eligible for reimbursement.
3. Services not listed on the individual’s POC other than services for screening and
diagnostics are not eligible for reimbursement.
2803.7 PHYSICAL THERAPY SERVICES
Physical Therapy Services are performed by an appropriately certified or licensed physical
therapist who develops a written individual program of treatment. Licensed physical therapist
assistants functioning under the supervision of the licensed physical therapist may assist in the
delivery of the POC.
Physical Therapy means services prescribed by a physician or other licensed practitioner of the
healing arts operating within their scope of practice under Nevada State law and provided to a
student by or under the direction of a qualified physical therapist to ameliorate or improve
neuromuscular, musculoskeletal and cardiopulmonary disabilities.
Physical therapy evaluation, and treatment includes: assessing, preventing, or alleviating
movement dysfunction and related functional problems; obtaining and interpreting information;
and coordinating care and integrating services relative to the student receiving treatment.
2803.7A COVERED SERVICES:
1. Evaluation and diagnosis to determine the existence and extent of motor delays, disabilities
and/or physical impairments effecting areas such as tone, coordination, movement,
strength and balance;
2. Individual Therapy provided to a student in order to correct or ameliorate the effects of
motor delays, disabilities and/or physical impairments;
3. Group Therapy provided to more than one student, but less than seven, simultaneously in
order to remediate correct or ameliorate the effects of motor delays, disabilities, and/or
physical impairments;
4. Therapeutic exercise, application of heat, cold, water, air, sound, massage, and electricity;
5. Measurements of strength, balance, endurance, range of motion (ROM); and
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6. Medical Team Conference participation time for the development of medical related
services in the POC. Payment is excluded for participation time POC development for
educational processes and goals.
2803.7B LIMITATIONS
Refer to MSM Chapter 1700 – Therapy for limitations.
2803.8 OCCUPATIONAL THERAPY SERVICES
Occupational Therapy is provided by an appropriately licensed occupational therapist who
evaluates the student's level of functioning and develops a KPOC. Licensed occupational therapist
assistants functioning under the general supervision of the licensed occupational therapist may
assist in the delivery of the POC.
Occupational Therapy evaluation and treatment includes: assessing, improving, developing, or
restoring functions impaired or lost through illness, injury or deprivation; improving ability to
perform tasks for independent functioning when functions are lost or impaired, preventing through
early intervention, initial or further impairment or loss of function; obtaining and interpreting
information; coordinating care and integrating services the student is receiving.
2803.8A COVERED SERVICES
1. Evaluation and diagnosis to determine the extent of a student's disabilities in areas such as
sensorimotor skills, self-care, daily living skills, play and leisure skills, and use of adaptive
or corrective equipment;
2. Individual Therapy provided to a student to remediate and/or adapt skills necessary to
promote the student's ability to function independently;
3. Group Therapy provided to more than one student but less than seven simultaneously to
correct or ameliorate and/or adapt skills necessary to promote the students' ability to
function independently;
4. Task-oriented activities to prevent or correct physical or emotional deficits to minimize the
disabling effect of these deficits;
5. Exercise to enhance functional performance;
6. Medical Team Conference participation time for the development of medical related
services in the POC. Payment is excluded for participation time of POC development for
educational processes and goals.
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2803.8B LIMITATIONS
Refer to MSM Chapter 1700 – Therapy for limitations.
2803.9 SPEECH THERAPY AND AUDIOLOGY SERVICES
Speech, hearing, and language pathology services are those services necessary for the diagnosis
and treatment of speech and language disorders that result in communication disabilities and for
the diagnosis and treatment of swallowing disorders with or without the presence of a
communication disability. The services must be of such a level of complexity and sophistication
or the condition of the student must be such that the services required can be safely and effectively
performed only by a qualified therapist.
The practice of audiology consists of rendering services for the measurement, testing, appraisal
prediction, consultation, counseling, research, or treatment of hearing impairment for the purpose
of modifying disorders in communication involving speech, language, and hearing. Audiology
services must be performed by a certified and licensed audiologist.
2803.9A COVERED SERVICES
1. Speech and Language evaluation and diagnosis of delays and/or disabilities including, but
not limited to, voice, communication, fluency, articulation or language development.
Audiological evaluation and diagnosis to determine the presence and extent of hearing
impairments that affect the student's educational performance. Audiological evaluations
include complete hearing and/or hearing aid evaluation, hearing aid fittings or re-
evaluations, and audiograms.
2. Individual Therapy provided to a student in order to correct or ameliorate delays and/or
disabilities associated with speech, language, hearing, or communication.
3. Group Therapy provided to one student, but less than seven, simultaneously in order to
correct or ameliorate delays and/or disabilities associated with speech, language, hearing,
or communication.
4. Medical Team Conference participation time for the development of medical related
services in the POC. Payment is excluded for participation time of POC development for
educational processes and goals.
2803.9B LIMITATION
Refer to MSM Chapter 1700 – Therapy for limitations.
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2803.10 AUDIOLOGICAL SUPPLIES, EQUIPMENT, MEDICAL SUPPLIES AND OTHER DURABLE
MEDICAL EQUIPMENT (DME)
The LEA/SEA, as a Medicaid SHS PT 60, may be reimbursed for medically necessary audiology
supplies, equipment, and medical supplies when shown to be appropriate to increase, or improve
the functional capabilities of individuals with disabilities. Refer to the DHCFP website for list of
available Healthcare Common Procedure Coding System (HCPCS) codes: SHS PT 60: Fee
Schedule http://dhcfp.nv.gov/RatesUnit.htm.
Such services must be reviewed and recommended by the presence of a signature on either the
POC or a prescription by a licensed physician, APRN, or PA providing services within the scope
of medicine as defined by Nevada State Law and provided through the POC.
2803.10A COVERED SERVICES
1. Disposable medical supplies are items purchased for use at school or home which are not
durable or reusable, such as surgical dressings, disposable syringes, catheters, tracheotomy
dressings, urinary tray, etc. SHS PT 60 may dispense audiological supplies, equipment,
and medical supplies by their qualified practitioners acting within the scope of their
practice under Nevada State Law.
2. DME is considered items such as ACDs (e.g. Speech Generating Devices), wheelchairs,
canes, standers, walkers, etc. Medicaid DME Providers are qualified to dispense and
receive reimbursement for medically necessary DME, prosthetic, orthotics, and supplies.
Some services may require prior authorization.
3. DME, ACDs, audiology supplies, equipment, and medical supplies are for the exclusive
use of the student that can be used at school, at home and is the property of the student.
Refer to MSM Chapter 1300 – DME, Disposable Supplies and Supplements for coverage and
limitations on DME, prostheses, and disposable medical supplies.
Refer to MSM Chapter 2000 – Audiology Services for coverage and limitations on audiological
supplies and equipment.
2803.10B LIMITATIONS
Refer to MSM Chapter 1300 – DME, Disposable Supplies and Supplements; and MSM Chapter
2000 – Audiology Services for limitations.
2803.11 PERSONAL CARE SERVICES (PCS) IN SCHOOL SETTING
PCS include a range of human assistance provided to a student with disabilities and/or chronic
conditions, which enables accomplishment of tasks that they would normally do for themselves if
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they did not have a disability and/or chronic condition. These services are provided where
appropriate, medically necessary, and within service limitations.
Assistance may be in the form of direct hands-on assistance or cueing the student to perform the
task themselves and related to the performance of ADLs and IADLs. Services are based on the
needs of the student being served, as determined by a SFASP approved by the DHCFP. All services
must be performed in accordance with the approved POC. LRIs may not be reimbursed for
providing PCS.
2803.11A COVERED SERVICES
1. Assistance with the following ADLs. Services must be directed to the individual student
and related to their health and welfare.
a. Dressing.
b. Toileting needs including but not limited to routine care of an incontinent student.
c. Transferring and positioning non-ambulatory student from one stationary position
to another, assisting a student out of chair or wheelchair, including
adjusting/changing student’s position in a chair or wheelchair.
d. Mobility/Ambulation, which is the process of moving between locations, including
walking or helping the student to walk with support of a walker, cane or crutches,
or assisting a student to stand up or get his/her wheelchair to begin ambulating.
e. Eating, including cutting up food. Specialized feeding techniques may not be used.
2. Assistance with the following IADLs is a covered service. Services must be directed to the
individual student and related to their health and welfare.
a. Meal preparation, which includes storing, preparing, and serving food.
2803.11B SERVICE LIMITATIONS
Assistance with the IADLs may only be provided in conjunction with services for ADLs.
2803.11C NON-COVERED SERVICES
Duplicative services are not considered medically necessary and will not be covered by Nevada
Medicaid. PCS services must be one-on-one with the PCA and individual student receiving the
service. PCAs may not overlap times between students being provided services.
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The following are not covered under PCS and are not reimbursable:
1. Instruction, tutoring or guidance in academics.
2. A task that the DHCFP or its designee determines could reasonably be performed by the
student.
3. Services normally provided by an LRI.
4. Any tasks not included in the student’s approved POC.
5. Services to maintain an entire classroom, such as cleaning areas of the room not used solely
by the student.
6. Services provided to someone other than the intended student.
7. Skilled care services requiring the technical or professional skill that State Statute or
regulation mandates must be performed by a health care professional licensed or certified
by the State of Nevada. Services include, but are not limited to, the following:
a. Insertion and sterile irrigation of catheters;
b. Irrigation of a body cavity. This includes both sterile and non-sterile procedures such
as ear irrigation, vaginal douches, and enemas;
c. Application of dressings involving prescription medications and aseptic techniques,
including treatment of moderate or severe skin problems;
d. Administration of injections of fluids into veins, muscles, or skin;
e. Administration of medication, including, but not limited to, the insertion of rectal
suppositories, the application of prescribed skin lotions or the instillation of
prescribed eye drops (as opposed to assisting with self-administered medications);
f. Physical assessments;
g. Monitoring vital signs;
h. Specialized feeding techniques;
i. Rectal digital stimulation;
j. Massage;
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k. Specialized ROM;
l. Toenail cutting;
m. Medical case management, such as accompanying a student to a physician’s office
for the purpose of providing or receiving medical information;
n. Any task identified with the Nurse Practice Act as requiring skilled nursing
including Certified Nursing Assistant (CNA) services.
8. Companion care, baby-sitting, supervision or social visitation.
9. Care of pets except in cases where the animal is a certified service animal.
10. A task the DHCFP determines is within the scope of services provided to the student as part
of an assisted living contract, a supported living arrangement contract, or a foster care
agreement.
11. Escort services for social, recreational, or leisure activities.
12. Transportation of the student by the PCA.
13. Any other service not listed under Covered Services in MSM Section 2803.11A of this
chapter.
2803.11D AUTHORIZATION PROCESS
A SFASP must be completed prior to the service date of any billable PCS. The SFASP must be
completed in person with the student present by a physician, APRN, PA, or trained physical or
occupational therapist working within their scope of practice. The SFASP should be added as part
of the student’s POC.
Students receiving PCS services must be reassessed with a SFASP at least annually. Annual
reassessments must be completed in person with the student present by a physician, APRN, PA, or
a trained physical or occupational therapist working within their scope of practice.
Significant change in condition or circumstance may cause a need to reassess a student. All
reassessments should be completed in person with the student present by a physician, APRN, PA,
or a trained physical or occupational therapist working within their scope of practice.
2803.11E FLEXIBILITY OF SERVICES DELIVERY
The total weekly authorized hours for PCS may be combined and tailored to meet the needs of the
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student, as long as the plan does not alter medical necessity. Any changes that do not increase the
total authorized hours can be made, for the student’s convenience, within a single week without an
additional SFASP.
Backup Mechanism
The provider shall have a written backup mechanism to provide a student with his or her service
hours in the absence of a regular PCA due to sickness, vacation or any unscheduled event. The
covering individual must be qualified to provide PCS services as outlined in MSM, Section
2803.2G of this chapter.
2803.11F SUPERVISION
PCAs providing PCS to students must have a supervisor available to them during their work hours.
Each time a PCA providing PCS to students is assigned to a new student the supervisor must review
the SFASP and the student’s POC. The supervisor must then clarify the following items with the
PCA providing PCS to that student:
1. The needs of the student and tasks to be provided;
2. Any student specific procedures including those which may require on-site orientation;
3. Situations in which the PCA should notify the supervisor.
The supervisor (or other designated agency representative) must review and approve all service
delivery records completed by the PCA providing the PCS.
2803.11G RECORDS
The LEA/SEA must maintain all records relating to PCS provided. The LEA/SEA must retain
records for a period pursuant to the State record retention policy, which is currently six years from
the date of payment for the specified service.
If any litigation, claim or audit is started before the expiration of the retention period provided by
the DHCFP, records must be retained until all litigation, claims, or audit findings have been finally
determined.
1. The LEA/SEA must maintain all required records for each individual employed to provide
PCS regardless of the length of employment.
2. The LEA/SEA must maintain the required record for each student who has been provided
services, regardless of the length of the service period.
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At a minimum, the LEA/SEA must document the following on all service records:
1. Consistent service delivery within program requirements;
2. Amount of services provided to students;
3. When services were delivered;
4. Documentation attesting to the services provided, and the time spent providing the service
signed or initialed by the PCA.
2803.12 APPLIED BEHAVIOR ANALYSIS (ABA)
Medicaid will reimburse for ABA services rendered to Medicaid eligible individuals under the age
of 21 years old in accordance with EPSDT coverage authority. The behavior intervention must be
medically necessary as defined in MSM Chapter 100, to develop, maintain, or restore to the
maximum extent practical the functions of an individual with a diagnosis of ASD, FASD, or other
condition for which ABA is recognized as medically necessary. It must be rendered according to
the written orders of the Physician, PA, or an APRN. The treatment regimen must be designed and
signed off on by the qualified ABA provider as defined in MSM Chapter 3700 – Applied Behavior
Analysis.
All services must be documented as medically necessary and appropriate and must be prescribed
on a POC.
2803.12A COVERED SERVICES
Covered services are detailed in MSM Chapter 3700. Covered services include the following
services when delivered as detailed in MSM Chapter 3700:
1. Behavioral Screening;
2. Comprehensive Diagnostic Evaluation;
3. Behavioral Assessment;
4. Adaptive Behavioral Treatment Intervention; and
5. Adaptive Behavioral Family Treatment.
2803.12B LIMITATIONS
All limitations listed in MSM Chapter 3700 – Applied Behavior Analysis.
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2803.13 DENTAL
Through the EPSDT benefits, individuals under the age of 21 receive comprehensive dental care
such as periodic and routine dental services needed for restoration of teeth, prevention of oral
disease, and maintenance of dental health. The EPSDT Program assures children receive the full
range of necessary dental services.
The Nevada Medicaid Dental Services Program is designed to provide dental care under the
supervision of a licensed provider. Dentist participating in Nevada Medicaid shall provide services
in accordance with the rules and regulations of the Nevada Medicaid Dental Program detailed in
MSM Chapter 1000 – Dental. Dental care provided in the Nevada Medicaid Program must meet
prevailing professional standards for the community-at-large.
2803.13A COVERED SERVICES
Covered services include the following services when delivered as detailed in MSM, Chapter 1000
– Dental:
1. Diagnostic and preventive services;
2. Restorative dentistry services;
3. Endodontic services;
4. Periodontic services;
5. Adjunctive general services; and
6. Fluoride supplements.
2803.13B LIMITATIONS
1. Dental services not listed above in covered services.
2. All limitations listed in MSM Chapter 1000 – Dental.
2803.14 OPTOMETRY
The Nevada Medicaid Ocular Program reimburses for medically necessary ocular services to
eligible Medicaid recipients.
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2803.14A COVERED SERVICES
Covered services include the following services when delivered as detailed in MSM Chapter 1100
– Ocular Services:
1. Healthy Kids (EPSDT) vision screening;
2. Glasses;
3. Refractive examinations; and
4. Ocular examinations.
2803.14B LIMITATIONS
1. Ocular services not listed above in covered services
2. All limitations listed in MSM Chapter 1100 – Ocular Services.
2803.15 CASE MANAGEMENT
The intent of case management services is to assist eligible students in gaining access to needed
medical, social, educational, and other support services including housing and transportation
needs. Case management services do not include the direct delivery of medical, clinical, or other
direct services. Components of the service include assessment, care planning, referral/linkage, and
monitoring/follow-up.
2803.15A COVERED SERVICES
Case Management services are covered for the following target groups when delivered as detailed
in MSM Chapter 2500 – Case Management:
1. Children and adolescents who are Non-Severely Emotionally Disturbed (Non-SED) as
defined in MSM Chapter 2500, and
2. Adults with a Non-Serious Mental Illness (Non-SMI) as defined in MSM Chapter 2500.
3. Medical Team Conference participation time for the development of medical related
services in the POC. Payment is excluded for participation time of POC development for
educational processes and goals.
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Subject:
MEDICAID SERVICES MANUAL POLICY
2803.15B LIMITATIONS
1. Case management services to target groups not listed above in covered services.
2. All limitations listed in MSM Chapter 2500 – Case Management.
2803.16 TELEHEALTH
Telehealth is the use of a telecommunications system to substitute for an in-person encounter for
professional consultations, office visits, office psychiatry services, and a limited number of other
medical services. “Telehealth” is defined as the delivery of service from a provider of health care
to a patient at a different location through the use of information and audio-visual communication
technology, not including standard telephone, facsimile or electronic mail.
Services provided via telehealth must be clinically appropriate and within the health care
professional’s scope of practice as established by its licensing agency.
2803.16A COVERAGE AND LIMITATIONS
Must follow all policies in MSM Chapter 3400 – Telehealth Services.
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Section:
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Subject:
MEDICAID SERVICES MANUAL RESERVED
2804 RESERVED FOR FUTURE USE
March 1, 2020 SCHOOL HEALTH SERVICES Section 2804 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2805
Subject:
MEDICAID SERVICES MANUAL HEARINGS
2805 HEARINGS
Please reference MSM Chapter 3100 – Hearings, for hearing procedures.
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Section:
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Subject:
MEDICAID SERVICES MANUAL REFERENCES AND CROSS
REFERENCES
2806 REFERENCES AND CROSS REFERENCES
2806.1 PROVIDER SPECIFIC INFORMATION
Specific information about each PT can be found in the following MSM Chapters and NCU
Manual Chapter:
Medicaid Services Manual (MSM):
Chapter 100 Medicaid Program
Chapter 400 Mental Health and Alcohol/Substance Abuse Services
Chapter 600 Physician Services
Chapter 1000 Dental
Chapter 1100 Ocular Services
Chapter 1300 DME, Disposable Supplies and Supplements
Chapter 1500 Healthy Kids Program
Chapter 1700 Therapy
Chapter 2000 Audiology Services
Chapter 2500 Case Management
Chapter 3100 Hearings
Chapter 3300 Program Integrity
Chapter 3400 Telehealth Services
Chapter 3600 Managed Care Organization
Chapter 3700 Applied Behavior Analysis
Nevada Check Up (NCU) Manual:
Chapter 1000 Nevada Check Up Program
March 1, 2020 SCHOOL HEALTH SERVICES Section 2806 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
June 29, 2021
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: JESSICA KEMMERER, HIPAA PRIVACY AND CIVIL RIGHTS OFFICER Jessica Kemmerer
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 2900 – FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS)
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 2900 – Federally Qualified Health Centers (FQHCs)
are being proposed to clarify policy and re-arrange the existing format to align with current MSM
conventions related to structure and content. The clarification of policy includes, Federal and State
authorities, further defining medical, behavioral/mental health, dental, and telehealth encounters.
Revisions will also include policy for dually enrolled Certified Community Behavioral Health Centers
(CCBHCs) and FQHCs, Pharmacy policy for immunizations within an FQHC pharmacy, and a clarification of
prior authorization policy for FQHCs not enrolled with a Managed Care Organization.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and re-
arranging of sections was necessary.
Entities Financially Affected: This proposed change affects all Medicaid-enrolled providers delivering
FQHC encounter type of services. Those provider types (PT) include but are not limited to: FQHCs (PT 17,
specialty 181); CCBHCs (PT 17, specialty 188); FQHC Pharmacies enrolled under Pharmacy, (PT 28) and
Managed Care Organizations (PT 62).
Financial Impact on Local Government: There is no anticipated fiscal impact known at this time.
These changes are effective June 30, 2021.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 11/21 MTL 15/18, 12/19
MSM 2900 – Federally Qualified Health Centers MSM 2900 – Federally Qualified Health Centers
(FQHCs) (FQHCs)
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2900 Federally Qualified Renamed to “Introduction” to conform with MSM
Health Centers conventions. Added statement related to FQHCs being
safety net providers.
Page 1 of 2
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
2901.(A) Authority Corrected citation of Omnibus Budget Reconciliation Act
of 1990.
2901.(B) Moved from 2903.4: Expanded Scopes of Practices
citation to include the applicable Nevada Revised Statutes
(NRS) defining scopes of practice for providers who
provide services within an FQHC.
2903 Health Services Renamed to “Policy”; defines types of allowed
encounters, payment and defines an FQHC encounter.
2903.1 Coverage and New Section: defines Medical, Behavioral/Mental Health,
Limitations Dental and Telehealth encounters. Provides guidance on
provider types and services allowed within each FQHC
encounter.
2903.3 FQHC Pharmacies New Section: Provides policy related to FQHC pharmacies
to administer immunizations.
2903.5 FQHCS Dually New Section: Provides policy and definition of services for
Enrolled as A FQHCs that are dually enrolled as an FQHC and a CCBHC.
Certified
Community
Behavioral Health
Center
(CCBHC)
2903.7.(B) Prior Authorizations Provides prior authorization policy for FQHCs that are not
enrolled in a Managed Care Organization.
Page 2 of 2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
FEDERALLY QUALIFIED HEALTH CENTERS
2900 INTRODUCTION ........................................................................................................................1
2901 AUTHORITY ...............................................................................................................................1
2902 RESERVED ..................................................................................................................................1
2903 POLICY ........................................................................................................................................1
2903.1 COVERAGE AND LIMITATIONS ............................................................................................2
2903.2 NON-COVERED SERVICES ......................................................................................................4
2903.3 FQHC PHARMACIES .................................................................................................................5
2309.4 ANCILLARY SERVICES ...........................................................................................................5
2903.5 FQHCs DUALLY ENROLLED AS A CERTIFIED COMMUNITY BEHAVIORAL
HEALTHCENTER (CCBHC) ......................................................................................................5
2903.6 MEDICAL NECESSITY ..............................................................................................................6
2903.7 PRIOR AUTHORIZATIONS .......................................................................................................6
2904 HEARINGS ..................................................................................................................................1
1
MTL 11/21
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2900
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
2900 INTRODUCTION
Federally Qualified Health Centers (FQHCs) are defined by the Health Resources and Services
Administration (HRSA) as health centers providing comprehensive, culturally competent, quality
primary health care services to medically underserved communities and vulnerable populations.
FQHCs increase access to care, promote quality and cost-effective care, improve patient outcomes,
and are uniquely positioned to spread the benefits of community-based care and patient-centered
care.
Nevada Medicaid reimburses for medically necessary services provided at FQHCs and follows
State and Federal laws pertaining to them.
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Section:
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Subject:
MEDICAID SERVICES MANUAL AUTHORITY
2901 AUTHORITY
A. Medicaid is provided in accordance with the requirements of Title 42 Code of Federal
Regulation (CFR) Part 440, Subpart A – Definitions, Subpart B and Sections 1861,
1929(a), 1902(e), 1905(a), 1905(p), 1915, 1920 and 1925 of the Social Security Act (SSA)
and Section 4161 of the Omnibus Budget Reconciliation Act of 1990. Physician’s services
are mandated as a condition of participation in the Medicaid Program Nevada Revised
Statute (NRS) 630A.220.
B. The Nevada State Legislature sets forth scopes of practice for licensed professionals in the
NRS for the following Specialists:
1. NRS Chapter 630 – Physicians, Physician Assistants, Medical Assistants,
Perfusionists and Practitioners of Respiratory Care;
2. NRS Chapter 631 – Dentistry, Dental Hygiene and Dental Therapy;
3. NRS Chapter 632 – Nursing;
4. NRS Chapter 633 – Osteopathic Medicine;
5. NRS Chapter 635 –Podiatric Physicians and Podiatry Hygienists;
6. NRS Chapter 636 – Optometry;
7. NRS Chapter 637 – Dispensing Opticians;
8. NRS Chapter 640E –Dietitians;
9. NRS Chapter 641 – Psychologists;
10. NRS Chapter 641B – Social Workers;
11. NRS Chapter 652 – Medical Laboratories.
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Subject:
MEDICAID SERVICES MANUAL RESERVED
2902 RESERVED
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2903 POLICY
A. The Division of Health Care Financing and Policy (DHCFP) reimburses FQHCs an
outpatient encounter rate. DHCFP reimburses for medically necessary services provided at
FQHCs.
B. Encounters must include preventive and/or primary health services and are categorized as:
1. Medical;
2. Mental/Behavioral Health; or
3. Dental.
C. FQHCs that have more than one Service Specific Prospective Payment Systems (SSPPS)
rate established may bill for each reimbursable service type once per patient/per day.
1. An FQHC that has one established SSPPS encounter rate, only one reimbursable
encounter may be billed per day.
2. An FQHC that has two established SSPPS encounter rates, the FQHC may bill up
to two reimbursable encounters per patient per day.
3. An FQHC that has three established SSPPS encounter rates, the FQHC may bill up
to three reimbursable encounters per patient per day.
4. For information about Rate Development, Prospective Payment Systems, SSPPS,
Change in Scope of Services, and Supplemental Payments, please refer to the
Nevada Medicaid State Plan, Attachment 4.19B.
D. For the purposes of reimbursement, an encounter is defined as:
A face-to-face “visit” or an “encounter” between a patient and one or more approved
licensed Qualified Health Professional that takes place on the same day with the same
patient for the same service type; this includes multiple contacts with the same provider.
Licensed Qualified Health Professionals approved to furnish services included in the
outpatient encounter are:
1. Physician or Osteopath;
2. Dentist;
3. Advanced Practice Registered Nurse (APRN);
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4. Physician Assistant (PA);
5. Certified Registered Nurse Anesthetist (CRNA);
6. Nurse Midwife (NM);
7. Psychologist;
8. Licensed Clinical Social Worker (LCSW);
9. Registered Dental Hygienist (RDH);
10. Podiatrist;
11. Radiology;
12. Optometrist;
13. Optician;
14. Registered Dietitian (RD); and
15. Clinical Laboratory Services.
2903.1 COVERAGE AND LIMITATIONS
A. Medical Encounter(s):
1. May be provided by an employed or contracted Physician or Osteopath, Advanced
Practice Registered Nurse (APRN), Physician Assistant (PA), Nurse Midwife
(NM), Certified Registered Nurse Anesthetist (CRNA), Podiatrist, Optometrist,
Optician, or Registered Dietitian (RD) under the FQHCs HRSA approved scope of
services and the practitioners applicable state regulatory board’s scope of practice.
Encounters are to be billed as applicable with the FQHC encounter reimbursement
methodology.
2. Services may include:
a. Primary care services medical history, physical examination, assessment of
health status, treatment of a variety of conditions amendable to medical
management on an ambulatory basis by an approved provider and related
supplies;
1. Vital signs including temperature, blood pressure, pulse, oximetry
and respiration;
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2. Integral laboratory and radiology services conducted during the
visits are included in the encounter as they are built into the
established encounter rate and are not to be billed separately.
b. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening
policy and periodicity recommendations; Refer to Medicaid Services
Manual (MSM) Chapter 1500 – Healthy Kids.
c. Preventive health services recommended with a grade of A or B by the
United States Preventive Services Task Force (USPSTF) and education
Refer to MSM Chapter 600 – Physicians Services;
d. Home visits;
e. Family planning services including contraceptives;
Up to two times a calendar year, the FQHC may bill for additional
reimbursement for family planning education on the same date of service
as the encounter. Refer to Billing Guide, Provider Type 17, Specialty 181
for more information.
f. For women: annual preventive gynecological examination, clinical breast
examination, thyroid function test, and maternity care services which
includes antepartum, labor and delivery, and postpartum care services;
g. Vision and hearing screening;
B. Behavioral/Mental Health Encounter(s):
1. May be provided by employed or contracted Psychiatrist, Psychologist, APRN, PA,
or LCSW who is authorized to provide mental/behavioral health services by the
FQHC under the FQHC’s HRSA approved scope of services and the practitioner’s
applicable state regulatory board’s scope of practice.
2. Conditions may include behavioral/mental health, and/or substance use disorders
including co-occurring disorders. Services may include:
a. Screening, assessments, diagnosis, and/or treatment.
b. Treatments may include clinically appropriate evidence-based practices
suchas therapy, counseling, and medication management.
c. Refer to MSM Chapter 400 – Mental Health and Alcohol and Substance
Abuse Services.
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C. Dental Encounter(s):
1. Dental encounters are provided by employed or contracted Dentists or RDHs, under
FQHCs HRSA approved scope of practices and the practitioner’s applicable
regulatory boards of practice. Encounters are to be billed as applicable with the
FQHC encounter reimbursement methodology.
2. An FQHC may bill a dental encounter for each face-to-face encounter for dental
services.
3. Dentures provided by an FQHC are included in the daily encounter rate unlike the
denture policy established in MSM Chapter 1000 – Dental.
a. Medicaid will pay for a maximum of one emergency denture reline and/or
a maximum of six adjustments (dental encounters) done not more often than
every six months, beginning six months after the date of partial/denture
purchase. A prior authorization is not required for relines.
b. Full denture/partial relines and adjustments required within the first six
months are considered prepaid with the Medicaid’s dental encounter
payment for the prosthetic.
4. The FQHCs in-office records must substantially document the medical need.
5. Refer to MSM Chapter 1000 for all other covered and non-covered dental services.
D. Telehealth
1. An FQHC may bill for an encounter in lieu of an originating site facility fee, if the
distant site is for ancillary services (i.e. consult with specialist). If, for example, the
originating site and distant site are two different encounter sites, the originating
encounter site must bill the telehealth originating Healthcare Common Procedural
Coding System (HCPCS) code and the distant encounter site may bill the encounter
code. Refer to MSM Chapter 3400 – Telehealth Services
2903.2 NON-COVERED SERVICES
A. Non-covered services under an FQHC encounter:
1. Group therapy;
2. Eyeglasses;
3. Hearing aids;
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Subject:
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4. Durable medical equipment, prosthetic, orthotics and supplies; and
5. Ambulance services.
2903.3 FQHC PHARMACIES
A. FQHC pharmacies who want to bill Medicaid for vaccines administered by pharmacists
must do so through point of sale as a Provider Type 28. Refer to MSM Chapter 1200 –
Prescribed Drugs
2903.4 ANCILLARY SERVICES
A. Ancillary services are those services which are an approved Nevada Medicaid State Plan
service but are not included within an approved FQHC encounter.
1. Ancillary services may be reimbursed on the same date of service as an encounter
by a licensed Qualified Health Professional.
2. The FQHC must enroll within the appropriate provider type and meet all the MSM
coverage guidelines for the specific ancillary service.
3. Partial Hospitalization Program (PHP) – As an extension of an FQHC’s delivery
model, an FQHC may have administrative oversight through a contractual
agreement with an organization that provides outpatient PHP services and meets
the criteria of a Certified Mental Health Clinic (CMHC). PHP services include a
variety of psychiatric treatment modalities designed for recipients with chronic
mental illness and/or substance abuse related disorders that require collaborative,
intensive assistance normally found in an inpatient setting. Refer to MSM Chapter
400 – Mental Health and Alcohol/Substance Abuse Services for PHP policy.
2903.5 FQHCs DUALLY ENROLLED AS A CERTIFIED COMMUNITY BEHAVIORAL HEALTH
CENTER (CCBHC)
A. FQHCs dually enrolled as a CCBHC should determine the appropriate model to bill
medically appropriate rendered services. The FQHC and the CCBHC must have internal
policies regarding the appropriate placement for treatment for their respective recipients.
Medical necessity and clinical appropriateness as determined by the clinical professionals,
under care coordination, are required and should be taken into consideration when services
overlap both within the FQHC and/or the CCBHC scope of services. This is to determine
which encounter (FQHC or CCBHC) is appropriate to request reimbursement. Care
coordination is required to prevent duplicative billing for the same service occurring at the
same time.
B. Services that are covered under the CCBHC model are identified on the services grid
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MEDICAID SERVICES MANUAL POLICY
located in the CCBHC billing guide. Recipients that are accessing services that are
primarily CCBHC and not an exclusively FQHC service will bill the CCBHC PPS rate.
Services that are primarily FQHC specific and not exclusively CCBHC services will bill
the FQHC encounter rate.
C. Refer to the MSM Chapter 2700 – Certified Community Behavioral Health Center, and
Billing Guide (Provider Type 17, Specialty 188), for guidance related to CCBHC policy
and billing.
D. The Medicaid Surveillance and Utilization Review (SUR) unit will monitor in a
retrospective review for any duplication of billing between the two delivery models.
2903.6 MEDICAL NECESSITY
A. To receive reimbursement, all services provided must be medically necessary as defined in
MSM Chapter 100 – Medicaid Program.
2903.7 PRIOR AUTHORIZATIONS
A. FQHC encounters do not require prior authorizations (PAs). PA requirements indicated in
reference to MSM Chapters do not apply when the service is performed as an FQHC
encounter. However, the patient file must contain documentation supporting medical
necessity of services provided.
B. FQHCs not contracted with a Managed care Organization (MCO), must follow the MCOs
prior authorization policy.
C. Ancillary services billed outside of an encounter must follow prior authorization policy
guidelines for the specific services provided.
For billing instructions for FQHCs, please refer to the Billing Guide for Provider Type 17,
Specialty 181.
For Indian Health Programs (IHP) policy, including Tribal FQHCs please refer to MSM Chapter
3000, Indian Health.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 2904
Subject:
MEDICAID SERVICES MANUAL HEARINGS
2904 HEARINGS
A. Please reference Nevada Medicaid Services Manual (MSM) 3100 for hearings procedures.
June 30, 2021 FEDERALLY QUALIFED HEALTH CENTERS Section 2904 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
March 24, 2020
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM:
CODY L. PHINNEY, DEPUTY ADMINISTRATOR /Cody L. Phinney/
SUBJECT:
MEDICAID SERVICES MANUAL CHANGES CHAPTER 3000 –
INDIAN HEALTH
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 3000, Section 3003.1 – Health Services
are being proposed to allow the opportunity for Tribal or Tribal Organization outpatient health
clinics to enroll as Federally Qualified Health Centers (FQHCs). This service model will promote
greater access to specialty and related services outside of the four walls of the tribal clinics for
Medicaid eligible American Indian/Alaska Native (AI/AN) recipients.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: Federal, State and Tribal Governmental Agencies.
Financial Impact on Local Government: Unknown at this time.
These changes are effective March 25, 2020.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 12/20 MTL 22/14
MSM Ch 3000 – Indian Health MSM Ch 3000 – Indian Health
Background and Explanation of Policy
Manual Section Section Title Changes, Clarifications and Updates
3003.1 Health Services To include new policy for tribal organizations
selecting to be recognized as Tribal FQHCs.
Page 1 of 1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
INDIAN HEALTH PROGRAM
3000 INTRODUCTION ...........................................................................................................................1
3001 AUTHORITY ..................................................................................................................................1
3002 DEFINITIONS .................................................................................................................................1
3003 POLICY ...........................................................................................................................................1
3003.1 HEALTH SERVICES ......................................................................................................................1
3003.2 TRIBAL GOVERNMENTS ............................................................................................................4
Page 1 of 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3000
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
3000 INTRODUCTION
Medically necessary (as defined in Medicaid Services Manual (MSM) Chapter 100 (Medicaid
Program) services are reimbursable when the services are provided by an Indian Health Program
to an eligible American Indian or Alaskan Native (AI/AN) Medicaid or Nevada Check Up
recipient. Indian Health Programs may be operated by the Indian Health Service (IHS), Tribal
Organization, or an Urban Indian Organization – (I/T/U).
Numerous public laws guide federal and state interactions with tribal governments and AI/ANs. A
basic understanding of these laws is essential to help facilitate the collaborative relationship
between the Division of Health Care Financing and Policy (DHCFP) and the tribes within the State
of Nevada. Below is a brief summation of these laws.
WORCESTER V. GEORGIA (1832): The Supreme Court of the United States held that the federal
government, and not state governments, had exclusive “authority over American Indian Affairs”.
GENERAL ALLOTMENT ACT OF 1877
The Act authorized the President of the United States to partial reservation lands into general
allotments. Federal trust land owned or possessed by an AI/AN may be exempt from Medicaid
estate recovery.
SNYDER ACT OF 1921
The Act made the federal government responsible for the health care of AI/ANs.
INDIAN CITIZENSHIP ACT OF 1924
The Act granted AI/ANs dual citizenship.
INDIAN REORGANIZATION ACT OF 1934
The Act reversed the General Allotment Act. The Act reinstated self-governance and returned
tribal lands to respective tribal governments.
INDIAN SELF-DETERMINATION AND EDUCATION ASSISTANCE ACT OF 1975
Prior to this Act, the federal government managed, coordinated, and provided health care services
for AI/ANs. The Act authorized tribal governments to establish contracts and compacts with the
federal government. In general, tribal governments may plan, conduct and administer their own
public programs – to include Indian Health Programs.
January 1, 2015 INDIAN HEALTH PROGRAM Section 3000 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
INDIAN HEALTH CARE IMPROVEMENT ACT OF 1976
The Act authorized 100% federal reimbursement to states for medical services provided to AI/ANs
when provided through the Indian Health Service (IHS) and/or tribal organizations.
AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009
The Act established:
• Guidelines surrounding the enrollment of AI/ANs in Medicaid Managed Care
Organizations (MCO);
• Prohibitions of state Medicaid agencies from charging AI/AN premiums and cost shares
for services provided through Indian Health Programs or tribal organizations to AI/ANs;
• Protections of certain properties held by AI/AN from federal or state recovery; and
• Mandates that states seek ongoing advice from Indian Health Programs on issues that are
likely to have a direct effect on Indian Health Programs.
PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010
The Act reauthorized and made permanent the Indian Health Care Improvement Act.
January 1, 2015 INDIAN HEALTH PROGRAM Section 3000 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3001
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
3001 AUTHORITY
• Public Law (PL) 49-43: General Allotment Act of 1877
• PL 67-85: Snyder Act of 1921
• PL 68-175: Indian Citizenship Act of 1924
• PL 73-383: General Allotment Act of 1934
• PL 93-638: Indian Self-Determination and Education Act of 1975
• PL 94-437: Indian Health Care Improvement Act of 1976
• Social Security Act (SSA), Title XIX (Grants to States for Medical Assistance Programs),
Chapter 1905 (Definitions), Section (b)
• SSA, Title XIX, Chapter 1911 (Indian Health Service Facilities)
• SSA, Title XIX, Chapter 1916A (State Option for Alternative Premiums and Cost Sharing)
• SSA, Title XIX, Chapter 1917 (Liens, Adjustments and Recoveries, and Transfers of
Assets)
• SSA, Title XIX, Chapter 1932 (Provisions Relating to Managed Care)
• United States Code (USC), Title 25 (Indians), Chapter 14 (Miscellaneous), Subchapter II
(Indian Self-Determination and Education Assistance)
• USC, Title 25 (Indians), Chapter 18 (Indian Health Care)
• Code of Federal Regulations, Title 42 (Public Health), Chapter IV (Centers for Medicare
& Medicaid Services, Department of Health and Human Services), Section 431.110
(Participation by Indians Health Service Facilities)
• Johnson v. McIntosh (1823)
• Worcester v. Georgia (1832)
• United States v. Wheeler (1978)
January 1, 2015 INDIAN HEALTH PROGRAM Section 3001 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3002
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
3002 DEFINITIONS
A. American Indians and Alaskan Natives (AI/AN)
In accordance with 25 USC, Section 1602: “The term [eligible] Indians or Indian, unless
otherwise designated, means any person who is a member of an Indian tribe, as defined in
subsection (d) hereof, except that, for the purpose of Sections 1612 and 1613 of this title,
such terms shall mean any individual who:
1. Irrespective of whether he or she lives on or near a reservation, is a member of a
tribe, band or other organized group of Indians, including those tribes, bands or
groups terminated since 1940 and those recognized now or in the future by the state
in which they reside, or who is a descendant, in the first or second degree, of any
such member, or
2. Is an Eskimo or Aleut or other Alaska Native, or
3. Is considered by the Secretary of the Interior to be an Indian for any purpose, or
4. Is determined to be an Indian under regulations promulgated by the Secretary.”
B. Children, Eligible
“Any individual who:
1. has not attained 19 years of age;
2. is the natural or adopted child, stepchild, foster child, legal ward or orphan of an
eligible Indian; and
3. is not otherwise eligible for health services provided by the Indian Health Service
(IHS), shall be eligible for all health services provided by IHS on the same basis
and subject to the same rules that apply to eligible Indians until such individual
attains 19 years of age.”
C. Indian Descent, Eligible
Indian descendants may be eligible for Indian health services if:
1. They are verifiable descendants of an enrolled tribal member – as established by
each tribe;
2. The recipient belongs to an Indian community which may be verified by tribal
January 1, 2015 INDIAN HEALTH PROGRAM Section 3002 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3002
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
record or census number; and
3. The recipient lives within the established contract health service delivery area.
D. Indian Health Programs
Indian Health Programs include the IHS, Tribal Organizations and Urban Indian
Organizations (I/T/U):
1. Indian Health Service: IHS is a federal agency within the Department of Health and
Human Services (DHHS).
2. Tribal Organizations: Tribal Organizations are operated by tribal governments.
3. Urban Indian Organizations: Urban Indian Organizations are nonprofit
organizations.
E. Pregnant Woman, Non-Indian, Non-Spouse, Eligibility
During the period of her pregnancy through postpartum – a non-Indian, non-spouse
pregnant woman with an eligible Indian child is eligible for tribal organization health
services on the same basis and subject to the same rules that apply to eligible Indians.
F. Sovereignty, Trust Relationship
Federally recognized tribes are sovereign governments. They may establish their own
governments, establish tribal membership guidelines and create and enforce their own
laws.
G. Tribes, Federally Recognized
Any Indian tribe, band, nation, or other organized group or community, which the Federal
government recognizes as eligible for programs and services provided by the United States
to AI/AN.
January 1, 2015 INDIAN HEALTH PROGRAM Section 3002 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3003
Subject:
MEDICAID SERVICES MANUAL POLICY
3003 POLICY
It is the policy of the DHCFP to follow State and Federal laws, uphold the tribal-state consultation
process, and promote Indian Health Programs (IHP).
3003.1 HEALTH SERVICES
A. The DHCFP reimburses Indian Health Services (IHS), Tribal organizations and Tribal
Federally Qualified Health Centers (FQHCs) at an outpatient encounter rate.
1. Encounter visits are limited to healthcare professionals as approved under the
Nevada Medicaid State Plan. Each healthcare professional is considered an
independent (i.e., separate) outpatient encounter.
2. Service Limits: Eligible Indians may receive up to five face-to-face IHS and/or
Tribal Organization outpatient encounter/visits per day, per recipient, any provider.
3. Medical Necessity: In order to receive reimbursement, all services must be
medically necessary as defined in the Medicaid Services Manual (MSM), Chapter
100 – Medicaid Program.
4. Tribes or Tribal organizations that choose to be recognized as a Tribal FQHC may
receive reimbursement for services furnished by an enrolled Medicaid non-
IHS/Tribal provider to AI/AN Medicaid recipient’s when requested by a Tribal
FQHC provider (refer to CMS SHO #16-002). Covered services include those in
the Medicaid State Plan.
a. The Tribal FQHC and the offsite non-IHS/Tribal provider must have a
written agreement in place that designates that the non-IHS/Tribal provider
is a contractual agent furnishing services as part of the Tribal FQHC.
b. The written agreement between the non-IHS/Tribal provider and the Tribal
FQHC provider must include:
1. The Tribal FQHC provider makes a specific request for specific
services to the non-IHS/Tribal provider;
2. The non-IHS/Tribal provider must send information about the
recipients care to the Tribal FQHC;
3. The Tribal FQHC continues to assume responsibility for the
recipient’s care; and
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3003
Subject:
MEDICAID SERVICES MANUAL POLICY
4. The Tribal FQHC incorporates the recipient’s information into their
medical record.
c. Both the Tribal FQHC and non-IHS/Tribal provider must be enrolled in
Nevada Medicaid.
d. There must be an established relationship between the recipient and the
Tribal FQHC provider.
e. The following services are not eligible:
1. Services that are self-requested by the recipient.
2. Services in which the Tribal FQHC does not remain responsible for
the recipient’s care.
3. Services requested by a non-IHS/Tribal provider.
a. The provider could furnish and bill for services via their own
Medicaid provider type but would not be eligible for
reimbursement through the Tribal FQHC.
B. Primary Care Provider (PCP)
In accordance with the American Recovery and Reinvestment Act of 2009, the DHCFP
supports eligible Indians in selecting an Indian Health Program as their PCP. These
recipients may select an Indian Health Program as their PCP, whether they are enrolled in
managed care or fee-for-service (FFS). Indian Health Programs that become PCPs for
eligible Indians do not have to be, but may be, enrolled with either of the Managed Care
Organizations (MCOs). Services which are referred out by PCPs must follow the service
limitation and prior authorization requirements set forth by the applicable benefit plan (i.e.,
managed care or FFS).
C. Managed Care Enrollment
Eligible Indians are exempt from mandatory enrollment in managed care. In situations
where Indians voluntarily enroll in managed care, they may access health care services
from Indian Health Programs without restriction. Health care services provided to Indians
through the IHS and/or tribal organizations may be reimbursed FFS or through the MCO.
D. Prior Authorizations
1. Medically necessary services provided by the IHS and/or Tribal Organizations do
not require prior authorization when:
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
a. The service is provided to an eligible Indian; and
b. The service is provided through IHS or a Tribal Organization.
E. Program Funding
1. Premiums and Cost Sharing
a. Adults – Age 21 and older: Eligible Indians may not be charged premiums
or cost shares when they receive medical services through an Indian Health
Program.
b. Children – Age 20 and younger: Eligible Indian children may not be
charged premiums or cost shares for covered Nevada Medicaid and/or
Check Up services – regardless if the services are provided through an
Indian Health Program, FFS providers or an MCO.
1. Federal Medical Assistance Percentage (FMAP)
The FMAP for services provided by the IHS or Tribal Organizations
to eligible Indians is 100 percent. This percentage does not apply to
non-emergency transportation services.
2. The FMAP for medical services provided by Urban Indian
Organizations to eligible Indians is the established state percentage.
3. Rates
a. IHS and Tribal Organization Clinics – Provider Type 47 (PT
47): PT 47s are paid the federally established Outpatient Per
Visit Rate (i.e., encounter rate). The rate is adjusted annually
by the federal government. The rate is posted on the Federal
Register.
b. Tribal Organization Inpatient Hospitals – Provider Type 51
(PT 51): PT 51s are paid the federally established Inpatient
Hospital Per Diem Rate. The rate is adjusted annually by the
federal government. The rate is posted on the Federal
Register.
c. IHS Inpatient Hospitals – Provider Type 78 (PT 78): PT 78s
are paid the federally established Inpatient Hospital Per
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3003
Subject:
MEDICAID SERVICES MANUAL POLICY
Diem Rate. The rate is adjusted annually by the federal
government. The rate is posted on the Federal Register.
F. Facility Licensure and Accreditation
1. IHS and Tribal Organizations:
a. Licensure: Facility licensure is not required.
b. Accreditation: In accordance with the Indian Health Care Improvement Act,
to assure nondiscrimination, Indian Health Programs must follow the same
provider enrollment criteria as other similar Medicaid provider types. The
DHCFP does not require tribal clinics to be accredited.
G. Staff Licensure and Certification
Health care professionals do not have to be licensed in the State of Nevada if:
1. They provide services at an Indian Health Program; and
2. They are currently licensed in another state.
H. Transportation
1. Non-emergency transportation is not a covered IHS benefit. Indian Health
Programs may enroll with the DHCFP’s Non-Emergency Transportation (NET)
broker (see MSM Chapter 1900).
2. Ambulance, Air or Ground – Provider Type 32: While emergency medical
transportation is not a covered IHS benefit, qualified Indian Health Programs may
enroll as a Provider Type 32 (see MSM Chapter 1900).
3003.2 TRIBAL GOVERNMENTS
A. Consultations
The DHCFP will consult with Tribes and Indian Health Programs on Medicaid State Plan
Amendments (SPAs), waiver requests, waiver renewals, demonstration project proposals
and/or on matters that relate to Medicaid and Nevada Check Up programs.
1. The notification will describe the purpose of the SPA, waiver request, waiver
renewal, demonstration project proposal and/or on matters relating to Medicaid and
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3003
Subject:
MEDICAID SERVICES MANUAL POLICY
Nevada Check Up programs and will include the anticipated impact on Tribal
members, Tribes and/or Indian Health Programs.
2. The notification will also describe a method for Tribes and/or Indian Health
Programs to provide official written comments and questions within a time-frame
that allows adequate time for State analysis, consideration of any issues that are
raised and the time for discussion between the State and entities responding to the
notification.
3. Tribes and Indian Health Programs will be provided a reasonable amount of time
to respond to the notification. Whereof, 30 days is considered reasonable.
4. In all cases where Tribes and/or Indian Health Programs request in-person
consultation meetings, the DHCFP will make these meetings available.
5. The tribe-state consultation process allows for an expedited process for notification
of policy changes due to budget cuts prior to changes being implemented. The
Centers for Medicare and Medicaid Services (CMS) requires Medicaid SPAs,
waiver requests and waiver renewals, which fall within this category to have a
notification process prior to these documents being submitted to CMS. Due to this,
the State is instituting an expedited process which allows for notification to the
Tribes and Indian Health Programs of at least one week notice prior to the changes
being implemented as agreed upon in the tribe-state consultation process or two
weeks prior to the submission of the SPAs, waiver requests and/or waiver renewals,
whichever date precedes.
January 1, 2015 INDIAN HEALTH PROGRAM Section 3003 Page 5
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
February 22, 2018
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: LYNNE FOSTER, CHIEF OF DIVISION COMPLIANCE
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 3100 – HEARINGS
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 3100 – Hearings, are being proposed for
consistency with the federal policy language in the Code of Federal Regulations (CFR), Title 42,
Chapter IV, 431 Subpart E. Language specifying the circumstances under which a provider can
request an expedited fair hearing for a recipient is proposed.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: All provider types are affected by this regulation.
Financial Impact on Local Government: Unknown at this time.
These changes are effective February 23, 2018.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 03/18 MTL 20/17
Chapter 3100 - Hearings Chapter 3100 - Hearings
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3104.1B.1 Medicaid Services Added the words “(only under circumstances described
Expedited Fair below)”and “Providers may file a request only in cases
Hearing where the recipient is unable to act on their own behalf,
either because of physical incapacity or mental
incapacity. Additional documentation may be required to
demonstrate the incapacity on a case by case basis.”
Page 1 of 1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
HEARINGS
3100 INTRODUCTION ...............................................................................................................................1
3101 AUTHORITY ......................................................................................................................................1
3102 RESERVED .........................................................................................................................................1
3103 POLICY ...............................................................................................................................................1
3104 RECIPIENT FAIR HEARINGS ..........................................................................................................1
3104.1 FAIR HEARINGS ...............................................................................................................................1
3104.1A MEDICAID SERVICES STANDARD FAIR HEARING ..................................................................1
3104.1B MEDICAID SERVICES EXPEDITED FAIR HEARINGS ..............................................................2
3104.2 DISPOSITION OF A FAIR HEARING REQUEST ...........................................................................4
3104.3 HEARING NOTIFICATION, SCHEDULING AND LOCATION ....................................................5
3104.4 PROGRAM PARTICIPATION PENDING A HEARING DECISION .............................................6
3104.5 HEARING PARTICIPATION ............................................................................................................7
3104.6 PREPARATION/PRESENTATION ...................................................................................................8
3104.7 CONDUCT OF HEARING .................................................................................................................9
3104.8 ACTION ON INCORRECT NOTICE OF DECISION (NOD) ........................................................10
3104.9 SUBMISSION OF ADDITIONAL EVIDENCE ..............................................................................10
3104.10 MEDICAL ISSUES ...........................................................................................................................10
3104.11 HEARING DECISION ......................................................................................................................11
3104.12 RIGHT TO APPEAL HEARING DECISION ..................................................................................12
3104.13 HEARING RECORDS ......................................................................................................................12
3105 MEDICAID PROVIDER HEARINGS ...............................................................................................1
3105.1 REQUEST FOR A MEDICAID PROVIDER FAIR HEARING ........................................................1
3105.2 DISPOSITION OF A MEDICAID PROVIDER FAIR HEARING REQUEST .................................2
3105.3 FAIR HEARING NOTIFICATION, SCHEDULING AND LOCATION..........................................3
3105.4 HEARING PARTICIPATION ............................................................................................................3
3105.5 PREPARATION/PRESENTATION ...................................................................................................4
3105.6 CONDUCT OF A FAIR HEARING ...................................................................................................5
3105.7 ACTION ON INCORRECT DETERMINATION NOTICE ..............................................................6
3105.8 SUBMISSION OF ADDITIONAL EVIDENCE ................................................................................6
3105.9 HEARING DECISION ........................................................................................................................6
3105.10 RIGHT TO APPEAL HEARING DECISION ....................................................................................7
3105.11 HEARING RECORDS ........................................................................................................................8
MTL 20/17
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3100
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
3100 INTRODUCTION
The Division of Health Care Financing and Policy (DHCFP) (also referred to as the “agency”)
makes a Fair Hearing process available to any Nevada Medicaid or Nevada Check Up (NCU)
recipient who disagrees with: any action resulting in the reduction, suspension, termination, denial
or denial-in-part of a Medicaid service; any recipient who makes a request for a service and
believes the request was not acted upon with reasonable promptness by the DHCFP and/or the
health plan. Also, the DHCFP makes available a Fair Hearing process for any Nursing Facility
(NF) resident eviction.
The DHCFP makes available a Fair Hearing process whereby providers may request a hearing for
any adverse action taken by the Division or its agents which affects the provider’s participation in
the Medicaid program, and/or reimbursement for services rendered to eligible Medicaid recipients’
recoupment of overpayments or disenrollment.
For purposes of this manual section, Medicaid and NCU are referred to as Medicaid. All Medicaid
policies and requirements (such as prior authorization, etc.) are the same for NCU, with the
exception of three areas where Medicaid and NCU policies differ as referenced in the NCU
Manual, Section 1003.6.
October 26, 2017 HEARINGS Section 3100 Page 1
MTL 20/17
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3101
Subject:
MEDICAID SERVICES MANUAL AUTHORITY
3101 AUTHORITY
The Fair Hearing process for recipients is a mandated service. The citation denoting the right to a
hearing is found in 42 Code of Federal Regulations (CFR), §431, Subpart E and 42 CFR 457.1130
and Nevada Revised Statute (NRS) 422.276. Please see CFR §431.244 for exceptions to the
Hearing decision due dates. In addition, the citation denoting the appeals procedure for NF and
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) is found in 42
CFR §431, Subpart D.
The Fair Hearing process for providers is cited at NRS Chapter 422.306 – Hearing to review action
taken against provider of services under state plan for Medicaid regulations; appeal of final
decision.
October 26, 2017 HEARINGS Section 3101 Page 1
MTL 18/11
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3102
Subject:
MEDICAID SERVICES MANUAL RESERVED
3102 RESERVED
August 24, 2011 HEARINGS Section 3102 Page 1
MTL 20/17
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3103
Subject:
MEDICAID SERVICES MANUAL POLICY
3103 POLICY
3103.1 The DHCFP provides the Fair Hearing process pursuant to Sections 3104 and 3105 of this Chapter
of the Medicaid Services Manual (MSM).
October 26, 2017 HEARINGS Section 3103 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
3104 RECIPIENT FAIR HEARINGS
3104.1 FAIR HEARINGS
3104.1A MEDICAID SERVICES STANDARD FAIR HEARING
1. WHO MAY REQUEST
A recipient or his authorized representative may request a Standard Fair Hearing. A request
for a Fair Hearing can be submitted via the internet, telephonically, in person, through other
commonly available electronic means and in writing and signed by the recipient or the
recipient’s authorized representative.
2. DATE OF REQUEST
The date of the request for a Standard Fair Hearing is the date the request is received by the
DHCFP office. The request must be received by the DHCFP office within 90 calendar days
from the Notice Date, unless a recipient can substantiate “good cause” for not doing so.
When the deadline falls on a weekend or holiday, the deadline is extended to the next
working day.
The request for hearing must contain the recipient’s name, address, telephone number and
Medicaid number as well as the name, telephone number and address of the authorized
representative, if applicable.
Recipients enrolled in a Managed Care Organization (MCO) must request a Fair Hearing
no later than 120 days from the date on the MCO’s Notice of Decision (NOD) (Action).
3. SUBJECT MATTER
The DHCFP must grant an opportunity for a hearing to:
a. a recipient who requests it because his request for services is denied, reduced,
suspended or terminated;
b. a recipient who requests it because his request for services is not acted upon with
reasonable promptness;
c. a recipient who requests it because he believes the agency or managed health plan
has taken an action erroneously;
d. any resident of a nursing facility who believes the facility erroneously determined
that he must be transferred or discharged;
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
e. any recipient who requests it because he believes the State has made an erroneous
determination with regard to the Pre-admission Screening and Resident Review
(PASRR) as outlined in Section 1917(e)(7) of the Social Security Act;
f. any recipient who is assigned (locked in) to using one pharmacy for all controlled
substance prescriptions.
This includes an adverse determination that the recipient does not require specialized
services as defined in 42 CFR §431.201, 431.206 and 431.220 as determined by a PASRR.
Pursuant to 42 CFR §483.204, the state will provide a system for a resident of a NF to appeal
a notice from the NF of intent to discharge or transfer the resident. Upon receipt of the
discharge notice, the resident may request a Fair Hearing via the internet, telephonically, in
person, through other commonly available electronic means or by submitting the request to
the DHCFP. The DHCFP will inform the Department of Administration of the residents
request for a Fair Hearing. The DHCFP does not take an adverse action against the resident;
rather the facility takes the action via the discharge. The DHCFP is not a party to the action.
3104.1B MEDICAID SERVICES EXPEDITED FAIR HEARING
1. WHO MAY REQUEST
A recipient, his/her authorized representative or a provider acting on a recipient’s behalf
(only under circumstances described below) may file for an Expedited Fair Hearing if the
clinical documentation shows that the time permitted for a Standard Fair Hearing could
jeopardize the individual’s life, health or ability to attain, maintain or regain maximum
function. The Expedited Fair Hearing request must be submitted with pertinent medical
information that supports the reason for the urgent need of the expedited timeframe.
Providers may file a request only in cases where the recipient is unable to act on their own
behalf, either because of physical incapacity or mental incapacity. Additional
documentation may be required to demonstrate the incapacity on a case by case basis. A
request for an Expedited Fair Hearing can be made via the internet, telephonically, in
person, through other commonly available electronic means and in writing.
2. DATE OF REQUEST
The date of the request for an Expedited Fair Hearing is the date the request is received by
the DHCFP office.
The request for an Expedited Fair Hearing must contain the recipient’s name, address,
telephone number and Medicaid number, as well as the name, telephone number and address
of the authorized representative and/or provider, if applicable, and must include all pertinent
medical information that supports the reason for the urgent need of the expedited timeframe.
February 23, 2018 HEARINGS Section 3104 Page 2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
If the Expedited Hearing request is submitted without pertinent medical information, the
Hearing request will be treated as a Standard Fair Hearing request (90-day decision). If the
required documentation is submitted after the initial Expedited Hearing request is received,
the timeframe for the Expedited Fair Hearing will begin the day the required pertinent
medical documentation is received by the DHCFP.
3. SUBJECT MATTER
The DHCFP must grant an opportunity for an Expedited Fair Hearing to:
a. a recipient who requests it because his request for services is denied, reduced,
suspended or terminated and the time permitted for a Standard Fair Hearing could
jeopardize the individual’s life, health or ability to attain, maintain or regain
maximum function;
b. a recipient who requests it because his request for services is not acted upon with
reasonable promptness and the time permitted for a Standard Fair Hearing could
jeopardize the individual’s life, health or ability to attain, maintain or regain
maximum function;
c. a recipient who requests it because he believes the agency or managed health plan
has taken an action erroneously and the time permitted for a Standard Fair Hearing
could jeopardize the individual’s life, health or ability to attain, maintain or regain
maximum function; or
d. any resident of a NF who believes the facility erroneously determined that he must
be transferred or discharged and the time permitted for a standard Fair Hearing could
jeopardize the individual’s life, health or ability to attain, maintain or regain
maximum function;
This includes an adverse determination that the recipient does not require specialized
services as defined in 42 CFR §431.201, 431.206 and 431.220 as determined by a PASRR.
Pursuant to 42 CFR §483.204, the state will provide a system for a resident of a NF to appeal
a notice from the NF of intent to discharge or transfer the resident. Upon receipt of the
discharge notice, the resident may request an Expedited Fair Hearing over the phone,
electronically or in writing by submitting a letter to the DHCFP. The DHCFP will inform
the Department of Administration of the resident’s request for a Fair Hearing. The DHCFP
does not take an adverse action against the resident; rather the facility takes the action via
the discharge. The DHCFP is not a party to the action. A decision will be provided within
seven working days from when the Hearing request was received.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
4. EXCEPTIONS TO EXPEDITED FAIR HEARINGS
a. The agency cannot reach a decision because the recipient, authorized representative
and/or provider request the delay.
b. The recipient, authorized representative and/or provider fails to take a required
action such as submitting the required documentation.
c. If Medicaid services have been continued at unreduced levels per MSM Section
3104.4(C), the Expedited Fair Hearing process is not applicable and the Fair Hearing
request will be treated as a Standard Fair Hearing request.
3104.2 DISPOSITION OF A FAIR HEARING REQUEST
A. DISMISSAL OF A HEARING REQUEST
A Fair Hearing request will be dismissed upon:
1. Withdrawal of a Hearing Request
A recipient may withdraw the request for a hearing at any time before a decision is
rendered via phone, written submission or electronically. Notification of the request
for withdrawal will be submitted to the Hearing Officer who will dismiss the hearing
request. Written confirmation will be sent to the recipient regarding the withdrawal.
2. Abandonment of a Hearing Request
A hearing is considered abandoned and may be dismissed by the Hearing Officer
when the recipient fails to appear for a scheduled hearing after having been properly
notified. The recipient's request for hearing is considered abandoned unless they
submit to the Hearing Officer substantiation for good cause for failing to appear.
The Hearing Officer must receive the substantiation within 10 calendar days of the
date of the scheduled hearing.
3. Agency Action
Medicaid may reverse its NOD at any time during the hearing process. If a
Medicaid reversal occurs, a report shall be submitted by the person conducting the
review detailing the reason(s) for the reversal if a Fair Hearing has been calendared.
The report must be forwarded to the Hearing Officer within five business days
following the reversal decision date or review date if a fair hearing has been
scheduled. The Hearing Officer notifies the recipient the request for hearing is
dismissed because Medicaid will not take action or has reversed the decision.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
B. DENIAL OF A HEARING REQUEST
A hearing need not be granted when:
1. the sole issue is a Federal or State law requiring an automatic change adversely
affecting some or all recipients;
2. the request is not received timely;
3. the agency and/or managed health plan has not taken any action affecting the
recipient, or made an Adverse Determination, nor denied a request for services or
failed to act upon the request within reasonable promptness;
4. a recipient is not Medicaid eligible, except for PASRR determinations; or
5. the primary insurance policy and access (including appeal/hearing process) has not
been exhausted. As Medicaid is the payer of last resort, all remedies under other
insurance must be exhausted.
3104.3 HEARING NOTIFICATION, SCHEDULING AND LOCATION
A. HEARING PREPARATION MEETING (HPM)
Within 10 calendar days of a request for a Standard Fair Hearing, the DHCFP Hearings
Office shall contact the recipient to offer an HPM. The purpose is to provide the recipient
an explanation of the action, which is the subject of the hearing request, and attempt to
resolve the matter. Every effort is made to reconcile the disagreement without the necessity
of a Fair Hearing. The right to a Fair Hearing is not affected by attendance at a HPM. The
recipient may allow participation in the HPM by legal counsel, a friend or other
spokesperson.
It is important the HPM be held at the earliest possible date, no later than 21 working days
after receipt of a hearing request. Rescheduling of an HPM shall be kept to a maximum of
two instances, assuring completion within 21 working days.
An HPM shall be conducted telephonically.
B. NOTICE OF A STANDARD FAIR HEARING
The Department of Administration Hearing Officer shall notify all parties by mail as to the
time, date and place the hearing has been scheduled. Recipients are given at least 10
calendar days advance notice of the scheduled hearing unless the recipient specifically
requests a hearing in a shorter period of time based on an emergency.
October 26, 2017 HEARINGS Section 3104 Page 5
MTL 20/17
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
At the discretion of the Hearing Officer, a Fair Hearing may be postponed if requested by
either party.
If the recipient requests a postponement, the number of days postponed will extend the
decision due date by an equal number of days.
C. FAIR HEARINGS BY TELEPHONE
Either party may request the Fair Hearing be conducted telephonically. If a telephone
hearing is held, the following procedures apply:
1. The recipient is advised at the time the hearing is scheduled that all other policies
and procedures relative to hearings and program requirements still apply.
2. The Hearing Officer may request the DHCFP, the managed health plan and the
recipient to provide copies of any evidence or exhibits to be presented during the
hearing to the Hearing Officer and the other parties prior to a scheduled telephone
hearing. This does not preclude additional information from being presented during
the hearing, or if requested, after the close of the hearing.
3. All telephone hearings must be tape recorded by the Hearing Officer over the
telephone. This recording is the official record.
All Expedited Fair Hearings are held telephonically due to time constraints.
3104.4 PROGRAM PARTICIPATION PENDING A HEARING DECISION
A. RECOVERY
If Medicaid services are continued until a decision is rendered, such cost of services are
subject to recovery by the DHCFP if the agency's action is sustained or the hearing request
is withdrawn by the recipient.
B. MAINTAINING MEDICAID SERVICES
If the agency mails the notice as required, and the recipient requests a hearing before the
Date of Action, the DHCFP or managed health plan will not terminate or reduce services
until a decision is rendered after the hearing unless:
1. the Hearing Officer makes a determination the sole issue is one of Federal or State
law or policy and the agency promptly informs the recipient in writing that services
are to be terminated or reduced pending the hearing decision; or
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
2. the recipient requests in writing that benefits not be continued pending a hearing
decision; or
3. the request for hearing is denied or dismissed.
C. REINSTATING MEDICAID SERVICES
1. Discretionary:
When a recipient requests a hearing no more than the 10th calendar day after the
Date of Action, the agency may reinstate benefits if requested by the recipient. The
reinstated services will continue until a hearing decision is rendered unless, at the
hearing, it is determined that the sole issue is one of Federal or State law or policy.
2. Mandatory:
The agency must reinstate and continue services until a decision is rendered after a
hearing if:
a. action is taken without the required advance notice;
b. the agency mails the 10-day or 5-day notice as required under 42 CFR
§431.211 or 42 CFR §431.214, and the recipient requests a hearing before
the date of action, the agency may not terminate or reduce services until a
decision is rendered after the hearing unless:
1. it is determined that the sole issue is one of Federal or State law or
policy; and
2. the agency promptly informs the recipient in writing that services
are to be terminated or reduced pending the hearing decision.
3104.5 HEARING PARTICIPATION
A. ATTENDANCE
Attendance at a hearing is limited to those directly concerned; namely, the Hearing Officer,
recipient(s), and/or their witnesses, counsel or authorized representative(s), interpreter,
witnesses and representatives of the DHCFP, and if applicable, representatives from the
managed health plan. Counsel for the agency and/or managed health plan may also attend
as necessary.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
Medicaid assures the availability for recipients, their authorized representatives and
witnesses of necessary transportation to and from the hearing.
B. GROUP HEARINGS
A series of recipient requests for a hearing may be consolidated upon agreement of all
parties by conducting a single group hearing in cases in which the sole issue involved is
one of State and/or Federal law, regulation or policy.
3104.6 PREPARATION/PRESENTATION
A. AGENCY/MANAGED HEALTH PLAN
It is the responsibility of the agency and/or managed health plan representative to be
present at the hearing, in person or telephonically, and to provide testimony and/or
evidence regarding the agency's and/or managed health plan's action. This includes the
organization of oral and written evidence and preparation of a Basis of Action summary
substantiating the decision to be presented at the hearing. This summary becomes part of
the record at the end of the hearing.
B. RECIPIENT
1. Before the date of the hearing and during the hearing, the recipient may examine
and request copies of their own case information. Authorized representatives must
provide a current signed release from the recipient to permit release of records. The
DHCFP and/or managed health plan will provide the copies free of charge. The
recipient shall not have access to confidential information.
2. It is the responsibility of the recipient to provide testimony and/or evidence in
support of their position either in person or telephonically. If the hearing involves
a legal issue only, the recipient's presence, in person or telephonically, is not
necessary. Testimony can be provided by a representative.
Recipients are allowed to bring witnesses and submit evidence to establish all
pertinent facts and circumstances relative to the issue and to present arguments
without undue interference. They are also allowed to question or refute any
testimony or evidence and confront and cross-examine adverse witnesses. New
evidence not previously provided to the DHCFP or managed health plan, but which
is believed to have a bearing on the action taken, must be provided to the DHCFP
prior to the hearing for evaluation and any necessary action.
3. Recipients are provided a copy of all evidence presented at the hearing by the
DHCFP.
October 20/17 HEARINGS Section 3104 Page 8
MTL 18/11
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
3104.7 CONDUCT OF HEARING
A. CONTROL
The Hearing Officer controls the hearing and ensures only relevant issues are considered.
Disrespectful language or contemptuous conduct, refusal to comply with directions or
continued use of dilatory tactics by any person at the hearing constitutes grounds for
immediate exclusion of such person from the hearing by the Hearing Officer and the
hearing decision will be based on evidence submitted. The Hearing Officer shall record
hearing proceedings. The Hearing Officer’s Transcripts of Evidence constitutes the sole
official record.
B. OPENING THE HEARING
At the opening of the hearing, the Hearing Officer shall:
1. Introduce their self;
2. Explain the reason for the hearing and the role of the Hearing Officer;
3. Assure all persons in attendance at the hearing are identified by name and purpose
of attendance;
4. Advise all persons in attendance that the hearing is being tape-recorded.
C. ADMINISTERING OATHS
Testimony under oath shall be required at the discretion of the Hearing Officer.
D. TESTIMONY AND EVIDENCE
Nevada Rules of Evidence do not apply in the hearing. The Hearing Officer:
1. Excludes irrelevant, immaterial or unduly repetitious evidence;
2. Provides the parties an opportunity to present their case, to present witnesses,
introduce evidence and cross-examine witnesses and examine evidence; and
3. Collects and logs relevant evidence exhibits.
E. CLOSING THE HEARING
At the close of the hearing, the Hearing Officer advises persons in attendance:
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
1. When a decision is expected to be made;
2. That the decision will be made based on program policy and exclusively on the
testimony and evidence presented at the hearing; and
3. The parties will be advised in writing by certified mail of the decision.
3104.8 ACTION ON INCORRECT NOTICE OF DECISION (NOD)
A. If, prior to the hearing, it becomes apparent the recipient has received an incorrect NOD
for Prior Authorization Request from the DHCFP or the managed health plan, a corrected
notice must be sent to the recipient if the proposed action remains unchanged.
B. If, after a hearing has begun, it becomes apparent the recipient received an incorrect NOD
for Prior Authorization Request (i.e., the notice quotes incorrect factual and legal reason(s)
or omits additional factual and legal reason(s) pertinent to the issue), the Hearing Officer
may offer the recipient the choice of either accepting the incorrect notice, with the
necessary corrections noted for the record and continuing with the hearing; or setting the
hearing to a later date to allow the DHCFP or the managed health plan time to prepare and
serve the corrected NOD.
3104.9 SUBMISSION OF ADDITIONAL EVIDENCE
During a hearing, additional evidence related to the hearing issue may be submitted. The Hearing
Officer, recipient, the DHCFP or managed health plan may request additional evidence be
submitted which is not available at the hearing.
The Hearing Officer shall:
A. Recess the hearing if additional evidence has been submitted, to allow for review by the
recipient, the DHCFP or managed health plan; or
B. Continue the hearing to a later date and order further investigation or request either party
to review or produce the additional evidence; or
C. Close the hearing, but hold the record open to permit submission of any additional
evidence.
3104.10 MEDICAL ISSUES
When the hearing involves medical issues such as those concerning a diagnosis or an examining
physician's report, the Hearing Officer may require an additional medical assessment other than
that of the person involved in making the original assessment. The request is directed to the
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
DHCFP or the managed health plan for evaluation and follow-up. Any additional assessment
determined to be necessary is obtained at the DHCFP or the managed health plan’s expense. The
hearing may be held open for a specified length of time pending receipt of such requested
information. This additional assessment must be made part of the record.
3104.11 HEARING DECISION
The Hearing Officer’s decision must be in writing and comply with Medicaid program policy. The
decision is based exclusively on evidence introduced at the hearing. Changed physical or social
factors following the DHCFP or managed health plan action being appealed cannot be considered
in rendering the hearing decision.
A. BASIS
Decisions by the Hearing Officer shall:
1. Be based exclusively on the evidence introduced at the hearing;
2. Comply with applicable regulations in effect at the time of the agency or managed
health plan’s action;
3. Summarize the findings of fact;
4. Identify and cite supporting evidence and regulation;
5. Be submitted in written format, to the Deputy Administrator, the DHCFP or
designee.
B. APPEAL IS DENIED
Denied decisions are adverse to the recipient. When the appeal is denied, the Hearing
Officer will notify the DHCFP or the managed health plan and the recipient of the right to
judicial review.
Recipient withdrawals and abandonments are equivalent to a denied appeal. The DHCFP
may institute recovery procedures against the recipient to recoup the cost of any services
furnished by Medicaid.
C. APPEAL IS SUSTAINED
Sustained decisions are favorable to the recipient. The DHCFP or the managed health plan
must take corrective action promptly, retroactive to the date an incorrect action was taken.
If appropriate, the agency must provide for admission or readmission of a recipient to a
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
facility if the hearing decision is favorable to the recipient or if the DHCFP decides in the
recipient's favor before the hearing.
D. DECISION DUE DATE
Within 90 calendar days after the date of the request for a hearing has been received by the
DHCFP office, the recipient and the Hearings Unit must be notified of the Hearing
Officer’s decision specifying the factual and legal reasons for the decision and identifying
the supporting evidence relied upon to reach the decision. A copy of the decision must be
delivered by certified mail to each party and to their attorney or other authorized
representative.
The time period for a hearing decision may be extended for a period equal to the total delay
if the recipient requests a delay or postponement of the hearing proceedings and waives his
right to have a decision rendered within 90 days after the date of the request for a hearing.
Decisions on Expedited Fair Hearing requests will be made expeditiously as the recipient’s
health condition requires, but no later than three working days after the date the request for
a hearing has been received by the DHCFP office.
3104.12 RIGHT TO APPEAL HEARING DECISION
The Decision of the Hearing Officer is final. The Hearing Decision may be appealed by any party,
within 90 days after the date on which the written notice of decision is mailed, to the appropriate
District Court of the State of Nevada. The day after the mailing is the first day of the 90-day period.
3104.13 HEARING RECORD
A. CONTENT
A hearing record is maintained by the Department of Administration, Hearing Office. The
record consists of all papers and requests filed in the proceeding, the transcript or recording
of testimony and exhibits, or an official report containing the substance of what happened
at the hearing, all exhibits received or considered and the Decision letter.
B. RETENTION OF HEARING RECORD
Administrative hearing files and taped recordings must be retained no less than six years
from the date the hearing decision was rendered.
If a hearing decision is appealed, the hearing record must be retained until the court action
is resolved or the designated retention period, whichever is later.
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MTL 20/17
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3104
Subject:
MEDICAID SERVICES MANUAL RECIPIENT HEARINGS
C. COPYING THE HEARING RECORD
Copies of the Hearing Record are made as follows:
1. The requestor may secure a copy of the recording and/or transcript of a Fair Hearing
by written request to the Department of Administration. Please note that the
requestor shall be invoiced from the Department of Administration for this service
and the requestor is responsible for the payment of these records.
2. An official typed transcription of the recording of the hearing is prepared for the
District Court and recipient when a hearing decision is appealed. Within 90 days
after the service of the petition for judicial review, the DHCFP or its designee shall
transmit to the court the original or a certified copy of the entire record of the
proceeding under review, including, without limitation, a transcript of the evidence
resulting in the final decision of the Hearing Officer.
* The requested recording and/or transcript is free of charge to the recipient in the
event that the recipient appeals to District Court.
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MTL 20/17
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3105
Subject:
MEDICAID SERVICES MANUAL PROVIDER HEARINGS
3105 MEDICAID PROVIDER HEARINGS
3105.1 REQUEST FOR A MEDICAID PROVIDER FAIR HEARING
A. WHO MAY REQUEST
A Nevada Medicaid provider may request a Fair Hearing when they disagree with an
adverse determination taken against them by the agency, the Quality Improvement
Organization (QIO)-like vendor/fiscal agent, managed health plan or other third-party plan
or Program Administrator. An adverse determination may include, but is not limited to:
1. an outcome of the Fiscal Agent’s provider appeal determination regarding a denied
claim;
2. a determination to suspend payment;
3. suspension, sanction, lockout or termination;
4. recoupment of an overpayment; or
5. disenrollment or denied renewal of a provider contract
6. ineligible determination for the Incentive Payment Program for Electronic Health
Record (EHR) enrollment.
The provider must exhaust any internal grievance process available through the QIO-like
vendor/Fiscal Agent, managed health plan or third-party plan or Program Administrator
prior to a DHCFP Fair Hearing.
B. DATE OF REQUEST
The date of request for a hearing is the date the request is received by the DHCFP Hearings
Office. A request for a Fair Hearing must be received by the DHCFP Hearings Office
within 90 calendar days from the date of the adverse determination notification. When a
determination notification provides a specific timeframe in which a Fair Hearing may be
requested, the timeframe specified in the notification is the applicable timeframe. When
the deadline falls on a weekend or holiday, the deadline is extended to the next working
day.
C. REQUEST FOR A FAIR HEARING
A request for a Fair Hearing must be submitted to the DHCFP Hearing Office in writing
and must include the provider name, Medicaid provider number, correspondence address,
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3105
Subject:
MEDICAID SERVICES MANUAL PROVIDER HEARINGS
contact telephone number, the reason(s) why the provider disagrees with the determination
and a copy of the determination notification from the agency, Fiscal Agent, managed health
plan or third-party plan or Program Administrator. A request for a Fair Hearing must be
signed by the provider or the provider’s authorized representative.
3105.2 DISPOSITION OF A MEDICAID PROVIDER FAIR HEARING REQUEST
A. DISMISSAL OF A HEARING REQUEST UPON:
1. Withdrawal of a Hearing Request
A provider may withdraw a request for a Fair Hearing at any time before a decision
is rendered. A request to withdraw a hearing must be submitted in writing to the
Hearing Officer who may dismiss the hearing request.
2. Abandonment of a Hearing Request
A provider hearing is considered abandoned and may be dismissed by the Hearing
Officer when the provider fails to appear for a scheduled hearing after having been
properly notified. The provider’s request for hearing is considered abandoned
unless they submit to the Hearing Officer substantiation for good cause for failing
to appear. The Hearing Officer must receive the substantiation within 10 calendar
days of the date of the scheduled hearing.
3. Agency, Fiscal Agent or Managed Health Plan Action
The agency, Fiscal Agent or managed health plan may reverse its adverse action
determination at any time during the hearing process. If a determination reversal
occurs, notification of the reversal must be made to the Hearing Officer, if a Fair
Hearing had been scheduled. The Hearing Officer notifies the provider the request
for hearing is dismissed because Medicaid, the Fiscal Agent or managed health plan
will not take the action or has reversed the decision.
B. DENIAL OF A HEARING REQUEST
A hearing need not be granted when:
1. the sole issue is a Federal suspension or ban of regulation at the Federal level
affecting providers.
2. the request is not received timely.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3105
Subject:
MEDICAID SERVICES MANUAL PROVIDER HEARINGS
3. the provider has not exhausted the Appeal process available through the Fiscal
Agent, the managed health plan or a third-party plan administrator.
3105.3 FAIR HEARING NOTIFICATION, SCHEDULING AND LOCATION
A. HEARING PREPARATION MEETING (HPM)
Nevada Medicaid Hearings Office will offer an HPM with the provider to allow an
opportunity to have an informal discussion regarding the determination being disputed, and
to attempt to resolve the disputed matter. A provider may refuse an HPM if they choose.
The right to a Fair Hearing is not affected by attendance at an HPM. A provider may
designate participation in the HPM by legal counsel or a representative.
An HPM shall be conducted telephonically.
B. NOTICE OF A FAIR HEARING
The Department of Administration Hearing Officer shall notify all parties by mail as to the
date, time and location of the Fair Hearing.
At the discretion of the Hearing Officer, a Fair Hearing may be postponed if requested by
either party.
C. HEARINGS BY TELEPHONE
1. A representative of each party must be in attendance at a Provider Fair Hearing.
2. The Hearing Officer may allow testimony from witnesses telephonically.
3. Telephonic testimony is recorded by the Hearing Officer and is part of the official
record.
3105.4 HEARING PARTICIPATION
A. ATTENDANCE
Attendance at a hearing is limited to those directly concerned, namely the:
1. Hearing Officer;
2. provider;
3. provider’s witnesses, counsel or authorized representative(s) for the provider;
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3105
Subject:
MEDICAID SERVICES MANUAL PROVIDER HEARINGS
4. interpreter;
5. witnesses, counsel and representatives of Medicaid; and
6. representatives, counsel and witnesses from the managed health plan.
B. GROUP HEARINGS
At the discretion of the Hearing Officer, a series of provider requests for a hearing may be
consolidated by conducting a single group hearing in cases in which the sole issue involved
is one of State and/or Federal law, regulation or policy.
3105.5 PREPARATION/PRESENTATION
A. AGENCY/MANAGED HEALTH PLAN
1. It is the responsibility of the agency and/or managed health plan representative to
be present at the Fair Hearing, unless permission has been granted prior to the Fair
Hearing by the Hearing Officer to participate telephonically.
2. The agency or the managed health plan must provide testimony and/or evidence
regarding the agency's and/or managed health plan's action. This includes the
organization of oral and written evidence and preparation of a Basis of Action
summary substantiating the decision to be presented at the Fair Hearing. This
summary becomes part of the record at the conclusion of the Fair Hearing. Witness
testimony may be provided telephonically at the discretion of the Hearing Officer.
3. All documents being presented at a Fair Hearing by the agency or managed health
plan must be made available to the provider or representative and to the Hearing
Officer at least five days prior to the Fair Hearing.
B. PROVIDER
1. It is the responsibility of the provider or representative to be present at the Fair
Hearing, unless permission has been granted prior to the Fair Hearing by the
Hearing Officer to participate telephonically.
2. Providers must provide testimony and/or evidence in support of their position.
Testimony may be provided telephonically at the discretion of the Hearing Officer.
Providers may bring witnesses and submit evidence to establish all pertinent facts
and circumstances relative to the issue and to present arguments without undue
interference. They may also question or refute any testimony or evidence and
confront and cross-examine adverse witnesses. New evidence not previously
provided to the DHCFP or the managed health plan, but which is believed to have
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3105
Subject:
MEDICAID SERVICES MANUAL PROVIDER HEARINGS
a bearing on the action taken, must be provided to all parties prior to the hearing
for evaluation and any necessary action.
3. All documents being presented at a Fair Hearing by the provider or representative
must be made available to the agency or managed health plan and to the Hearing
Officer at least five days prior to the Fair Hearing.
3105.6 CONDUCT OF A FAIR HEARING
A. CONTROL
The Hearing Officer controls the hearing and ensures only relevant issues are considered.
Disrespectful language or contemptuous conduct, refusal to comply with directions or
continued use of dilatory tactics by any person at the hearing constitutes grounds for
immediate exclusion of such person from the hearing by the Hearing Officer and the
hearing decision will be based on evidence submitted. A recorder shall be used by the
hearing officer to record hearing proceedings. The Hearing Officer’s Transcripts of
Evidence constitutes the sole official record.
B. OPENING THE HEARING
At the opening of the hearing, the Hearing Officer shall:
1. introduce their self;
2. explain the reason for the hearing and the role of the Hearing Officer;
3. assure all persons in attendance at the hearing are identified by name and purpose
of attendance; and
4. advise all persons in attendance that the hearing is being recorded.
C. ADMINISTERING OATHS
Testimony under oath shall be required at the discretion of the Hearing Officer.
D. TESTIMONY AND EVIDENCE
Nevada Rules of Evidence do not apply in the hearing. The Hearing Officer shall:
1. exclude irrelevant, immaterial or unduly repetitious evidence;
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3105
Subject:
MEDICAID SERVICES MANUAL PROVIDER HEARINGS
2. provide the parties an opportunity to present their case, to present witnesses,
introduce evidence and cross-examine witnesses and examine evidence; and
3. collect and log relevant evidence exhibits.
E. CLOSING THE HEARING
At the close of the hearing, the Hearing Officer shall advise persons in attendance:
1. when a decision is expected to be made;
2. that the decision will be made based on program policy and exclusively on the
testimony and evidence presented at the hearing; and
3. the parties will be advised in writing by certified mail of the decision.
3105.7 ACTION ON INCORRECT DETERMINATION NOTICE
If the agency, fiscal agent or managed health plan recognizes an incorrect or inaccurate
determination Notice has been issued, a corrected Amended Notice will be issued by the agency,
Fiscal Agent or managed health plan. The action and effective date remain unchanged unless
otherwise notified in the Amended Notice.
3105.8 SUBMISSION OF ADDITIONAL EVIDENCE
During a hearing, additional evidence related to the hearing issue may be submitted. The Hearing
Officer, provider, the DHCFP or managed health plan may request additional evidence be
submitted which is not available at the hearing. The Hearing Officer may:
A. recess the hearing if additional evidence has been submitted, to allow for review by the
provider, the DHCFP or managed health plan;
B. continue the hearing to a later date and order further investigation or request either party to
review or produce the additional evidence; or
C. close the hearing, but hold the record open to permit submission of any additional evidence.
3105.9 HEARING DECISION
The Hearing Officer’s decision must be in writing and comply with Nevada Medicaid or the
managed health plan’s program policy. The decision is based exclusively on evidence introduced
at the hearing.
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MEDICAID SERVICES MANUAL PROVIDER HEARINGS
A. BASIS
Decisions by the Hearing Officer shall:
1. be based exclusively on the evidence introduced at the hearing;
2. comply with applicable regulations in effect at the time of the agency’s or managed
health plan’s action;
3. summarize the findings of fact;
4. identify and cite supporting evidence and regulation; and
5. be submitted in written format, to the Deputy Administrator, Medicaid or designee.
B. APPEAL IS DENIED
Denied decisions are adverse to the provider. When an appeal is denied, the Hearing Officer
will notify the DHCFP or the managed health plan and the provider of their right to judicial
review.
Provider withdrawals and abandonments are equivalent to a denied appeal. The DHCFP
may institute recovery procedures against the provider to recoup the cost of any services
furnished.
C. APPEAL IS SUSTAINED
Sustained decisions are favorable to the provider. The DHCFP or the managed health plan
must take corrective action promptly, retroactive to the date an incorrect action was taken.
If appropriate, the agency must provide for admission or readmission of a recipient to a
facility if the hearing decision is favorable to the provider or if the DHCFP decides in the
provider's favor before the hearing.
D. DECISION DUE DATE
Within 30 calendar days following the Fair Hearing, or the date the record is closed,
whichever is later, the Hearing Officer shall issue a final Decision.
3105.10 RIGHT TO APPEAL HEARING DECISION
Reference NRS 422.306
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3105.11 HEARING RECORD
Reference NRS 422.306
October 26, 2017 HEARINGS Section 3105 Page 8
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
February 22, 2017
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: LYNNE FOSTER, CHIEF OF DIVISION COMPLIANCE
SUBJECT: MEDICAID SERVICES MANUAL CHANGES,
CHAPTER 3200 – HOSPICE
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 3200 – Hospice are being proposed to
better coincide with the Code of Federal Regulation (CFR) Title 42 Part 418, Conditions of
Participation (COP) updates and to coincide with the Medicare Guidelines Criteria for Non-Cancer
Terminal Illnesses. The chapter was also updated to clarify the criteria for pediatric hospice
recipients.
Throughout the chapter, grammar, punctuation, and capitalization changes were made,
duplications removed, acronyms used and standardized, and language reworded for clarity.
Renumbering and re-arranging of sections was necessary.
Entities Financially Affected: Provider Type (PT) 64 – Hospice and PT 65 – Hospice, Long
Term Care.
Financial Impact on Local Government: None.
These changes are effective February 23, 2017.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 05/17 MTL 02/14, 29/11, 41/10
HOSPICE HOSPICE
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3203.1 HOSPICE The second sentence was made in to its own paragraph.
SERVICES New language was added in the first paragraph for
clarification.
Page 1 of 6
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
The second paragraph was moved to a new section,
Section 3203.1A, “Pediatric Recipients.”
The new third and fifth paragraph were moved here from
Section 3203.1B, Provider Responsibility. The fourth
paragraph is new language.
The word "condition" in the sixth paragraph was changed
to "illness."
3203.1e HOSPICE This sentence was deleted.
SERVICES
3203.1h HOSPICE The second sentence was deleted due to duplication.
SERVICES
3203.1A COVERAGE AND This section was deleted and renamed “Pediatric
LIMITATIONS Recipients,” with new language.
3203.1B PROVIDER This section was deleted. The language from Section
RESPONSIBILITY 3203.7, “Hospice Coverage and Waiver recipients” was
moved here and renamed, “Waiver Recipients.” New
language was added related to the pediatric waiver
recipient.
3203.1C RECIPIENT This section was deleted. The language from Section
RESPONSIBILITY 3203.8, “Managed Care and Hospice Recipients” was
moved here and renamed, “Managed Care Recipients.”
3203.1A.3 HOSPICE CARE This was renumbered as Section 3203.2, “Covered
SERVICES Services.” All the language from Section 3203.1A3 was
moved to this new section, with the last sentence in item
number 3 being deleted for clarification, and item number
4 being deleted for clarification.
3203.1A.4 LEVEL OF CARE This section renumbered as Section 3203.3 and renamed,
“Hospice Categories” per CFR language. All language
from Section 3203.1A4 was moved and inserted here.
3203.1A.4 LEVEL OF CARE The last paragraph became its own Section 3203.4.
3203.1B PROVIDER This section was deleted.
RESPONSIBILITY
Page 2 of 6
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3203.1.C RECIPIENT This section was moved to a new Section 3211,
RESPONSIBILITY “Recipient Responsibility.”
3203.2 NON-HOSPICE This section was moved and renumbered as Section 3204.
SERVICES
3203.2A COVERAGE AND This section was deleted and the language was moved to
LIMITATIONS Section 3204 for better flow.
3203.2B PROVIDER This section was deleted. The language was moved to
RESPONSIBILITY new Section, 3207, “Election of Hospice Care.”
3203.2C RECIPIENT This section was deleted and the language was moved to
RESPONSIBILITY Section 3204 for better flow.
3203.3 CHANGING THE This section was deleted. The language was moved to
DESIGNATED new Section 3212, “Changing the Designated Hospice.”
HOSPICE New language added due to new forms.
3203.4 REVOKING THE This section was deleted. The language was moved to
ELECTION OF new Section 3213, “Revoking the Election of Hospice
HOSPICE CARE Care.” New language added due to new forms.
3203.5 DISCHARGE OF A The language was moved to new Section 3214,
RECIPIENT FROM “Discharge of a Recipient from Hospice.” New language
HOSPICE added due to new forms. This section was renamed,
“Hospice Recipients Residing in a Nursing Facility.”
3203.6 HOSPICE This section was deleted. The language was moved to a
RECIPIENTS new Section 3203.5, “Hospice Recipients Residing in a
RESIDING IN A Nursing Facility.” The first sentence was removed for
NURSING redundancy. New language was added for clarification.
FACILITY
3203.6A COVERAGE AND This section deleted and language moved to Section
LIMITATIONS 3203.5, “Hospice Recipients Residing in a Nursing
Facility.”
3203.6B PROVIDER This section deleted and language moved to Section
RESPONSIBILITIES 3203.5B, “Coordination of Services.”
3203.6B.2 NURSING This section deleted except for the first sentence which
FACILITY was moved to Section 3203.5, “Hospice Recipients
SCREENINGS Residing in a Nursing Facility.”
Page 3 of 6
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3203.7-3203.7B HOSPICE This section moved to new Section 3203.1B, “Waiver
COVERAGE AND Recipients.”
WAIVER
RECIPIENTS
3203.8 MANAGED CARE This section moved to new Section 3203.1C, “Managed
AND HOSPICE Care Recipients.”
RECIPIENTS
3203.9 CLINICAL This section was deleted.
RECORDS
3203.10 DHCFP REVIEW This section was moved to new Section 3203.6, “DHCFP
Review.” New language was added for clarification.
3203.10A PROVIDER This section was moved to new Section 3203.6, “DHCFP
RESPONSIBILITY Review” for better flow.
3204 HEARINGS This section was moved to new Section 3215, “Hearings”
for better flow.
3203.5A HOSPICE PLAN OF New section.
CARE
3203.5B COORDINATION New section with new language and retained language.
OF SERVICES
3203.6 DHCFP REVIEW New section with new language and retained language
.
3204 NON-HOSPICE New section with new language and retained language.
SERVICES
3205 CURATIVE New section with retained language.
SERVICES
3206 INITIATION OF New section.
SERVICES
3206.1 ELIGIBILITY New section with new language and retained language.
REQUIREMENTS
3206.1A CERTIFICATION New section with retained language and new language.
OF TERMINAL
ILLNESS
Page 4 of 6
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3206.1B HOSPICE PLAN OF New section with retained language and new language.
CARE (POC)
3207 ELECTION OF New section with retained language and new language.
HOSPICE CARE
3207.1 DURATION OF New section with retained language and new language.
HOSPICE CARE
PERIODS
3208 COORDINATION New section with retained language and new language.
OF SERVICES
3209 DETERMINING New section.
TERMINAL
STATUS-LOCAL
COVERAGE
DETERMINATIONS
(LCD) - ADULTS
3209.1 NON-CANCER New section.
TERMINAL
ILLNESSES
3209.2 HOSPICE New section.
CRITERIA FOR
ADULT CANCER
3210 REASONS FOR New section.
DENIAL OF ANY OF
THE ABOVE
3211 RECIPIENT New section with retained language.
RESPONSIBILITY
3212 CHANGING THE New section with retained language and new language.
DESIGNATED
HOSPICE
3213 REVOKING THE New section with retained language and new language.
ELECTION OF
HOSPICE CARE
Page 5 of 6
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3214 DISCHARGE OF A New section with retained language and new language.
RECIPIENT FROM
HOSPICE
3215 HEARINGS New section with retained language.
Page 6 of 6
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
HOSPICE
3200 INTRODUCTION ...........................................................................................................................1
3201 AUTHORITY ..................................................................................................................................1
3202 RESERVED .....................................................................................................................................1
3203 POLICY ...........................................................................................................................................1
3203.1 HOSPICE SERVICES .....................................................................................................................1
3203.1A PEDIATRIC RECIPIENTS .............................................................................................................2
3203.1B WAIVER RECIPIENTS ..................................................................................................................3
3203.1C MANAGED CARE RECIPIENTS ..................................................................................................3
3203.2 COVERED SERVICES ...................................................................................................................4
3203.3 HOSPICE CATEGORIES ...............................................................................................................5
3203.4 OPTIONAL CAP ON OVERALL HOSPICE REIMBURSEMENT .............................................7
3203.5 HOSPICE RECIPIENTS RESIDING IN A NURSING FACILITY ..............................................7
3203.5A HOSPICE PLAN OF CARE............................................................................................................9
3203.5B COORDINATION OF SERVICES .................................................................................................9
3203.6 DHCFP REVIEW ..........................................................................................................................10
3204 NON-HOSPICE SERVICES ...........................................................................................................1
3205 CURATIVE SERVICES .................................................................................................................1
3206 INITIATION OF SERVICES ..........................................................................................................1
3206.1 ELIGIBILITY REQUIREMENTS ..................................................................................................1
3206.1A CERTIFICATION OF TERMINAL ILLNESS ..............................................................................1
3206.1B HOSPICE PLAN OF CARE (POC) ................................................................................................3
3207 ELECTION OF HOSPICE CARE...................................................................................................1
3207.1 DURATION OF HOSPICE CARE PERIODS................................................................................1
3208 COORDINATION OF SERVICES .................................................................................................1
3209 DETERMINING TERMINAL STATUS - Local Coverage Determination (LCD) - Adults .........1
3209.1 NON-CANCER TERMINAL ILLNESSES ....................................................................................1
3209.2 HOSPICE CRITERIA FOR ADULT CANCER ...........................................................................14
3210 REASONS FOR DENIAL OF ANY OF THE ABOVE .................................................................1
3211 RECIPIENT RESPONSIBILITY ....................................................................................................1
3212 CHANGING THE DESIGNATED HOSPICE ...............................................................................1
1
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
3213 REVOKING THE ELECTION OF HOSPICE CARE ....................................................................1
3214 DISCHARGE OF A RECIPIENT FROM HOSPICE .....................................................................1
3215 HEARINGS .....................................................................................................................................1
2
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3200
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
3200 INTRODUCTION
The Nevada Division of Health Care Financing and Policy (DHCFP) Medicaid Hospice Services
program is designed to provide support and comfort for Medicaid eligible recipients who have a
terminal illness and have decided to receive end of life care. Covered hospice services address the
needs of the individual, their caregivers and their families while maintaining quality of life as a
primary focus. The hospice philosophy provides for the physical needs of recipients as well as
their emotional and spiritual needs. This care is provided in the recipient’s place of residence,
which could be a specialized hospice facility, an Intermediate Care Facility (ICF) or in his or her
own home. Hospice care incorporates an interdisciplinary team approach which is sensitive to the
recipient and family’s needs during the final stages of illness, dying and the bereavement period.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), with the exception of the areas where Medicaid and NCU policies differ as
documented in the NCU Manual Chapter 1000. Refer to Medicaid Services Manual (MSM)
Chapter 3600 for Managed Care recipients for differences in Hospice enrollment, claims and
payment.
April 1, 2014 HOSPICE Section 3200 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL AUTHORITY
3201 AUTHORITY
Hospice Services are an optional program under the Social Security Act XVIII Sec.
1905.(o)(1)(A), and are governed by The Code of Federal Regulations (CFR) Title 42, Part 418
and Title 42 Part 489.102, Subpart I.
Effective October 1, 1997, the Nevada Revised Statutes (NRS) Chapter 422.304 mandated
reimbursement for hospice care under the Medicaid State Plan.
Patient Protection and Affordable Care Act (PPACA) Section 2302.
Health Care and Education Affordability Reconciliation Act of 2010.
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3202
Subject:
MEDICAID SERVICES MANUAL RESERVED
3202 RESERVED
November 9, 2011 HOSPICE Section 3202 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
3203 POLICY
3203.1 HOSPICE SERVICES
Hospice services must be identified in the established plan of care; maintain a high standard of
quality and be reasonable and necessary to palliate or manage the terminal illness and related
illnesses. Hospice must include a comprehensive set of services identified and coordinated by an
Interdisciplinary Group (IDG) to provide for the physical, psychosocial, spiritual and emotional
needs of a terminally ill recipient and/or family members, as delineated in a specific recipient plan
of care.
All services must be provided in accordance with recognized professional standards of practice
and within the limitations and exclusions hereinafter specified, as described in the Centers for
Medicare and Medicaid Services (CMS) – State Operations Manual (SOM) and the Code of
Federal Regulations (CFR) Title 42, Part 418 which sets forth the Conditions of Participation
(COP). The COP is the eligibility, health and safety requirements that all hospices are required to
meet. COPs also provide a guide for continuous quality improvement and current standards of
practice.
All Nevada Medicaid recipients electing Hospice services, including those with primary insurance
such as Medicare or a private insurance, must be enrolled in Nevada Medicaid's Hospice Program
regardless of where hospice services are provided.
Nevada Medicaid shall be available to assist hospice providers in coordinating the services and
shall require that the other service providers cooperate in these coordination efforts and understand
that the hospice provider is the lead case coordinator.
NOTE: Enrollment paperwork for hospice recipients who are pending a Nevada Medicaid
eligibility determination should not be submitted until Medicaid benefits have been approved. All
enrollment forms must be received by the Quality Improvement Organization (QIO)-like vendor
within 60 days of the date of decision of eligibility determination.
Should a terminally ill adult recipient elect to receive hospice care, he or she must waive all rights
to Medicaid payments for the duration of the election of hospice care for any Medicaid services
that are related to the treatment of the terminal illness for which hospice care was elected or a
related illness or that are equivalent to hospice care except for services:
1. Provided (either directly or under arrangement) by the designated hospice;
2. Provided by the individual’s attending physician if that physician is not an employee of the
designated hospice or receiving compensation from the hospice for those services;
3. Provided as room and board by a Nursing Facility (NF) if the individual is a resident, or
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Section:
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Subject:
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4. Provided by a Home and Community-Based Waiver (HCBW) whose services do not
duplicate hospice services.
A hospice program may arrange for another individual or entity to furnish services to the hospice’s
recipients. If services are provided under arrangement, the hospice must meet the following
standards:
1. Continuity of Care: The hospice program assures the continuity of recipient/family care in
home, outpatient, and inpatient settings;
2. Written Agreement: The hospice has a legally binding written agreement for the provision
of arranged services. The agreement includes at least the following:
a. Identification of the services to be provided;
b. A stipulation that services may be provided only with the express authorization of
the hospice;
c. The manner in which the contracted services are coordinated, supervised, and
evaluated by the hospice;
d. The delineation of the role(s) of the hospice and the contractor in the admission
process, recipient/family assessment, and the interdisciplinary group care
conferences;
e. Requirements for documenting services are furnished in accordance with the
agreement; and
f. The qualification of the personnel providing the services.
Professional Management Responsibility:
The hospice retains professional management responsibility for those services and ensures that
they are furnished in a safe and effective manner by persons meeting the qualifications, and in
accordance with the recipient’s Plan of Care (POC) and other requirements.
3203.1A PEDIATRIC RECIPIENTS
Recipients under the age of 21 are entitled to concurrent care under the Affordable Care Act (ACA);
that is curative care and palliative care at the same time while an eligible recipient of the Medicaid
Hospice Program, and shall not constitute a waiver of any rights of the child to be provided with,
or to have payment made for services that are related to the treatment of the child's terminal illness.
Upon turning 21 years of age, the recipient will no longer have concurrent care benefits and will be
February 23, 2017 HOSPICE Section 3203 Page 2
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Section:
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subject to the rules governing adults who have elected Medicaid hospice care. Upon turning 21
years of age, the recipient must sign a Nevada Medicaid Hospice Program Election Notice-Adult
(FA-93), continuing in the certification period currently in place.
Pediatric hospice care is both a philosophy and an organized method for delivering competent,
compassionate and consistent care to children with terminal illnesses and their families. This care
focuses on enhancing quality of life, minimizing suffering, optimizing function and providing
opportunities for personal and spiritual growth, planned and delivered through the collaborative
efforts of an interdisciplinary team with the child, family and caregivers as its center.
3203.1B WAIVER RECIPIENTS
As part of the admission procedure it is the responsibility of the hospice agency to obtain
information regarding recipient enrollment in HCBW programs.
When a Waiver recipient is enrolled in the hospice program there can be no duplication of hospice
covered services, such as PCA services, homemaker services, home health services, respite, or
companion services. Close case coordination between the hospice agency and the waiver case
manager is required to prevent any duplication of services.
Pediatric waiver recipients are entitled to continue to receive Waiver services that are related to
their terminal illness, but are not covered by the hospice benefit because they are curative not
palliative in nature. Close coordination between the hospice agency and the waiver case manager
is required to avoid any unnecessary duplication of services.
This also includes all HCBW recipients who have Medicare as their primary insurance and
Medicare is paying for the hospice services. The hospice agency must immediately notify the QIO-
like vendor of any new hospice admissions who are receiving services through a Medicaid HCBW.
3203.1C MANAGED CARE RECIPIENTS
Managed care participants who elect hospice care must be disenrolled from their managed care
program.
1. The hospice is responsible for notifying the QIO-like vendor in such situations.
2. The recipient electing the hospice benefit will then return to Fee-for-Service (FFS)
Medicaid.
3. There should be no delay in enrolling managed care recipients in hospice services.
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Section:
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Subject:
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3203.2 COVERED SERVICES
Nursing services, physician services, and drugs and biologicals must be routinely available on a
24-hour basis; all other covered services must be available on a 24-hour basis to the extent
necessary to meet the needs of individuals for care that is reasonable and necessary for the
palliation and management of terminal illness and related conditions and provide these services in
a manner consistent with accepted standards of practice.
The hospice must designate a Registered Nurse (RN) to: coordinate the implementation of the
POC; to ensure that the nursing needs of the recipient are met as identified in the recipient’s initial
assessment, comprehensive assessment, and updated assessments; and coordinate and oversee all
services for each recipient.
The following services are included in the hospice reimbursement when consistent with the POC.
The services must be provided in accordance with recognized professional standards of practice.
1. Nursing Services: Nursing services must comply with the following: The hospice must
provide nursing care and services by or under the supervision of a qualified RN; a qualified
RN is one who is authorized to practice as an RN by the Nevada State Board of Nursing or
the licensing board in the state in which the RN is employed. Recipient care responsibilities
of nursing personnel must be specified.
2. Medical Social Services: Medical Social Services (MSS) must be provided by a qualified
social worker, under the direction of a physician. A qualified social worker is a person who
has at least a bachelor’s degree from a school accredited or approved by the Council on
Social Work Education and is licensed to practice social work in the State of Nevada or the
state in which the social worker is employed.
3. Physician Services: In addition to palliative care and management of the terminal illness
and related conditions, physician employees of the hospice, including the physician
member(s) of the interdisciplinary group, must also meet the general medical needs of the
recipients to the extent these needs are not met by the attending physician.
a. Reimbursement for physician supervisory and interdisciplinary group services for
those physicians employed by the hospice agency is included in the rate paid to the
agency.
b. Costs for administrative and general supervisory activities performed by physicians
who are employees of or working under arrangements made with the hospice are
included in the reimbursement rates for routine home care, continuous home care,
and inpatient respite care. These activities include participation in the establishment
of POCs and services, periodic review and updating of POCs, and contribute to
establishment of governing policies.
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Subject:
MEDICAID SERVICES MANUAL POLICY
c. Services provided by an independent attending physician must be coordinated with
any direct care services provided by hospice physicians, and are not considered
hospice services, therefore are not included in the amount subject to the hospice
payment limit.
4. Counseling Services: Counseling services are available to both the individual and the
family. Counseling includes bereavement counseling, dietary, spiritual and any other
counseling services for the individual and family provided while the individual is enrolled
in the hospice. Bereavement counseling for the client’s family and significant others, as
identified in the POC, must be provided for up to one year after the recipient’s death and
is not reimbursable per 42 CFR 418.204.(c).
5. Medical Appliances, Supplies and Pharmaceuticals:
a. Medical supplies include those that are part of the written POC. Only drugs which
are used primarily for the relief of pain and symptom control related to the
individual’s terminal illness are covered. Appliances may include covered durable
medical equipment as well as other self-help and personal comfort items related to
the palliation or management of the client’s terminal illness. Equipment is provided
by the hospice for use in the recipient’s home while he or she is under hospice care
and the reimbursement for this is included in the rates calculated for all levels of
hospice care.
b. Drugs, supplies and durable medical equipment prescribed for conditions other than
for the palliative care and management of the terminal illness are not covered
benefits under the Nevada Medicaid hospice program and are to be billed in
accordance with the appropriate Medicaid Services Manual (MSM) chapter for
those services.
6. Home Health Aide (HHA), Personal Care Aide (PCA) and Homemaker Services: HHA
services and homemaker services when provided under the general supervision of an RN.
Services may include personal care services and such household services which may be
necessary to maintain a safe and sanitary environment in the areas of the home used by the
recipient.
7. Physical Therapy (PT), Occupational Therapy (OT), Respiratory Therapy and Speech-
Language Pathology Services: PT, OT, respiratory therapy and speech-language pathology
when provided for the purpose of symptom control, or to enable the recipient to maintain
Activities of Daily Living (ADLs) and basic functional skills.
3203.3 HOSPICE CATEGORIES
1. Routine Home Care: The reimbursement rate for routine home care is made without regard
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
to the intensity or volume of routine home care services on any specific day.
2. Continuous Home Care:
a. Continuous home care is only furnished during brief periods of crisis, described as
a period in which a recipient requires continuous care to achieve palliation or
management of acute medical symptoms, and only as necessary to maintain the
terminally ill recipient at home.
b. Nursing care must be provided by an RN or Licensed Practical Nurse (LPN) and
the nurse (RN or LPN) must be providing care for more than half of the period of
care. HHA or homemaker services or both may be provided on a continuous basis.
c. The hospice payment on a continuous care day varies depending on the number of
hours of continuous services provided. The continuous home care rate is divided
by 24 to yield an hourly rate. The number of hours of continuous home care day is
then multiplied by the hourly rate to yield the continuous home care payment for
that day.
3. Inpatient Care (Respite or General):
a. The appropriate inpatient rate (general or respite) is paid depending on the category
of care furnished on any day on which the recipient is an inpatient in an approved
facility. The inpatient rate (general or respite) is paid for the date of admission and
all subsequent inpatient days, except the day on which the recipient is discharged.
For the day of discharge, the appropriate home care rate is paid unless the recipient
is deceased; the discharge day is then paid at the general or respite rate.
b. Inpatient care must be provided by a facility that has a written contract with the
hospice. This may be an approved Nursing Facility (NF), hospital or hospice
capable of providing inpatient care.
c. Respite care is short-term inpatient care provided to the recipient only when
necessary to relieve the family members or other persons caring for the recipient.
Respite care may be provided on an occasional basis and may not be reimbursed
for more than five consecutive days at a time. Payment for the sixth and any
subsequent day of respite care is made at the routine home care rate.
d. Time limited for reimbursement: In a 12-month period the inpatient reimbursement
is subject to the following limitation. During the 12-month period beginning
November 1 of each year and ending October 31, the aggregate number of inpatient
days (both for general inpatient care and inpatient respite care) may not exceed 20%
of the aggregate total number of days of hospice care provided to all Medicaid
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Section:
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Subject:
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recipients during that same period. Refer to the 42 CFR 418.302 for further
information on the calculation of the inpatient limitation.
3203.4 OPTIONAL CAP ON OVERALL HOSPICE REIMBURSEMENT
The DHCFP may limit overall aggregate payments made to a hospice during a hospice cap period.
The cap period runs from November 1st of each year through October 31st of the next year. The
total payment made for services furnished to Medicaid beneficiaries during this period is compared
to the “cap amount” for this period. Any payments in excess of the cap must be refunded by the
hospice.
3203.5 HOSPICE RECIPIENTS RESIDING IN A NURSING FACILITY
The hospice recipient residing in a Skilled Nursing Facility (SNF) must not experience any lack
of services or personal care because of his or her status as a hospice recipient. The NF must offer
the same services to its residents who have elected the hospice benefit as it furnishes to its residents
who have not elected the hospice benefit. The recipient has the right to refuse any services.
The NF must continue to still comply with all requirements for participation in Medicare and/or
Medicaid for hospice-enrolled Nevada Medicaid residents.
Refer to MSM Chapter 500 for specific guidelines regarding NF pre-admission screenings.
A hospice that provides hospice care to residents of a SNF/NF or ICF/IID must abide by the
following additional standards:
1. Resident eligibility, election and duration of benefits. Recipients receiving hospice services
and residing in a SNF, NF or ICF/IID are subject to the Medicaid/Medicare hospice
eligibility criteria set out at Title 42 CFR 418.20 through CFR 418.30.
2. Written agreement. The hospice and SNF/NF or ICF/IID must have a written agreement that
specifies the provision of hospice services in the facility. The agreement must be signed by
authorized representatives of the hospice and the SNF/NF or ICF/IID before the provision
of hospice services. The written agreement must include at least the following:
a. The manner in which the SNF/NF or ICF/IID and the hospice are to communicate
with each other and document such communications to ensure that the needs of
recipients are addressed and met 24 hours a day.
b. A provision that the SNF/NF or ICF/IID immediately notifies the hospice when:
(1) A significant change in a recipient's physical, mental, social or emotional
status occurs;
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(2) Clinical complications appear that suggest a need to alter the plan of care;
(3) A need to transfer a recipient from the SNF/NF or ICF/IID, and the hospice
makes arrangements for, and remains responsible for, any necessary
continuous care or inpatient care necessary related to the terminal illness and
related illnesses; or
(4) A recipient dies.
c. A provision stating that the hospice assumes responsibility for determining the
appropriate course of hospice care, including the determination to change the level
of services provided.
d. An agreement that it is the SNF/NF or ICF/IID responsibility to continue to furnish
24-hour room and board care, meeting the personal care and nursing needs that
would have been provided by the primary caregiver at home at the same level of
care provided before hospice care was elected.
e. An agreement that it is the hospice's responsibility to provide services at the same
level and to the same extent as those services would be provided if the SNF/NF or
ICF/IID resident were in his or her own home.
f. A delineation of the hospice's responsibilities, which include, but are not limited to,
the following: Providing medical direction and management of the recipient;
nursing; counseling (including spiritual, dietary and bereavement); social work;
provision of medical supplies, durable medical equipment and drugs necessary for
the palliation of pain and symptoms associated with the terminal illness and related
illnesses; and all other hospice services that are necessary for the care of the
resident's terminal illness and related illnesses.
g. A provision that the hospice may use the SNF/NF or ICF/IID nursing personnel
where permitted by State law and as specified by the SNF/NF or ICF/IID to assist
in the administration of prescribed therapies included in the plan of care only to the
extent that the hospice would routinely use the services of a hospice recipient's
family in implementing the plan of care.
h. A provision stating that the hospice must report all alleged violations involving
mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including
injuries of unknown source, and misappropriation of recipient property by anyone
unrelated to the hospice to the SNF/NF or ICF/IID administrator within 24 hours of
the hospice becoming aware of the alleged violation.
i. A delineation of the responsibilities of the hospice and the SNF/NF or ICF/IID to
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provide bereavement services to SNF/NF or ICF/IID staff.
3203.5A HOSPICE PLAN OF CARE
In accordance with Title 42 CFR 418.56, a written hospice plan of care must be established and
maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided must
be in accordance with this hospice plan of care.
3203.5B COORDINATION OF SERVICES
The hospice must:
1. Designate a member of each interdisciplinary group that is responsible for a recipient who
is a resident of a SNF/NF or ICF/IID. The designated interdisciplinary group member is
responsible for:
a. Providing overall coordination of the hospice care of the SNF/NF or ICF/IID
resident with SNF/NF or ICF/IID representatives; and
b. Communicating with SNF/NF or ICF/IID representatives and other health care
providers participating in the provision of care for the terminal illness and related
illnesses and other illnesses to ensure quality of care for the recipient and family.
2. Ensure that the hospice IDG communicates with the SNF/NF or ICF/IID medical director,
the recipient's attending physician and other physicians participating in the provision of
care to the recipient as needed to coordinate the hospice care of the hospice recipient with
the medical care provided by other physicians.
3. Provide the SNF/NF or ICF/IID with the following information:
a. The most recent hospice plan of care specific to each recipient;
b. Hospice election form and any advance directives specific to each recipient;
c. Physician certification and recertification of the terminal illness specific to each
recipient;
d. Names and contact information for hospice personnel involved in hospice care of
each recipient
e. Instructions on how to access the hospice's 24-hour on-call system;
f. Hospice medication information specific to each recipient; and
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g. Hospice physician and attending physician (if any) orders specific to each recipient.
4. The hospice agency and the NF must have a written agreement under which the hospice is
responsible for the professional management of the recipient's hospice care. The NF is
responsible to provide room and board to the recipient.
a. Room and board includes:
(1) Performance of personal care services;
(2) Assistance in the ADLs;
(3) Socializing activities;
(4) Administration of medication;
(5) Maintaining the cleanliness of a resident's room; and
(6) Supervising and assisting in the use of Durable Medical Equipment (DME)
and prescribed therapies.
3203.6 DHCFP REVIEW
The DHCFP may conduct a review of a hospice provider to ensure appropriateness of care and
accuracy of claims. The hospice provider being reviewed must comply with the DHCFP staff on
providing all information requested in a timely manner.
The methods of review may include, but are not limited to:
1. On-site visits with recipients and family at their residence;
2. Chart reviews at the hospice agency;
3. Post-payment review of claims data;
4. The DHCFP desk review;
5. On-site review in facilities; and
6. Independent Physician Review for Extended Care.
Medicaid hospice benefits are reserved for terminally ill recipients who have a medical prognosis
to live no more than six months if the illness runs its normal course.
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When an adult recipient (21 years of age or older) reaches 12 months in hospice care, an
independent face-to-face physician review is required. Independent reviews are subsequently
required every 12 months thereafter if the recipient continues to receive extended hospice care.
Hospice agencies should advise recipients of this requirement and provide The Nevada Medicaid
Independent Physician Review for Extended Care form (FA-96) to take with them to each
independent review.
Prior authorization requests for extended hospice care will be denied if this form is not submitted
along with the PA request or if this form indicates the recipient does not continue to meet program
eligibility requirements.
The following medical professionals may conduct the Independent Physician Review:
1. Physician (MD)
2. Doctor of Osteopathic Medicine (D.O.)
3. Physician's Assistant (PA)
4. Advanced Practice Registered Nurse (APRN)
The Independent Physician Review can occur at a physician's office or at the recipient’s place of
residence, whether it be a private home or a nursing facility. The review must be completed no
sooner than 30 days before the end of the recipient's 12-month certification period. In cases when
the independent physician reviewer claims the recipient should no longer be appropriate for hospice
services, the hospice provider will be notified. The hospice physician has seven days to submit a
narrative update on the recipient to staff at LTSS for further review. The Independent Physician
review is not required for dual-eligible recipients. Due to concurrent care allowed for the pediatric
recipient of hospice services, the Independent Physician Review is required for the pediatric hospice
recipient who has elected not to pursue curative treatment.
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3204 NON-HOSPICE SERVICES
1. Nevada Medicaid recipients continue to be eligible for applicable state benefits for services
unrelated to the terminal illness and related conditions for which hospice was elected.
Pediatric recipients continue to be eligible for the applicable State benefits for services that
are curative in nature and related to the terminal illness for which hospice was elected. The
hospice provider is expected to be the lead case coordinator and maintain communication
with other services including those listed below:
a. Personal Care Services (PCS) for Recipients Enrolled in Hospice:
PCS may be provided for recipients enrolled in hospice when the need for PCS is
unrelated to the terminal illness and related conditions, and the personal care needs
exceed the personal care services provided under the hospice benefit. If a recipient
enrolls in hospice, the DHCFP or its designee will conduct an evaluation of an
individual’s comprehensive personal and skilled care needs. The evaluation will
differentiate between personal care needs unrelated to the terminal illness and those
needs directly related to hospice, clearly documenting total personal care needs. PCS
provided under hospice will be subtracted from total PCS needs to document any
personal care needs not met by hospice services and which may be provided by the
Personal Care Agency. The PCS provided by a personal care agency to a recipient
because of needs unrelated to the terminal illness may not exceed State Plan program
limitations. Refer to MSM Chapter 3500 for regulations regarding PCS.
b. Home Health Agency (HHA) Services for Recipients Enrolled in Hospice:
HHA Services may be provided for recipients enrolled in hospice when the need for
HHA Services is unrelated to the terminal illness and related conditions. The HHA
Services provided to a recipient for needs unrelated to the terminal illness may not
exceed State Plan program limitations. Refer to MSM Chapter 1400 for HHA
Services policy.
c. Private Duty Nursing (PDN) for Recipients Enrolled in Hospice:
PDN may be provided for recipients enrolled in hospice when the need for PDN is
unrelated to the terminal illness and related conditions. PDN provided to a recipient
for needs unrelated to the terminal illness may not exceed State Plan program
limitations. Refer to MSM Chapter 900 for PDN policy.
2. Typical services available that are not covered by the hospice benefit but payable by the
DHCFP may include, but are not limited to:
a. Attending physician care (e.g., office visits, hospital visits, etc.);
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b. Optometric services;
c. Any services, drugs, equipment or supplies for an illness other than the recipient’s
terminal illness.
3. The recipient/guardian/agent is responsible for communicating fully with the hospice
agency regarding all services unrelated to the terminal illness to ensure continuity of care.
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3205 CURATIVE SERVICES
Neither the hospice nor Nevada Medicaid is responsible for payment for curative services related
to an adult’s terminal illness.
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3206 INITIATION OF SERVICES
3206.1 ELIGIBILITY REQUIREMENTS
All Nevada Medicaid recipients, including those with primary insurance such as Medicare or a
private insurance, must be enrolled in Nevada Medicaid’s Hospice Program regardless of where
hospice services are provided.
NOTE: Enrollment paperwork for hospice recipients who are pending a Nevada Medicaid
eligibility determination should not be submitted until Medicaid benefits have been approved. All
enrollment forms must be received by the Quality Improvement Organization (QIO)-like vendor
within 60 days of the date of decision of eligibility determination.
For the initial election period, the DHCFP requires the following documentation be received by
the QIO-like vendor within eight working days of the hospice admission:
1. Nevada Medicaid Hospice Program Election Notice for Adults or a Nevada Medicaid
Hospice Program Election Notice for Pediatrics.
2. Nevada Medicaid Hospice Program Physician Certification of Terminal Illness.
3. A face-to-face visit with the recipient within 15 days of admission to Hospice.
4. The hospice Plan of Care.
3206.1A CERTIFICATION OF TERMINAL ILLNESS:
The hospice must obtain written certification of terminal illness, within two calendar days of
initiation of services, signed by the medical director of the hospice or the physician member of the
hospice interdisciplinary group and the individual’s attending physician. If the recipient does not
have an attending physician, this must be indicated on the Hospice Medicaid Information Form. If
the hospice cannot obtain a written certification within two days, a verbal certification may be
obtained within these two days, and a written certification obtained no later than eight days after
care is initiated. If these requirements are not met, no payment will be made for days prior to the
certification. Both the certification and election of hospice services statement must be in place for
payment to commence. Ideally, the dates on the certification statement and the election statement
should match, but if they differ, the earliest date will be the date payment will begin.
The certification of terminal illness must meet the following requirements:
1. The recipient must have a face-to-face encounter with any of the following within 15
business days from date of planned admission to Hospice Services. This face-to-face is not
for certification of hospice services, but to ensure that recipient has been seen, examined
and deemed appropriate for admission to Hospice. This encounter can occur in any setting
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prior to Hospice admission:
a. Acute Care hospital
b. Nursing Facility
c. Private residence
d. Medical professional’s office
e. Long Term Acute Care (LTACH)
The medical professional will make a note in their progress notes or discharge summaries when in
the acute care setting:
The face-to-face may be performed by the following:
a. Physician
b. Doctor of Osteopathic Medicine (DO)
c. Physician Assistant
d. Advanced Practice Registered Nurse (APRN)
2. The Certification of Terminal Illness (CTI) must specify that the recipient’s prognosis is
terminal and life expectancy is six months or less if the illness runs its normal course.
3. Clinical information and other documentation that supports the medical prognosis must
accompany the certification and must be filed in the medical record with the written
certification. Initially, the clinical information may be provided verbally, and must be
documented in the medical record and included as part of the recipient’s eligibility
assessment.
4. The physician must include a brief narrative explanation of the clinical findings that
supports a life expectancy of six months or less as part of the certification and re-
certification. The content of the narrative must support the terminal illness diagnosis by
adhering to the Local Coverage Determination for Hospice (LCD) Guidelines and the
Medicare Non-Cancer and Cancer Diagnosis Determination Guidelines for Hospice (see
Section 3209, Determining Terminal Status).
5. Pediatric patients may not meet LCD criteria given that the criteria is largely geared toward
adult prognosis and diseases. Hospices providing services to pediatric recipients must
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submit clinical narratives describing the signs and symptoms that support the terminal
illness and life expectancy prediction of six month or less without taking into account
whether the patient is receiving concurrent care services.
3206.1B HOSPICE PLAN OF CARE (POC)
1. All hospice care and services furnished to recipients and their families must follow an
individualized written plan of care established by the hospice interdisciplinary group in
collaboration with the attending physician (if any), the recipient or representative and the
primary caregiver in accordance with the recipient's needs if any of them so desire. The
hospice must ensure that each recipient and the primary care giver(s) receive education and
training provided by the hospice as appropriate to their responsibilities for the care and
services identified in the plan of care.
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3207 ELECTION OF HOSPICE CARE
An individual who is a designated Nevada Medicaid recipient, and has been certified as terminally
ill, may file a Nevada Medicaid Hospice Election form (FA-92 for adults and FA-93 for pediatrics)
with a licensed hospice provider who is contracted with the DHCFP. If the recipient is physically
or mentally incapacitated, his or her representative may file a signed hospice election statement
which must include the following:
1. Identification of the particular hospice and of the attending physician that will provide care
to the individual. The individual or representative must acknowledge that the identified
attending physician was his or her choice;
2. The recipient’s or representative’s acknowledgment he or she has been given a full
understanding of the palliative rather than curative nature of hospice care, as related to the
individual’s terminal illness;
3. Acknowledgment that certain otherwise covered Medicaid services are waived by the
election, except for children under the age of 21;
4. The effective date of the election, which may be the first day of hospice care or a later date,
but may be no earlier than the date the election statement was executed and the date
certification was made; and
5. The signature of the recipient or representative. In cases where a recipient signs the Hospice
Election Statement with an "X", there must be two witnesses to sign next to his/her mark.
The witnesses must also indicate relationship to the recipient and daytime phone numbers.
Hospice provider representatives, employees or subcontractors cannot sign as witnesses.
Verbal elections are prohibited.
The hospice agency will not be reimbursed for hospice services unless all signed paperwork has
been submitted to the QIO-like vendor and prior authorization has been obtained. It is the
responsibility of the hospice provider to ensure that prior authorization is obtained for services
unrelated to the hospice benefit. Authorization requests for admission to Hospice Services must be
submitted as soon as possible, but not more than eight business days following admission. Please
note: if the authorization request is submitted after admission, the Hospice Provider is assuming
responsibility for program costs if the authorization request is denied. Prior Authorization only
approves the existence of medical necessity, not recipient eligibility.
3207.1 DURATION OF HOSPICE CARE PERIODS
1. An eligible recipient may elect to receive hospice care during one or more of the following
election periods:
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a. An initial 90-day period;
b. A subsequent 90-day period;
c. An unlimited number of subsequent 60-day periods.
2. An eligible recipient may receive an unlimited number of subsequent 60 day periods
without a break in care as long as:
a. The recipient is re-certified by the hospice physician;
b. A hospice physician or Nurse Practitioner (NP) has a face-to-face encounter with
the recipient to determine continued eligibility prior to the 180th day recertification,
and prior to each subsequent recertification. The face-to-face encounter must occur
no more than 30 calendar days prior to the 180th day benefit period recertification
and no more than 30 calendar days prior to every subsequent recertification
thereafter. These face-to-face encounters are used to gather clinical findings to
determine continued eligibility for hospice services.
c. The practitioner certifies that the recipient has a life expectancy of six months or
less if the illness runs its normal course;
d. The recipient does not revoke the election of hospice; and
e. The recipient in the care of a hospice remains appropriate for hospice care.
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3208 COORDINATION OF SERVICES
The hospice must develop and maintain a system of communication and integration, in accordance
with the hospice's own policies and procedures, to:
1. Ensure that the interdisciplinary group maintains responsibility for directing, coordinating
and supervising the care and services provided.
2. Ensure that the care and services are provided in accordance with the plan of care.
3. Ensure that the care and services provided are based on all assessments of the recipient and
family needs.
4. Provide for and ensure the ongoing sharing of information between all disciplines
providing care and services in all settings, whether the care and services are provided
directly or under arrangement.
5. Provide for an ongoing sharing of information with other non-hospice healthcare providers
furnishing services unrelated to the terminal illness and related illnesses.
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3209 DETERMINING TERMINAL STATUS – Local Coverage Determinations (LCD) - Adults
Pediatric recipients may not meet LCD criteria given that the criteria is geared toward adult
prognosis and diseases. Hospices providing services to pediatric recipients need to ensure all
narratives and clinical documentation address all body systems, showing clinical data supporting
the recipient's terminally ill status and decline in condition if curative care were no longer being
pursued.
3209.1 NON-CANCER TERMINAL ILLNESSES:
1. CMS acknowledges that the primary diagnoses of hospice recipients have shifted from
cancers to non-cancer terminal illnesses.
2. CMS clarifies that "debility" and "adult failure to thrive" SHOULD NOT be used as
principal hospice diagnoses on the hospice claim form. When reported as a principal
diagnosis, these would be considered questionable encounters for hospice care.
3. Claims would be returned to the provider (RTPd) for a more definitive principal diagnosis.
"Debility" and "adult failure to thrive" could be listed on the hospice claim as other,
additional or coexisting diagnoses. CMS expects providers to code the most definitive,
contributory terminal diagnosis in the principal diagnosis field with all other related
illnesses in the additional diagnoses fields for hospice claims reporting.
4. All recipients must have a terminal illness with a life expectancy of six months or less if the
illness runs its normal course.
a. Hospice Criteria for Adult Failure to Thrive Syndrome:
(1) Terminal Illness Description: The adult failure to thrive syndrome is
characterized by unexplained weight loss, malnutrition and disability. The
syndrome has been associated with multiple primary illnesses (e.g.,
infections and malignancies), but always includes two defining clinical
elements, namely nutritional impairment and disability. The nutritional
impairment and disability associated with the adult failure to thrive
syndrome must be severe enough to impact the recipient's short-term
survival. The adult failure to thrive syndrome presents as an irreversible
progression in the recipient's nutritional impairment/disability despite
therapy (i.e., treatment intended to affect the primary illness responsible for
the recipient's clinical presentation).
(2) Criteria for initial certification or recertification: Criteria below must be
present at the time of initial certification or re-certification for hospice. An
individual is considered to be terminally ill if the individual has a medical
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prognosis that his or her life expectancy is six months or less if the terminal
illness runs its normal course. Recipients must meet a) and b) below:
a) The nutritional impairment associated with the adult failure to thrive
syndrome must be severe enough to impact a beneficiary's weight.
The Body Mass Index (BMI) of beneficiaries electing the Medicaid
Hospice Benefit for the adult failure to thrive syndrome must be
below 22 kg/m2 and the recipient must be either declining
enteral/parenteral nutritional support or has not responded to such
nutritional support.
b) The disability associated with the adult failure to thrive syndrome
should be such that the individual is significantly disabled.
Significant disability must be demonstrated by a Karnofsky or
Palliative Performance Scale value less than or equal to 40%. Both
the recipient’s BMI and level of disability should be determined
using measurements/observations made within six months (180
days) of the most recent certification/recertification date. If enteral
nutritional support has been instituted prior to the hospice election
and will be continued, the BMI and level of disability should be
determined using measurements/observations made at the time of
the initial certification and at each subsequent recertification. At the
time of recertification recumbent measurement(s) - (anthropometry)
such as mid-arm circumference in cm may be substituted for BMI
with documentation as to why a BMI could not be measured. This
information will be subject to review on a case by case basis.
b. Hospice Criteria for Adult HIV Disease:
(1) Criteria for initial certification: Criteria below must be present at the time
of initial certification for hospice. Recipients will be considered to be in the
terminal stage of their illness (life expectancy of six months or less) if they
meet the following criteria: HIV Disease a) and b) must be present; factors
from (3) will add supporting documentation.
a) CD4+ Count less than 25 cells/mcL or persistent viral load greater
than 100,000 copies/ml, plus one of the following:
1) CNS lymphoma.
2) Untreated, or not responsive to treatment, wasting (loss of
33% lean body mass).
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3) Mycobacterium avium complex (MAC) bacteremia,
untreated, unresponsive to treatment or treatment refused.
4) Progressive multifocal leukoencephalopathy.
5) Systemic lymphoma, with advanced HIV disease and partial
response to chemotherapy.
6) Visceral Kaposi's sarcoma unresponsive to therapy.
7) Renal failure in the absence of dialysis.
8) Cryptosporidium infection.
9) Toxoplasmosis, unresponsive to therapy.
b) Decreased performance status, as measured by the Karnofsky
Performance Status (KPS) scale, of less than or equal to 50.
c) Documentation of the following factors will support eligibility for
hospice care:
1) Chronic persistent diarrhea for one year
2) Persistent serum albumin less than 2.5 gm/dl
3) Age greater than 50 years
4) Absence of antiretroviral, chemotherapeutic and
prophylactic drug therapy related specifically to HIV disease
5) Advanced AIDS dementia complex
6) Toxoplasmosis
7) Congestive heart failure, symptomatic at rest, New York
Heart Association (NYHA) classification Stage IV
c. Hospice Criteria for Adult Pulmonary Disease
(1) Criteria for initial certification: Criteria below must be present at the time
of initial certification for hospice. Recipients will be considered to be in the
terminal stage of pulmonary disease (life expectancy of six months or less)
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if they meet the following criteria. The criteria refer to recipients with
various forms of advanced pulmonary disease who eventually follow a final
common pathway for end stage pulmonary disease: a) and b) must be
present; documentation of c), d) and/or e) will lend supporting
documentation:
a) Severe chronic lung disease as documented by both factors below:
1) Recipient with Forced Expiratory Volume in one second
[FEV1], after bronchodilator, less than 30% of predicted and
disabling dyspnea at rest, poorly responsive to
bronchodilators, resulting in decreased functional capacity,
e.g., bed to chair existence, fatigue and cough
(documentation of Forced Expiratory Volume in one second
[FEV1], after bronchodilator, less than 30% of predicted is
objective evidence for disabling dyspnea and must be
provided when performed). If the FEV1 has not been
performed, the clinical condition must support an FEV1 less
than 30% of predicted.
2) Progression of end stage pulmonary disease as documented
by two or more episodes of pneumonia or respiratory failure
requiring ventilatory support within the last six months.
Alternatively, medical record documentation of serial
decrease in FEV1 greater than 40 ml/year for the past two
years can be used to demonstrate progression.
b) Hypoxemia at rest on room air, with a current ABG PO2 at or below
59 mm Hg or oxygen saturation at or below 89% taken at rest or
hypercapnia, as evidenced by PCO2 greater than or equal to 50
mmHg (these values may be obtained from recent hospital records).
c) Cor pulmonale and right heart failure (RHF) secondary to
pulmonary disease (e.g. not secondary to left heart disease or
valvulopathy).
d) Unintentional progressive weight loss of greater than 10% of body
weight over the preceding six months.
e) Resting tachycardia greater than 100/min.
d. Hospice Criteria for Adult Alzheimer’s Disease, Dementia & Related Disorders:
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(1) Terminal Illness Description: An individual is considered to be terminally
ill if the medical prognosis indicates a life expectancy of six months or less.
Alzheimer’s disease and related disorders are further substantiated with
medical documentation of a progressive decline in the Reisburg Functional
Assessment Staging (FAST) Scale, within a six-month period of time, prior
to the Medicaid hospice election.
Criteria below must be present at the time of initial certification and recertification
for hospice. Alzheimer's disease and related disorders may support a prognosis of
six months or less under many clinical scenarios. The structural and functional
impairments associated with a primary diagnosis of Alzheimer's disease are often
complicated by co-morbid and/or secondary illnesses. Co-morbid illnesses
affecting recipients with Alzheimer's disease are by definition distinct from the
Alzheimer's disease itself - examples include coronary heart disease (CHD) and
chronic obstructive pulmonary disease (COPD). Secondary illnesses on the other
hand are directly related to a primary illness - in the case of Alzheimer's disease
examples include delirium and pressure ulcers.
(2) The presence of secondary illnesses is thus considered separately by this
policy. Recipients must meet a) and b) below:
a) To be eligible for hospice, the individual must have documentation
of a FAST scale level equal to 7 and documentation of at least 4 or
6 sub-stage FAST scale indicators under level 7.
FAST Scale Items:
Stage #1: No difficulty, either subjectively or objectively.
Stage #2: Complains of forgetting location of objects; subjective
work difficulties.
Stage #3: Decreased job functioning evident to coworkers; difficulty
in traveling to new locations.
Stage #4: Decreased ability to perform complex tasks (e.g., planning
dinner for guests; handling finances).
Stage #5: Requires assistance in choosing proper clothing.
Stage #6: Decreased ability to dress, bathe, and toilet independently:
Sub-stage 6a: Difficulty putting clothing on properly.
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Sub-stage 6b: Unable to bathe properly; may develop fear of
bathing.
Sub-stage 6c: Inability to handle mechanics of toileting (e.g.,
forgets to flush the toilet, does not wipe properly).
Sub-stage 6d: Urinary incontinence.
Sub-stage 6e: Fecal incontinence.
Stage #7: Loss of speech, locomotion and consciousness:
Sub-stage 7a: Ability to speak limited to approximately a
half dozen intelligible different words or fewer, in
the course of an average day or in the course of an
intensive interview.
Sub-stage 7b: All intelligible vocabulary lost (Speech ability
limited to the use of a single intelligible word in an
average day or in the course of an intensive interview
– the person may repeat the word over and over).
Sub-stage 7c: Non-ambulatory (Ambulatory ability lost –
cannot walk without personal assistance).
Sub-stage 7d: Unable to sit up independently (Cannot sit up
without assistance - e.g., the individual will fall over
if there are not lateral rests [arms] on the chair).
Sub-stage 7e: Loss of ability to smile.
Sub-stage 7f: Loss of ability to hold head up independently.
b) Documentation of specific secondary illness(es) related to
Alzheimer’s Disease must be present, including but not limited to,
Contractures, Pressure Ulcers, recurrent UTI, Dysphagia,
Aspiration Pneumonia.
e. Hospice Criteria for Adult Stroke and/or Coma
(1) Criteria below must be present at the time of initial certification and
recertification for hospice. The medical criteria listed below would support
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a terminal prognosis for individuals with a diagnosis of stroke. Recipients
must meet a) and b) below:
a) A Palliative Performance Scale (PPS) of less than or equal to 40:
1) Degree of ambulation - Mainly in bed.
2) Activity/extent of disease - not able to do work; extensive
disease.
3) Ability to do self-care - Mainly Assistance.
4) Food/fluid intake - Normal to reduced.
5) State of consciousness - Either fully conscious or
drowsy/confused.
b) Inability to maintain hydration and caloric intake with any one of
the following:
1) Weight loss greater than 10% during previous three months.
2) Weight loss greater than 7.5% in previous six weeks.
3) Serum albumin less than 2.5 gm/dl.
4) Current history of pulmonary aspiration without effective
response to speech language pathology interventions to
improve dysphagia and decrease aspiration events.
5) Calorie counts documenting inadequate caloric/fluid intake.
(Recipient’s height and weight - caloric intake is too low to
maintain normal BMI or fewer calories than necessary to
maintain normal BMI - determine with caloric counts).
6) Dysphagia severe enough to prevent the recipient from
receiving food and fluids necessary to sustain life in a
recipient who declines or does not receive artificial nutrition
and hydration.
c) The medical criteria listed below would support a terminal
prognosis for individuals with a diagnosis of coma (any etiology).
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Comatose recipients with any three of the following on day three or
after of coma:
1) Abnormal brain stem response.
2) Absent verbal response.
3) Absent withdrawal response to pain.
4) Increase in serum creatinine greater than 1.5 mg/dl.
f. Hospice Criteria for Adult Amyotrophic Lateral Sclerosis (ALS).
(1) Criteria for initial certification: Criteria below must be present at the time
of initial certification for hospice. ALS tends to progress in a linear fashion
over time. The overall rate of decline in each Recipient is fairly constant
and predictable, unlike many other non-cancer diseases. No single variable
deteriorates at a uniform rate in all recipients. Therefore, multiple clinical
parameters are required to judge the progression of ALS. Although ALS
usually presents in a localized anatomical area, the location of initial
presentation does not correlate with survival time. By the time recipients
become end-stage, muscle denervation has become widespread, affecting
all areas of the body, and initial predominance patterns do not persist. In
end-stage ALS, two factors are critical in determining prognosis: ability to
breathe, and to a lesser extent, ability to swallow. The former can be
managed by artificial ventilation, and the latter by gastrostomy or other
artificial feeding, unless the recipient has recurrent aspiration pneumonia.
While not necessarily a contraindication to hospice care, the decision to
institute either artificial ventilation or artificial feeding will significantly
alter six-month prognosis. Examination by a neurologist within three
months of assessment for hospice is required, both to confirm the diagnosis
and to assist with prognosis. Recipients will be considered to be in the
terminal stage of ALS (life expectancy of six months or less) if they meet
the following criteria (must fulfill a), b) or c)):
a) The recipient must demonstrate critically impaired breathing
capacity.
Critically impaired breathing capacity as demonstrated by all the
following characteristics occurring within the 12 months preceding
initial hospice certification:
1) Vital capacity (VC) less than 30% of normal.
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2) Continuous dyspnea at rest.
3) Hypoxemia at rest on room air, with a current ABG PO2 at
or below 59mm Hg or oxygen saturation at or below 89%.
4) Recipient declines artificial ventilation.
b) Recipient must demonstrate both rapid progression of ALS and
critical nutritional impairment.
1) Rapid progression of ALS as demonstrated by all the
following characteristics occurring within the 12 months
preceding initial hospice certification:
(a) Progression from independent ambulation to
wheelchair or bed bound status.
(b) Progression from normal to barely intelligible or
unintelligible speech.
(c) Progression from normal to pureed diet.
(d) Progression from independence in most or all
activities of daily living (ADLs) to needing major
assistance by caretaker in all ADLs.
2) Critical nutritional impairment as demonstrated by all the
following characteristics occurring within the 12 months
preceding initial hospice certification:
(a) Oral intake of nutrients and fluids insufficient to
sustain life.
(b) Unintentional progressive weight loss of greater than
10% of body weight over the preceding six months.
c) Recipient must demonstrate both rapid progression of ALS and life-
threatening complications.
1) Rapid progression of ALS, see b) 1) above.
2) Life-threatening complications as demonstrated by one of
the following characteristics occurring within the 12 months
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preceding initial hospice certification: Upper urinary tract
infection (pyelonephritis) and Sepsis.
3) Other medical complications not identified above will be
reviewed on a case-by-case basis with appropriate medical
justification.
g. Hospice Criteria for Adult Heart Disease
(1) Criteria for initial certification or recertification: Criteria below must be
present at the time of initial certification or re-certification for hospice. The
medical criteria listed below would support a terminal prognosis for
individuals with a diagnosis of heart disease. Medical criteria a) and b) must
be present as they are important indications of the severity of heart disease
and would thus support a terminal prognosis if met.
a) When the recipient is approved or recertified the recipient is already
optimally treated with diuretics and vasodilators, which may include
angiotensin converting enzymes (ACE) inhibitors or the
combination of hydralazine and nitrates. If side effects, such as
hypotension or hyperkalemia, or evidence of treatment failure
prohibit the use of ACE inhibitors or the combination of hydralazine
and nitrates, or recipient voluntarily declines treatment, the
documentation must be present in the medical records or with lab
results and medical records submitted upon request.
b) The recipient has significant symptoms of recurrent congestive heart
failure (CHF) at rest, and is classified as a New York Heart
Association (NYHA) Class IV:
1) Unable to carry on any physical activity without symptoms.
2) Symptoms are present even at rest.
3) If any physical activity is undertaken, symptoms are
increased.
c) Documentation of the following factors may provide additional
support for end stage heart disease:
1) Treatment resistant symptomatic supraventricular or
ventricular arrhythmias.
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2) History of cardiac arrest or resuscitation.
3) History of unexplained syncope.
4) Brain embolism of cardiac origin.
5) Concomitant HIV disease.
6) Documentation of ejection fraction of 20% or less.
7) Angina pectoris, at rest.
h. Hospice Criteria for Adult Liver Disease
.
(1) Criteria for initial certification and recertification: Criteria below must be
present at the time of initial certification/recertification for hospice.
Recipients will be considered to be in the terminal stage of liver disease (life
expectancy of six months or less) if they meet the following criteria:
a) Documentation of progression with active decline as evidenced by
worsening clinical status, symptoms, signs and laboratory results.
The recipient’s terminal illness must be supported by one or more
of the items below:
1) Clinical Status
(a) Recurrent or intractable infections such as
pneumonia, sepsis or upper urinary tract.
2) Documented progressive inanition (II) Symptoms
(a) Dyspnea with increasing respiratory rate.
(b) Nausea/vomiting poorly responsive to treatment.
(c) Diarrhea, intractable.
(d) Pain requiring increasing doses of major analgesics
more than briefly.
3) Signs
(a) Ascites.
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(b) Edema.
(c) Weakness.
(d) Increasing pCO2 or decreasing pO2 or decreasing
SaO2.
(e) Increasing liver function studies.
(f) Progressively decreasing or increasing serum
sodium.
4) Decline in Karnofsky Performance Status (KPS) or
Palliative Performance Score (PPS) due to progression of
disease.
5) Progression to dependence on assistance with additional
activities of daily living.
6) History of increasing ER visits, hospitalizations or physician
visits related to the hospice primary diagnosis prior to
election of the hospice benefit.
b) End stage liver disease is present and the recipient shows at least
one of the following:
1) Change in level of consciousness.
2) Ascites, refractory to treatment or recipient non-complaint.
3) Spontaneous bacterial peritonitis.
4) Hepatorenal syndrome (elevated serum creatinine and BUN
with oliguria (<400 ml/day) and urine sodium concentration
less than 10 mEq/l.
5) Hepatic encephalopathy, refractory to treatment or recipient
non-compliant.
6) Recurrent variceal bleeding, despite intensive therapy.
c) Documentation of the following factors will also support eligibility
for hospice care:
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1) Progressive malnutrition.
2) Muscle wasting with reduced strength and endurance.
3) Continued active alcoholism (>80 gm ethanol/day).
4) Hepatocellular carcinoma.
5) HBsAg (Hepatitis B) positivity.
6) Hepatitis C refractory to interferon treatment.
i. Hospice Criteria for Adult Renal Disease
When an individual elects Hospice care for end stage renal disease or for a
condition to which the need for dialysis is related, the Hospice agency is financially
responsible for the dialysis. In such cases, there is no additional reimbursement
beyond the per diem rate. The only situation in which a recipient may access both
the hospice benefit and ESRD benefit is when the need for dialysis is not related to
the patient's terminal illness, or if the pediatric recipient is pursuing concurrent care.
(1) Criteria for initial certification: Criteria below must be present at the time
of initial certification for hospice. Recipients will be considered to be in the
terminal stage of renal disease (life expectancy of six months or less) if they
meet the following criteria:
a) Acute renal failure 1) and 2) must be present:
1) Creatinine clearance less than 10 cc/min (less than 15 cc/min
for diabetes).
2) Serum creatinine greater than 8.0 mg/dl (greater than 6.0
mg/dl for diabetes).
b) Chronic renal failure 1), 2) and 3) must be present:
1) Creatinine clearance less than 10 cc/min (less than 15 cc/min
for diabetes).
2) Serum creatinine greater than 8.0 mg/dl (greater than 6.0
mg/dl for diabetes).
3) Glomerular filtration rate (GFR) less than 30 ml/min.
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3209.2 HOSPICE CRITERIA FOR ADULT CANCER
1. Criteria for initial certification or recertification: Criteria below must be present at the time
of initial certification or re-certification for hospice. Recipients will be considered to be in
the terminal stage of cancer (life expectancy of six months or less) if (a) or (b) below are
present:
a. Documentation of metastasis or final disease stage is required with evidence of
progression as documented by worsening clinical status, symptoms, signs and/or
laboratory results.
b. Progression from an earlier stage of disease to metastatic disease with either:
(1) A continued decline in spite of therapy, that is, aggressive treatment, or
(2) Recipient declines further disease directed therapy.
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3210 REASONS FOR DENIAL OF ANY OF THE ABOVE
1. Recipients not meeting the specific medical criteria in this policy.
2. Absence of supporting documentation of progression or rapid decline.
3. Failure to document terminal status of six months or less if the illness runs its normal
course.
4. Recipient is not eligible for full Medicaid benefits.
5. A person who reaches a point of stability and is no longer considered terminally ill must not
be recertified for hospice services. The individual must be discharged to traditional
Medicaid benefits.
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3211 RECIPIENT RESPONSIBILITY
The Medicaid recipient is responsible for signing the election statement to receive hospice care.
The election statement may be signed by the recipient’s representative.
The recipient is responsible to comply with the POC as established by the hospice interdisciplinary
group.
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3212 CHANGING THE DESIGNATED HOSPICE
An individual or representative may change, once in each election period, the designation of the
particular hospice from which hospice care will be received.
1. The change of the designated hospice is not a revocation of the hospice election for the
period in which it was made.
2. To change the designation of hospice agencies, the individual or representative must file,
with the hospice agency from which care has been received and with the newly designated
hospice, a Nevada Medicaid Hospice Action Form that includes the following:
a. The name of the hospice from which the individual has received care;
b. The name of the hospice from which he or she plans to receive care;
c. The effective date of the transfer of hospice care.
3. The transferring hospice agency files the notice in the medical record and faxes one copy
to the receiving hospice and faxes one copy to the QIO-like vendor along with a Hospice
Medicaid Information form.
4. The receiving hospice agency must fax an updated Hospice Medicaid Information form,
Hospice Ancillary Information form, a signed election statement and a signed copy of the
physician's certification of terminal illness to the QIO-like vendor.
5. If a hospice recipient is residing in an NF, the transferring hospice agency is required to
submit a copy of the transfer statement to the NF for their records.
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3213 REVOKING THE ELECTION OF HOSPICE CARE
An individual or representative may revoke the election of hospice care at any time during an
election period.
1. To revoke the election of hospice care, the recipient or representative must file with the
hospice a Nevada Medicaid Hospice Action Form to be placed in the medical record that
includes the following information:
a. Signed statement that the recipient or representative revokes the recipient’s election
for coverage of hospice care for the remainder of that election period with the date
that the revocation is to be effective. (An individual or representative may not
designate an effective date earlier than the date that the revocation is made);
b. The hospice agency is required to fax the QIO-like vendor the signed copy of the
revocation notice and a Medicaid Hospice Information form/Notice of Revocation
within 72 hours, once the revocation notice has been signed.
2. If the hospice recipient is residing in an NF, the hospice agency is required to immediately
submit to the NF a signed copy of the notice of revocation for their medical records.
3. An individual, upon revocation of the benefit election of hospice care for a particular
election period:
a. Is no longer covered for hospice care for that election period;
b. Resumes eligibility for all Medicaid covered services as before the election to
hospice; and
c. May at any time elect to receive hospice coverage for any other hospice election
periods for which he or she is eligible to receive.
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3214 DISCHARGE OF A RECIPIENT FROM HOSPICE
With adequate documentation explaining cause, a hospice may discharge a recipient.
1. Reasons for discharge may include:
a. Noncompliance with hospice POC;
b. Moves out of the hospice’s service area or transfers to another hospice;
c. No longer meets the criteria for hospice;
d. No longer eligible for Medicaid; or
e. Request of recipient, or representative.
2. The hospice must have policies in place to address disruptive, abusive or uncooperative
behavior, on the part of the recipient or other individuals in the home, to the extent that
delivery to the recipient or the ability of the hospice to operate is seriously impaired. The
hospice must do the following prior to discharge for cause:
Advise the recipient that a discharge for cause is being considered.
a. Make a serious effort to resolve the problem(s) presented by the recipient’s
behavior or situation;
b. Ascertain that the recipient’s proposed discharge is not due to the recipient’s use of
necessary services; and
c. Document the problem(s) and efforts made to resolve the problems(s) and enter this
documentation into its medical records.
3. Prior to discharge, the hospice must obtain a written discharge order from the hospice
medical director. If a recipient has an attending physician, the physician must be consulted
and his/her recommendation or decision must be included in the discharge note.
4. A copy of the signed discharge notice, physician’s discharge order and the Nevada
Medicaid Hospice Action Form are required to be faxed to the QIO-like vendor within 72
hours of the discharge. A copy is retained in the client's record at the hospice.
5. If the hospice recipient is residing in an NF, the hospice is required to immediately submit
a copy of the signed discharge notice to the facility for their records the day the discharge
notice has been signed. The hospice agency is required to also verbally inform the NF staff
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of the discharge.
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3215 HEARINGS
All Medicaid recipients and providers have rights to hearings regarding reimbursement and
treatment issues. Please refer to Medicaid Services Manual (MSM) Chapter 3100, Hearings for the
hearing process
February 23, 2017 HOSPICE Section 3215 Page 1
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
April 30, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: LYNNE FOSTER, CHIEF OF DIVISION COMPLIANCE
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 3300 – PROGRAM INTEGRITY
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 3300 – Program Integrity are being
proposed to clarify the authority to implement payment suspensions as outlined in 42 Code of
Federal Regulations (CFR) 455.23.
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: All Medicaid Providers.
Financial Impact on Local Government: None known at this time.
These changes are effective May 1, 2019.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 08/19 MTL 19/07, 07/07
MSM Ch 3300 – Program Integrity MSM Ch 3300 – Program Integrity
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3302.2 Administrative Add: “payment suspensions;” between “status;” and
Action “and.”
3303.2B(4) Coverage and Add “if payment” in between “to determine” and “has or
Limitations will be made.”
3303.3A(2) Coverage and Replace: “The” with “the” before “DHCFP.”
Limitations
Page 1 of 2
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3303.3A(2)(1) Coverage and Move text regarding the fair hearing process within the
Limitations section.
3303.3A(4) Coverage and Paragraph now reads: "Payment suspensions to the
Limitations provider. The DHCFP may implement a payment
suspension and withhold payments to the provider, in
whole or in part, upon determining there is a credible
allegation of fraud or willful misrepresentation under the
Medicaid or Nevada Check Up programs. The DHCFP
may suspend payment without first notifying the
provider. The DHCFP will send notice to the provider in
accordance with 42 CFR 455.23."
3303.3A(4)(a) Coverage and Remove: "Specify the claims affected by the withholding
Limitations action."
Add: "Set forth the general allegations as to the nature of
the suspension action, but need not disclose any specific
information concerning an ongoing investigation."
3303.3A(4)(b) Coverage and Remove: "withholding action will be."
Limitations
Add: "payment suspension is."
3303.3A(4)(c) Coverage and Add: "the payment suspension."
Limitations
Remove: "withholding."
3303.3A(4)(d) Coverage and Remove: "Cite the duration of the withholding."
Limitations
Add: "Specify, when applicable, to which type or types
of Medicaid claims or business units o f a provider are
subject to the payment suspension;"
3303.3A(4)(e) Coverage and Remove: "and."
Limitations
3303.3A(4)(t) Coverage and Add: "Set forth the applicable State administrative
Limitations appeals process and corresponding citations to State law;
and."
Page 2 of2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
PROGRAM INTEGRITY
3300 INTRODUCTION .................................................................................................. 1
3301 REGULATORY AUTHORITY ............................................................................. 1
3302 DEFINITIONS ........................................................................................................ 1
3302.1 ABUSE ................................................................................................................... 1
3302.2 ADMINISTRATIVE ACTION .............................................................................. 1
3302.3 FRAUD ................................................................................................................... 1
3302.4 IMPROPER PAYMENT ........................................................................................ 1
3302.5 KICKBACKS ......................................................................................................... 2
3302.6 OVERPAYMENT /UNDERPAYMENT ............................................................... 2
3302.7 PERM REVIEW ERRORS..................................................................................... 2
3302.8 RECOUPMENT/RECOVERY ............................................................................... 2
3302.9 UNBUNDLING ...................................................................................................... 2
3302.10 UP-CODING........................................................................................................... 2
3303 POLICY .................................................................................................................. 1
3303.1 IDENTIFICATION OF FRAUD, ABUSE & IMPROPER PAYMENTS ............. 1
3303.1A COVERAGE AND LIMITATIONS ...................................................................... 1
3303.1B PROVIDER RESPONSIBILITY............................................................................ 5
3303.1C RECIPIENT RESPONSIBILITY ........................................................................... 5
3303.2 INVESTIGATIONS OF FRAUD, ABUSE OR IMPROPER PAYMENTS ......... 6
3303.2A COVERAGE AND LIMITATIONS ...................................................................... 6
3303.2B PROVIDER RESPONSIBILITY............................................................................ 8
3303.3 ADMINISTRATIVE ACTIONS AND CIVIL AND CRIMINAL
PENALTIES ........................................................................................................... 9
3303.3A COVERAGE AND LIMITATIONS ...................................................................... 9
3304 REFERENCES AND CROSS REFERENCES ...................................................... 1
3304.1 FRAUD, ABUSE OR IMPROPER PAYMENT REFERRALS ............................ 1
3304.2 POLICY REFERENCES ........................................................................................ 2
3304.3 OTHER CONTACTS ............................................................................................. 2
MTL 07/07
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3300
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
3300 INTRODUCTION
The Division of Health Care Financing and Policy (DHCFP) is responsible for the fiscal integrity
of the Medicaid and Nevada Check Up programs and is committed to a program that identifies and
reduces fraud, abuse and improper payments. The DHCFP must ensure Medicaid and Nevada
Check Up recipients have access to quality care and claims are paid appropriately and in
accordance with state statutes and federal laws and regulations, program policies and billing
manuals. The DHCFP has three distinct programs to assist in ensuring the fiscal integrity of the
programs it administers: the Surveillance and Utilization Review (SUR) program, the Payment
Error Rate Measurement (PERM) program and the Financial and Compliance Audit program.
Surveillance and Utilization Review
Federal regulations require the DHCFP to operate a statewide SUR program to safeguard against
unnecessary or inappropriate use of services and prevent excess payments in an efficient,
economical and effective manner. The DHCFP has methods in place to: identify, investigate and
refer suspected cases of provider and recipient fraud and abuse; methods and processes to review
provider over-utilization of services and in the case of managed care providers, under-utilization
of services and recover improper payments. The DHCFP will conduct reviews to determine if
services were billed in accordance with applicable policies and/or regulations. Providers are
selected for review based on complaints, referrals and through the use of fraud detection and other
analysis. All providers are at risk for review.
The DHCFP must refer all cases of suspected fraud and abuse, pursuant to Nevada Revised Statutes
(NRS) 422.540 to 422.570, to the Office of the Attorney General, Medicaid Fraud Control Unit
(MFCU). The MFCU has the primary authority and responsibility to fully investigate and
prosecute, for civil and/or criminal action, violations of fraud and abuse in the Medicaid and
Nevada Check Up programs.
The Division of Welfare and Supportive Services (DWSS) is responsible for all recipient related
Medicaid fraud and abuse, including unlawful acts relating to Medicaid cards. To report any
fraudulent activity related to Medicaid recipients contact the Investigations and Recovery Unit
within the DWSS or fill out a fraud report on-line at http://welfare.state.nv.us/I&R/ir.htm.
The DHCFP must ensure the exclusion of certain individuals and entities from participation in the
Medicaid and Nevada Check Up programs. For the DHCFP policies and applicable state and
federal statutes and regulations relating to this process, refer to the Medicaid Services Manual
(MSM) Chapter 100.
The DHCFP must ensure all entities receiving payments of $5 million or more from the Medicaid
program establish policies for the entity’s employees providing detailed information about: the
entity’s procedures for detecting and preventing fraud, waste and abuse; false claims; civil and
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criminal penalties; and whistle blower protections. For the DHCFP policy relating to this provider
requirement, refer to MSM Chapter 100.
Payment Error Rate Measurement (PERM)
The Improper Payments Act of 2002 (IPIA) requires the Centers for Medicare and Medicaid
Services (CMS) to estimate improper payments in all state Medicaid and State Children’s Health
Insurance Programs (SCHIP) (Nevada Check Up). CMS must annually calculate and report to
Congress the national error rates in each of these programs and the actions it is taking to reduce
improper payments in these health care programs. To meet the requirements of the federal
mandate, CMS requires each state to undergo a PERM review once every three years. Nevada will
be reviewed in federal fiscal year 2008 and every third year thereafter.
PERM reviews consist of a thorough analysis of recipient eligibility, claims processing and
medical record or service documentation. Recipient eligibility reviews will be conducted by the
DWSS. The claims processing and medical record or service documentation reviews for the
mandated PERM program will be conducted by federal contractors.
Financial and Policy Compliance Audits
The DHCFP will conduct regular financial and policy compliance audits of programs and services
provided under the Medicaid and Nevada Check Up programs. These audits consist of a thorough
review of program policy, claims processing and/or medical or service record documentation.
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Section:
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Subject:
MEDICAID SERVICES MANUAL AUTHORITY
3301 REGULATORY AUTHORITY
Provider and recipient fraud, abuse and improper payments are regulated by federal law and state
statute, specifically, the Social Security Act (SSA), United States Code (USC) (Title 42), Code of
Federal Regulation (42 CFR) and the Nevada Revised Statutes (NRS). Specific authorities include,
but are not limited to:
Social Security Act (SSA)
A. The penalty for fraud is regulated by Section 1107.
B. Section 1128A outlines civil monetary penalties for acts involving federal health care
programs.
C. Section 1128B outlines criminal penalties for acts involving federal health care programs.
D. Section 1902 and Section 2103 govern the amount, duration and scope of medical
assistance for Medicaid and Nevada Check Up recipients, respectively.
E. Section 1902(a)(68) describes the requirements for false claims education for entities
receiving $5 million in payments from the Medicaid program. Refer to the Deficit
Reduction Act of 2005, Section 6032.
F. Section 1903 and Section 2105 govern federal and other payments to states for Medicaid
and Nevada Check Up programs, respectively.
G. Section 1903(q) describes the requirements of state MFCU.
H. Sanctions for non-compliance of provisions relating to managed care are regulated by
Section 1932.
Code of Federal Regulations (CFR)
A. 42 CFR Part 431, Subpart Q – Requirements for Estimating Improper Payments in
Medicaid and SCHIP.
B. 42 CFR 431.54(e) – Regulates recipient lock-in for recipients over utilizing services.
C. 42 CFR 431.54(f) – Regulates restrictions such as provider lock-out or suspension for
abuse of the Medicaid program.
D. 42 CFR 455 Subpart A – Describes the requirements of Medicaid Agency Fraud Detection
and Investigation Programs.
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E. 42 CFR 456 Subpart A – Describes the general provisions for utilization control in state or
federal health care programs.
F. 42 CFR 456 Subpart B – Describes the requirements of a statewide Surveillance and
Utilization Review control program for all Medicaid services.
G. 42 CFR 457.915-.935 – Pertains to fraud detection and investigation associated with the
SCHIP.
H. 42 CFR 1001 – Regulates the mandatory and permissive provider exclusions for state or
federal health care programs.
I. 42 CFR 1002 – Includes regulations for state-initiated exclusions from Medicaid programs.
J. 42 CFR 1003 – Provides for the imposition of civil money penalties and other applicable
regulations regarding exclusion of individuals or entities from federal or state health care
programs.
K. 42 CFR 1005 – Regulates appeals of exclusions, civil money penalties and assessments.
Nevada Revised Statutes (NRS)
A. NRS 193.120-193.150 – Details the types of crimes and punishments associated with
fraudulent acts.
B. NRS 228.410 – Established the MFCU, including their duties and powers. The MFCU is
responsible for the investigation and prosecution of violations of NRS 422.540-422.570.
C. NRS 357 – Governs false claims submitted to state or local governments.
D. NRS 422.2374 – Details the required cooperation between the DHCFP and the MFCU
involving the suspension or exclusion of provider services under Medicaid.
E. NRS 422.305 – Regulates confidentiality of information obtained in investigations of a
provider of services for Medicaid.
F. Unlawful acts regarding Medicaid cards are regulated by NRS 422.366-422.369.
G. Unlawful acts; fraud by person authorized to provide care to holder of stolen, forged,
expired or revoked card; penalties are regulated by NRS 422.369.
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H. NRS 422.410-422.590 – Covers unlawful acts and penalties related to services provided
by or through the DHCFP.
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3302 DEFINITIONS
Definitions apply to this chapter and do not supersede applicable state or federal law.
3302.1 ABUSE
Abuse means provider practices that are inconsistent with sound fiscal, business or medical
practices, and result in an unnecessary cost to the Medicaid or Nevada Check Up programs, or in
reimbursement for services that are not medically necessary or fail to meet professionally
recognized standards for health care. It also includes recipient practices that result in unnecessary
cost to the Medicaid or Nevada Check Up programs. (42 CFR 455.2)
3302.2 ADMINISTRATIVE ACTION
Administrative Action is an action taken by the DHCFP which includes but is not limited to: the
recovery of improper payments; issuance of educational letters; issuance of warning letters;
issuance of recoupment/recovery letters; special claims reviews or on-site audits; requests for
provider corrective action plans; requests for provider self audits; referral to appropriate civil
agencies (licensing bodies); referral to the MFCU; denial of provider applications; suspension and
termination of provider status; payment suspensions; and other actions as stated in policy 3303.3A.
See the SSA Sections: 1128, 1128A, 1128B, and 1903.
3302.3 FRAUD
Fraud is an intentional deception or misrepresentation made by a person with the knowledge that
the deception could result in some unauthorized benefit to himself/herself or some other person. It
includes any act that constitutes fraud under applicable federal or state law. (42 CFR 455.2)
3302.4 IMPROPER PAYMENT
An improper payment is any payment that is billed to or paid by the DHCFP that is not in
accordance with: The Medicaid or Nevada Check Up policy governing the service provided; fiscal
agent billing manuals; contractual requirements; standard record keeping requirements of the
provider discipline; and federal law or state statutes. An improper payment can be an overpayment
or an underpayment. Improper payments include but are not limited to: improper payments
discovered during federal PERM reviews or Financial and Policy Compliance Audits; payments
for ineligible recipients; payments for ineligible, non-covered or unauthorized services; duplicate
payments; payments for services that were not provided or received; payments for unbundled
services when an all-inclusive bundled code should have been billed; payments not in accordance
with applicable pricing or rates; data entry errors resulting in incorrect payments; payments where
the incorrect procedure code was billed (up-coding); payments over Medicaid allowable amounts;
payments for non-medically necessary services; payments where an incorrect number of units were
billed; submittal of claims for unauthorized visits; and payments that cannot be substantiated by
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appropriate or sufficient medical or service record documentation. Improper payments can also be
classified as fraud and/or abuse.
3302.5 KICKBACKS
The offering or receiving of any payments or incentives by/from a provider for referring patients,
including illegal cash reimbursements, vacations, merchandise or personal services. (NRS
422.560)
3302.6 OVERPAYMENT/UNDERPAYMENT
This is an amount paid by the DHCFP, to a provider, which is in excess of or less than the amount
that is allowable for services furnished under applicable policy, rate or regulation.
3302.7 PERM REVIEW ERRORS
These are payment errors discovered during the course of PERM medical record, processing or
eligibility reviews.
3302.8 RECOUPMENT/RECOVERY
Recoupment or recovery is an administrative action by the DHCFP or its fiscal agent to initiate re-
payment of an overpayment, with or without advance official notice. Recoupment or recovery can
be made by reducing future payments to a provider or by direct reimbursement from the provider.
3302.9 UNBUNDLING
Unbundling is the billing of separate procedure codes rather than one all-inclusive code when an
all-inclusive code is required to be billed.
3302.10 UP-CODING
Up-coding is billing using procedure codes that overstate the level or amount of health care or
other service provided.
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3303 POLICY
3303.1 IDENTIFICATION OF FRAUD, ABUSE AND IMPROPER PAYMENTS
The DHCFP has methods and criteria to identify and track suspected cases of fraud, abuse and/or
improper payments. These methods or criteria must not infringe on the legal rights of persons
involved; must afford due process of law; and must comply with federal law and state statutes.
3303.1A COVERAGE AND LIMITATIONS
1. The following activities are the responsibility of the DHCFP:
a. Conduct regular investigations or reviews of claims or other payments to determine
if improper payments have been made or fraud and/or abuse has occurred;
b. Investigate and track referrals from all sources;
c. Refer suspected fraud and abuse cases to the MFCU in accordance with the
Memorandum Of Understanding (MOU) between the DHCFP and the MFCU and
state statutes;
d. Request and/or monitor provider self-audits;
e. Assist the DHCFP administrative staff, as necessary, in clarification or revision of
Medicaid and Nevada Check Up policies to aid in preventing or reducing fraud,
abuse and/or improper payments;
f. Assist with assuring Medicaid recipients receive necessary health or other care
services at an appropriate level and quality;
g. Process and track recoupment or recovery of improper payments or improperly paid
claims;
h. Educate providers about the requirements related to provision of service
documentation mandated by the PERM program;
i. Assist in providing education to providers on proper billing practices;
j. Assist in assuring provider compliance with the DHCFP program policy, MSM,
Medicaid Operations Manual (MOM), provider billing manuals and federal law and
state statutes;
k. Develop and maintain methodologies to verify services reimbursed by the DHCFP
were actually furnished to recipients. The DHCFP fiscal agent sends out
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approximately 500 notices each month to a random sample of Medicaid and Nevada
Check Up recipients receiving services. This is the Verification of Service (VOS)
program. Recipients are asked to notify the DHCFP if the services listed were not
received. All recipient responses received by the DHCFP are reviewed and if
warranted, investigations are conducted;
l. Take all necessary steps to ensure the fiscal integrity and effectiveness of the
programs administered by the DHCFP.
2. Fraudulent acts, false claims or abusive billing practices include, but are not limited to:
a. Knowingly and designedly, by any false pretense, false or misleading statement,
impersonation or misrepresentation, obtain or attempt to obtain authorization to
furnish services, receive payment for services, receive public assistance, money,
property or medical care;
b. Submitting a claim or causing a claim to be submitted knowing the claim to be
false, in whole or in part, by commission or omission;
c. Make or cause to be made a statement or representation for use in obtaining or
seeking to obtain authorization to provide specific goods or services, knowing the
statement or representation to be false, in whole or in part, by commission or
omission;
d. Make or cause to be made a statement or representation for use by another in
obtaining goods or services pursuant to the state plan, knowing the statement or
representation to be false, in whole or in part, by commission or omission;
e. Make or cause to be made a statement or representation for use in qualifying as a
provider, knowing the statement or representation to be false, in whole or in part,
by commission or omission;
f. Concealing or failing to disclose knowledge affecting the initial or continued right
to any payment or to secure such payment either in greater quantity than is due or
when no such payment is authorized or due;
g. Converting part or all of any payment intended for another person to
himself/herself;
h. Soliciting, receiving, offer or pay any remuneration (including any kickback, bribe
or rebate) directly or indirectly, overtly or covertly, in cash or in kind, in return for
or to induce any person to make:
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1. Referral of an individual to a provider;
2. Purchase, lease, order, arrange for or recommend the purchase, lease or
order of any item, service, good or facility for which payment may be made,
in whole or part, under the programs operated by the DHCFP;
3. Submit or cause to be submitted bills or requests for payment containing
charges or costs that are substantially in excess of customary charges or
costs;
i. Submit a false application for provider status;
j. Submitting false information to obtain compensation for services, supplies or
equipment the provider is not entitled to from the programs operated by the
DHCFP;
k. Submitting repeated claims for services that are not reimbursable by the DHCFP;
l. Submitting repeated claims from which required information is missing or
incorrect;
m. Violating any provision in the DHCFP provider agreement (contract between the
DHCFP and the provider);
n. Acts which result in termination, suspension or exclusion of the provider from other
governmental programs;
o. Any acts which violate professional conduct standards adopted by state medical
licensure boards and other medical professional organizations;
p. Submitting a duplicate claim for services or items for which the provider has
already received or claimed reimbursement from a source;
q. Submitting a claim for services or items which were not rendered by the provider
or were not rendered to an eligible recipient;
r. Submitting a claim for services or items which includes costs or charges which are
not related to the cost of the services or items;
s. Except in emergency situations, dispensing, rendering or providing a service or
items without a practitioner’s written order and the consent of the recipient;
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t. Submitting a claim which misrepresents the description of the services, supplies or
equipment dispensed or provided, the date of service, the identity of the recipient
or of the attending, prescribing, referring or actual provider;
u. Submitting a claim for medically unnecessary services;
v. Coercion of recipients to sign Verification of Service forms for services not
provided;
w. Reporting or billing for hours or services when services were not provided to the
extent reported or billed;
x. False statements include, but are not limited to:
1. Falsification of medical records;
2. Submitting a bill for a service not provided;
3. Up-coding;
4. Unbundling;
5. Business, fiscal or medical practices which result in unnecessary costs to
the programs operated by the DHCFP;
6. Duplicate billing for services, supplies or equipment;
7. Providing medical care, services or equipment which are not medically
necessary or which fail to meet professionally recognized standards for
health care; and/or
8. Failure to develop and maintain health service records as required by NRS
422.570 and the DHCFP policy.
3. Confidentiality of information.
a. All material gathered during an inquiry of fraud, abuse or improper payment will
only be used for the purpose for which it was gathered and will not be distributed
to any individual(s) or organization(s), with the exception of MFCU and/or the
Office of the Inspector General, the CMS or their sub-contractors.
b. Any information obtained by the DHCFP or the MFCU in an investigation of a
provider of services under the State Plan for Medicaid is confidential unless it is
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used as evidence at a hearing to enforce the provisions of NRS 422.450 to 422.590
or to review an action by the DHCFP against a provider.
c. Release of information or evidence is done in compliance with published
confidentiality and privacy law, rules and regulations. Materials collected by the
DHCFP may be of an extremely sensitive nature. All such materials are kept secure.
d. The identity of any person reporting fraud, abuse or improper payments is not
disclosed unless mandated by court order or the person agrees to the disclosure of
their identity.
The identity of any recipient or applicant receiving assistance is always kept
confidential unless disclosure is authorized by the recipient or legally responsible
adult.
e. The DHCFP is a covered entity, as defined by the Health Insurance Portability and
Accountability Act (HIPAA) regulations (45 CFR Parts 160, 162 and 164), and as
such, must comply with all aspects of this federal regulation.
3303.1B PROVIDER RESPONSIBILITY
1. Providers have an obligation to report to the DHCFP any suspicion of fraud or abuse in the
DHCFP programs, including fraud or abuse associated with recipients or other providers.
2. Providers must adhere to:
a. The DHCFP policy;
b. Provider services and operations manuals;
c. Fiscal agent billing manuals;
d. All applicable federal law and state statutes; and
e. Any other guidance furnished by the DHCFP or their fiscal agent regarding
provider requirements and responsibilities.
3303.1C RECIPIENT RESPONSIBILITY
Recipients have an obligation to report to the DHCFP any suspicion of fraud, abuse or improper
payment in the DHCFP programs or concerning the DHCFP recipients or providers.
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3303.2 INVESTIGATIONS OF FRAUD, ABUSE OR IMPROPER PAYMENTS
The DHCFP conducts investigations of all suspected cases of fraud, abuse or improper payments.
Investigations continue until an appropriate action is taken or the case is closed.
PERM reviews are done in accordance with the requirements mandated by CMS. PERM reviews
are completed by CMS or their sub-contractors every three years starting in FY 2008.
Financial and Policy Compliance audits are performed regularly by the DHCFP and follow the
standards and guidelines developed by CMS for the PERM reviews.
Suspected fraud or abuse discovered during the course of a PERM review or a Financial and Policy
Compliance Audit will be referred to the MFCU for further investigation or action.
3303.2A COVERAGE AND LIMITATIONS
1. An investigation or review is initiated by the DHCFP when questionable practices are
identified or the DHCFP receives complaints of suspected fraud, abuse or improper
payments.
2. An investigation consists of a thorough review of the complaint or questionable practice
and may include: An analysis of the paid claims; review of provider and recipient reports;
review of policy and billing manuals; review of applicable rates; review of medical or other
service record documentation; and review of appropriate federal law and state statutes.
3. The MFCU of the Attorney General’s Office is the single state agency responsible for the
investigation and prosecution of violations of NRS 422.540 to 422.570, inclusive (NRS
228.410). All suspected cases of provider fraud and/or abuse are referred to the MFCU in
accordance with the MOU between the DHCFP and the MFCU.
4. PERM reviews consist of an analysis of randomly sampled Fee-for-Service (FFS) and
managed care claims or line items.
a. FFS claims or line items will undergo a medical record or service documentation
review and a claims processing review.
1. At a minimum, the following items will be considered PERM Review
Errors resulting from medical reviews:
a. No documentation or insufficient documentation provided within
specified timeframes to support the service billed and paid by the
DHCFP.
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b. Claim billed with incorrect procedure code.
c. Provider billed separate procedure codes when a bundled procedure
code should have been used.
d. The number of units billed was incorrect.
e. Service was medically unnecessary.
f. Service or procedure was not in agreement with documented policy.
2. At a minimum, the following items will be considered PERM Review
Errors resulting from processing reviews:
a. Duplicate claims billed for same service, same recipient and same
date of service.
b. Claim paid for a non-covered service.
c. FFS claim paid although the recipient was enrolled in managed care.
d. Incorrect rate was used to pay the claim.
e. Logical edit issues (e.g. gender and procedure code are
incompatible).
f. Data entry errors.
b. Managed care payments will undergo a claims processing review only. The
managed care claims reviewed will include monthly capitation payments and
condition specific payments such as maternity payments and re-insurance
payments. At a minimum, the following items will be considered PERM Review
Errors resulting from managed care reviews:
1. Recipient not eligible for enrollment in a Health Maintenance Organization
(HMO).
2. Recipient not enrolled in the HMO that received the capitation or other
payment.
3. Incorrect capitation or other payment – either the wrong rate cell was used
to pay the claim or the rate was not consistent with the rate in the HMO
contract.
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5. Financial and Policy Compliance Audits may utilize random sampling techniques or may
target specific provider types, procedures or services. These audits will utilize the
guidelines for PERM reviews addressed in 4. of Section 3303.2A above.
3303.2B PROVIDER RESPONSIBILITY
1. Providers are bound by both federal and state statutes and regulations, the DHCFP policy
and the DHCFP provider agreement to cooperate and provide any and all documentation
(e.g., medical records, charts, billing information and any other documentation) requested
by the DHCFP or other state and/or federal officials or their authorized agents for the
purpose of determining the validity of claims and the reasonableness and necessity of all
services billed to and paid by the DHCFP.
2. The DHCFP providers are required to keep records sufficient and necessary to establish
medical necessity and to fully disclose the basis for the type, extent and level of the services
provided to recipients. All services billed to and paid by the DHCFP which cannot be
validated by appropriate documentation are subject to recovery.
3. Requested documentation must be provided within timeframes specified by the DHCFP or
other state or federal officials.
4. Records, documentation and information must be available regarding any service for which
payment has been or will be claimed to determine if payment has or will be made in
accordance with applicable federal and state requirements.
5. Providers must make all documentation requested by the DHCFP readily available for
review by state and/or federal officials or their authorized agents. Readily available means
the records shall be made available at the provider’s place of business or, upon written
request, forwarded without charge to the state or federal official requesting the
documentation.
6. For medical record requests associated with the DHCFP audits or investigations, providers
are required to submit documentation to support the claims under review within 15 calendar
days after receipt of a letter from the DHCFP requesting such information.
7. For medical record requests associated with the mandated federal PERM reviews,
providers are required to submit documentation to support the claim or line item under
review within the timeframes specified in the PERM Final Rule (released in the Federal
Register on August 31, 2007) or any subsequent policy instruction issued by CMS.
8. All records subject to audit or review must be produced at no cost to the DHCFP.
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9. Providers must adhere to both federal and state statutes and regulations and the DHCFP
policy concerning the appropriate and adequate documentation of services billed to the
DHCFP.
10. Providers are required to keep patient records that adhere to basic standards of practice and
in accordance with the DHCFP operations or services manuals and state and federal statutes
and regulations.
11. Providers must retain patient records in accordance with state and or federal statutes and
regulations or at a minimum for six years from the date of payment for the specified service.
3303.3 ADMINISTRATIVE ACTIONS AND CIVIL AND CRIMINAL PENALTIES
The DHCFP is required and authorized to review identified cases of suspected fraud, abuse and
improper payments and impose appropriate actions upon offending parties. The DHCFP is able to
impose a variety of Administrative Actions including referral to the MFCU at the Attorney
General’s Office. The MFCU has the authority to impose civil monetary and other penalties as
well as criminally prosecute offenders.
In determining the appropriate action(s) to recommend in a fraud, abuse or improper payment
situation, the following will be considered:
A. Recommendations of the MFCU;
B. Action(s) necessary to eliminate fraud or abuse and to recover payments related to the
fraud, abuse or improper payment;
C. Seriousness of the offense(s);
D. Number of current and past violations;
E. Provider’s willingness to cooperate;
F. Past sanctions applied; and
G. Other available services in the area.
3303.3A COVERAGE AND LIMITATIONS
1. Administrative Actions. The DHCFP is authorized to take Administrative Actions to
ensure compliance with program policies, state statutes and federal laws and regulations.
2. In response to the discovery of fraud, abuse or improper payments in the Medicaid and
Nevada Check Up programs, the DHCFP may initiate more than one Administrative Action
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at one time, if warranted (e.g. issuance of a recoupment/recovery letter and request a
corrective action plan). The types of Administrative Actions that may be taken by the
DHCFP are as follows:
a. Issuance of educational letters. The DHCFP or the DHCFP fiscal agent may issue
an educational letter to a provider if the results of an investigation indicate the
provider was only in need of policy or billing clarification and an improper payment
did not occur. This action is used primarily when minor billing errors are detected.
The provider Fair Hearing process is not available to dispute an educational letter.
b. Issuance of warning letters. The DHCFP may issue a warning letter to a provider if
the provider has taken an action which violates or is not in accordance with policy,
state statutes, federal laws or regulations or the terms of the provider contract with
the DHCFP. Warning letters will be sent by certified mail with a return receipt
requested. Warning letters are to assist the provider in rectifying improper billing
practices and will give notice to the provider that continuation of the activity in
question will result in further action. Warning letters may request submittal of
sufficient and appropriate documentation to substantiate claims billed to and paid
by the DHCFP. Failure of providers to submit appropriate documentation within
timeframes specified by the DHCFP in a warning letter may result in payment
recoupments/recovery without additional notice. The provider Fair Hearing process
is not available to dispute a warning letter.
c. Issuance of recoupment/recovery letters. The DHCFP may issue a
recoupment/recovery letter to a provider if the results of an investigation indicate
the provider was improperly paid for one or more services. A recoupment/recovery
letter may also be sent after a provider fails to submit sufficient and appropriate
documentation within the timeframes requested in a warning letter.
Recoupment/recovery letters will be sent by certified mail with a return receipt
requested. The letter will notify the provider of the nature of the improper payment,
the amount to be recovered and the method of repayment. The provider Fair
Hearing process is available to dispute recoupment/recovery letters unless the
recoupment/recovery letter was the result of the provider’s failure to provide
sufficient and necessary information to establish medical necessity and to fully
disclose the basis for the type, extent and level of services provided within the
timeframes indicated in the letter that requested such information; or the provider’s
failure to provide sufficient and appropriate documentation within specified
timeframes for the mandated federal PERM reviews.
d. Recovery of improper payments. The DHCFP may recover improper payments
with or without prior notice to the provider. All improper payments discovered may
be recovered by the DHCFP. If documentation sufficient to support the amount
billed to or paid by the DHCFP is not provided within the timeframes specified by
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the DHCFP, the associated payments for the service are subject to recovery. All
improper payments discovered during the course of mandated federal PERM
reviews are subject to recovery.
e. Special claims reviews or on-site audits. The DHCFP can perform special claims
reviews or on-site audits of any provider billing claims for Medicaid or Nevada
Check Up programs. The reviews or audits can be conducted with or without prior
notice to the provider under review. The provider Fair Hearing process is not
available to dispute special claims reviews or on-site audits.
f. Corrective Action Plan. After the DHCFP conducts an investigation or audit and
determines improper payments have been made, the DHCFP may require the
provider to complete a Corrective Action Plan (CAP), specifying how, as well as
when, the provider expects to achieve compliance. The provider Fair Hearing
process is not available to dispute requests for Corrective Action Plans.
g. Provider self audits. The DHCFP may request a provider or group of providers to
perform self audits. This action can be taken with or without the discovery of
improper payments, or fraud or abusive billing practices. The DHCFP will accept
reimbursement for improper payments, discovered during provider self audits,
without penalty, if the improper payment was disclosed voluntarily by the provider
and the acts that led to the improper payment were not the result of fraudulent
conduct on the part of the provider, its employees or agents. Provider self audits do
not relieve the provider of any liability for civil or criminal action by the MFCU, if
improper payments were the result of fraud or fraudulent acts. The provider Fair
Hearing process is not available to dispute requests for provider self audits.
h. Referrals to appropriate civil agencies (licensing bodies). If the DHCFP discovers
licensing or other regulatory violations while conducting an investigation or audit,
the DHCFP may make referrals to appropriate licensing or governing entities, such
as the Nevada Bureau of Licensure and Certification, the federal Office of the
Inspector General, the federal Office of Civil Rights or other such governing
entities. The provider Fair Hearing process is not available to dispute referrals to
civil agencies or licensing bodies.
i. Referrals to the MFCU. The DHCFP is required to refer all suspected cases of fraud
and abuse to the MFCU. Providers are never notified about this action.
j. Denials of provider applications. Providers may be denied DHCFP provider status
if they are found to be out of compliance with policy, state and/or federal
regulations or the terms of the provider contract with the DHCFP. Refer to Chapter
100 of the Medicaid Services Manual for further information.
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k. Suspension and termination of provider status. Termination, lock-out suspension,
exclusion, non-renewal of the DHCFP provider status are possible actions applied
to providers found to be out of compliance with policy, state and/or federal
regulations, the terms of the provider contract with the DHCFP, or who commit
fraud. Refer to Chapter 100 of the Medicaid Services Manual for further
information.
l. Other action. The DHCFP may impose special requirements on providers as a
condition of participation. The provider Fair Hearing process is not available to
dispute the other actions. The other actions include, but are not limited to:
1. Requirement for all services to be prior authorized to be eligible for
reimbursement; and/or
2. Requirement for provider to submit all records or documentation to support
the services billed prior to payment.
3. Any administrative action taken by the DHCFP does not eliminate any civil or criminal
liability from the provider.
4. Payment suspensions to the provider. The DHCFP may implement a payment suspension
and withhold payments to the provider, in whole or in part, upon determining there is a
credible allegation of fraud or willful misrepresentation under the Medicaid or Nevada
Check Up programs. The DHCFP may suspend payment without first notifying the
provider. The DHCFP will send notice to the provider in accordance with 42 CFR 455.23.
The notice to the provider will:
a. Set forth the general allegations as to the nature of the payment suspension action,
but need not disclose any specific information concerning an ongoing investigation;
b. State that the payment suspension is for a temporary period;
c. Cite the circumstances under which the payment suspension will be terminated;
d. Specify, when applicable, to which type or types of Medicaid claims or business
units of a provider are subject to the payment suspension;
e. Inform the provider of the right to submit written evidence for consideration by the
DHCFP;
f. Set forth the applicable State administrative appeals process and corresponding
citations to State law; and
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g. Cite that payments are being withheld in accordance with 42 CFR 455.23.
5. Repayment Requirements. The DHCFP will determine the repayment method for all
overpayments or improper payments to providers. Repayment can be made by either direct
reimbursement by the provider or the provider may be allowed to make repayment through
deductions from future payments. To be acceptable, repayment through reductions to future
payments or direct reimbursement must ensure the total overpayment amount will be repaid
to the DHCFP within 60 days from the date the provider was first notified of the improper
payment, as required by Section 1903(d)(2)(c) of the SSA. The provider’s request for a
Fair Hearing does not suspend the provider’s obligation to repay the amount of the
overpayment.
6. Statute of Limitations. Erroneous billing resulting in a benefit overpayment violates the
provider contract and brings the issue within the authority of NRS 11.190 Actions Other
Than for the Recovery of Real Property. NRS 11.190.1 states: “Within 6 years: 1(b) an
action upon a contract, obligation or liability founded upon an instrument in writing, except
those mentioned in the preceding sections of this chapter.” This statute gives the DHCFP
the authority that unless limited by a specific statute, a recovery action may be commenced
within a six year period. Additionally, 31 USC 235-Limitation of Suit provides “Every
such civil suit shall be commenced within six years from the commission of the act and not
afterward.”
7. Civil Monetary and Criminal Penalties
The SSA and the NRS identify certain activities as misdemeanors or felonies and provide
for fines and/or imprisonment upon conviction.
a. The MFCU of the Nevada Attorney General’s Office can assess civil monetary
penalties and criminally prosecute violations of NRS 422.540 to 422.570, inclusive.
This includes offenses regarding: false claims; mis-statements or mis-
representations; and sale, purchase or lease of goods, service materials or supplies
associated with payments under the State Plan for Medicaid or the SCHIP (Nevada
Check Up). Providers can be liable at both the state and federal level and prosecuted
by both. Additionally, the provider may be excluded from state and federal health
care programs based on a conviction.
b. State civil monetary penalties are not less than $5,000 and can equal three times the
amount unlawfully obtained in addition to expenses incurred by the State for
investigation activities.
c. State criminal penalties, in addition to the civil monetary penalties, range from a
gross misdemeanor punishable by imprisonment in the county jail for not more than
September 25, 2007 PROGRAM INTEGRITY Section 3303 Page 13
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
one year to a Class D felony punishable by 1 – 4 years in a State prison. (NRS
193.130 to 193.140)
d. In addition to State penalties, there are federal penalties associated with false or
fraudulent acts involving federal health care programs. Civil monetary and criminal
penalties are sought by the Department of Justice (DOJ) according to Section
1128A and Section 1128B of the SSA. Providers who are convicted by a federal
court of willfully defrauding the Medicaid or Nevada Check Up program may be
subject to a $25,000 fine or up to five years imprisonment or both.
e. Any action brought pursuant to NRS 422.540 through 422.580, inclusive, must be
commenced within four years of discovery by the aggrieved party.
September 25, 2007 PROGRAM INTEGRITY Section 3303 Page 14
MTL 07/07
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3304
Subject:
MEDICAID SERVICES MANUAL REFERENCES AND CROSS
REFERENCES
3304 REFERENCES AND CROSS REFERENCES
3304.1 FRAUD, ABUSE OR IMPROPER PAYMENT REFERRALS
A. To report alleged fraud, abuse or improper payment to the DHCFP contact:
Phone: (775) 684-3648
Fax: (775) 684-3643
E-Mail: [email protected]
Mail: Division of Health Care Financing and Policy
Program Integrity Unit
1100 E. William St., Suite 102
Carson City, NV 89701
Provide as much identifying information as possible. Include: provider name, address,
phone number and details regarding the allegation or nature of the referral. Explain the
basics of who, what, when, where, why and how. Include your name and phone number
unless you wish to remain anonymous when calling or writing.
The DHCFP will not provide any information regarding actions taken by the DHCFP or
others on any allegations reported, even to the person making the referral or allegation.
Once the allegation is received, there will be no further communication with the person
making the referral.
B. To Report Medicaid Fraud or Abuse to the Medicaid Fraud Unit in the Attorney’s Office:
Phone: (800) 266-8688
Mail: MFCU
100 N. Carson St.
Carson City, NV 89701-4717
C. To report fraud in all federal health care programs, including Medicare, Medicaid and
Nevada Check Up contact the Office of Inspector General:
Phone: (800) 447-8477
Fax: (800) 223-8164
TTY: (800) 377-4950
E-Mail: [email protected]
By Mail: Office of the Inspector General, DHHS
Attn: HOTLINE
330 Independence Ave., S.W.
Washington, DC 20201
May 8, 2007 PROGRAM INTEGRITY Section 3304 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL REFERENCES AND CROSS
REFERENCES
The following is the link to the Office of Inspector General (OIG) Hotline website, where
there is more information regarding how to make alleged fraud and abuse referrals:
http://oig.hhs.gov/hotline.html
3304.2 POLICY REFERENCES
1. For policy information governing services covered under Medicaid and Nevada Check Up
programs consult the MSMs located on the DHCFP Website: http://www.dhcfp.nv.gov
2. For billing manuals, web announcements and other information governing services
covered under Medicaid and Nevada Check Up programs consult the DHCFP fiscal agent
Website: https://nevada.fhsc.com/
3304.3 OTHER CONTACTS
A. DHCFP Fiscal Agent
Provider Enrollment Issues: Provider Claims Issues:
First Health Services First Health Services
Provider Enrollment Claims
PO Box 300412 PO Box 30042
Reno NV 89520-30412 Reno NV 89520-3042
B. DHCFP Administration Office
1100 E. Williams Street, Suite 102
Carson City, NV 89703
Telephone: (775) 684-3600
Toll free (800) 992-0900 Extension 3600
May 8, 2007 PROGRAM INTEGRITY Section 3304 Page 2
MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
July 26, 2017
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: LYNNE FOSTER, CHIEF OF DIVISION COMPLIANCE
SUBJECT: MEDICAID SERVICES MANUAL CHANGES
CHAPTER 3400 – TELEHEALTH SERVICES
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 3400, Telehealth Services, are being
proposed for language change to clarify the telehealth originating site. If the originating site is not
enrolled in Medicaid, the site is not eligible for a facility fee from the Division of Health Care
Financing and Policy (DHCFP).
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: Outpatient Surgery (Provider Type (PT) 10), Hospital, Inpatient (PT
11), Hospital, Outpatient (PT 12), Psychiatric Hospital, Inpatient (PT 13), Behavioral Health
Outpatient Treatment (PT 14), Special Clinics (PT 17), Nursing Facility (PT 19), Physician, M.D.,
Osteopath, D.O. (PT 20), Podiatrist (PT 21), Dentist (PT 22), Advanced Registered Nurses (PT
24), Optometrist (PT 25), Psychologist (PT 26), Radiology & Noninvasive Diagnostic Centers (PT
27), Home Health Agency (HHA) (PT 29), Personal Care Aide (PCA) (PT 30), Ambulance, Air
or Ground (PT 32), Durable Medical Equipment (DME) (PT 33), Therapy (PT 34), Chiropractor
(PT 36), Home & Community Based Waiver – Waiver for Individuals with Intellectual Disabilities
and Related Conditions (ID) (PT 38), Adult Day Health Center (PT 39), Primary Care Case
Management Services (PT 40), Optician, Optical Business (PT 41), Outpatient Psychiatric
Hospital Private and Community Health Center (PT 42), Laboratory Pathology/Clinical (PT 43),
Swing Bed Acute Hospital (PT 44), End Stage Renal Disease (ESRD) Facility (PT 45),
Ambulatory Surgical Centers (ASC) (PT 46), Indian Health Programs (IHP) and Tribal Clinics
(PT 47), Home and Community Based Waiver for the Frail Elderly (PT 48), Indian Health Program
Hospital Inpatient (PT 51), Indian Health Program Hospital Outpatient (PT 52), Transitional
Rehabilitative Center, Outpatient (PT 55), Rehabilitation, Specialty and Long Term Acute Care
Hospital (PT 56), Elderly in Adult Residential Care Waiver (PT 57), Waiver for People with
Physical Disabilities (PT 58), Home and Community Based Assisted Living Waiver (PT 59),
School Based (PT 60), Health Maintenance Organizations (HMO) (PT 62), Residential Treatment
Center (RTC) (PT 63), Hospice (PT 64), Hospice Long Term Care (PT 65), Intermediate Care
Facilities for Individuals with Intellectual Disabilities/Private (PT 68), Nurse Anesthetist (PT 72),
Nurse Midwife (PT 74), Critical Access Hospital Inpatient (PT 75), Audiologist (PT 76), and
Page 1 of 2
Physician's Assistant (PT 77), Indian Health Program (IHP) Hospital Inpatient (Non-Tribal) (PT
78), IHP Hospital Outpatient (Non-Tribal) (PT 79), IHP Travel (Non-Tribal) (PT 80), Behavioral
Health Rehabilitative Treatment (PT 82) and Personal Care Aide (PCA) - Intermediary Service
Organization (PT 83).
There will be no financial impact on local government.
These changes are effective July 27, 2017.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL 16/17 MTL 30/15, 22/16
TELEHEALTH SERVICES TELEHEALTH SERVICES
Background and Explanation of Policy Changes,
Manual Section Section Title Clarifications and Updates
3403.1 Telehealth Capitalization correction in Section A with language
Originating Site revision in Section B, removing "without an enrolled
Medicaid provider onsite," adding, an originating site
"not enrolled in Medicaid," punctuation correction in
Section C, and removal of the word "then."
Page 2 of2
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
TELEHEALTH SERVICES
3400 INTRODUCTION ...........................................................................................................................1
3401 AUTHORITY ..................................................................................................................................1
3402 RESERVED .....................................................................................................................................1
3403 TELEHEALTH POLICY ................................................................................................................1
3403.1 TELEHEALTH ORIGINATING SITE ...........................................................................................1
3403.2 TELEHEALTH DISTANT SITE ....................................................................................................2
3403.3 SYNCHRONOUS TELEHEALTH SERVICES .............................................................................2
3403.4 ASYNCHRONOUS TELEHEALTH SERVICES ..........................................................................2
3403.5 COVERAGE AND LIMITATIONS ...............................................................................................2
3403.6 NON-COVERED SERVICES .........................................................................................................3
3403.7 PRIOR AUTHORIZATION ............................................................................................................4
3403.8 HEARINGS .....................................................................................................................................4
1
MTL 30/15
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3400
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
3400 INTRODUCTION
Telehealth is the use of a telecommunications system to substitute for an in-person encounter for
professional consultations, office visits, office psychiatry services and a limited number of other
medical services.
All providers participating in the Medicaid and Nevada Check Up (NCU) programs must offer
services in accordance with the rules and regulations of the Division of Health Care Financing and
Policy (DHCFP).
Telehealth services are an optional benefit within the DHCFP.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for NCU.
For further clarification, please refer to the NCU Manual, Chapter 1000.
December 1, 2015 TELEHEALTH SERVICES Section 3400 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL AUTHORITY
3401 AUTHORITY
The State Legislature grants authority to the relevant professional licensure boards to set the
standard of practice for licensed professionals in the Nevada Revised Statutes (NRS) for the
following specialists:
A. NRS – Chapter 449-Hospitals;
B. NRS – Chapter 629-Healing Arts Generally;
C. NRS – Chapter 630-Physicians and Physician Assistants;
D. NRS – Chapter 632-Nursing;
E. NRS – Chapter 633-Osteopathic Medicine; and
F. NRS – Chapter 641-Psychologists, Social Workers.
December 1, 2015 TELEHEALTH SERVICES Section 3401 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL RESERVED
3402 RESERVED
December 1, 2015 TELEHEALTH SERVICES Section 3402 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3403
Subject:
MEDICAID SERVICES MANUAL POLICY
3403 TELEHEALTH POLICY
The DHCFP reimburses for telehealth services. The originating site must be located within the
state. "Telehealth" is defined as the delivery of service from a provider of health care to a patient
at a different location through the use of information and audio-visual communication technology,
not including standard telephone, facsimile or electronic mail. Services provided via telehealth
must be clinically appropriate and within the health care professional's scope of practice as
established by its licensing agency. Services provided via telehealth have parity with in-person
health care services. Health care professionals must follow the appropriate Medicaid Services
Manual (MSM) policy for the specific service they are providing.
A. Photographs must be specific to the patient’s condition and adequate for rendering or
confirming a diagnosis or a treatment plan. Dermatologic photographs (e.g., photographs
of a skin lesion) may be considered to meet the requirement of a single media format under
this instruction.
B. Reimbursement for the DHCFP covered telehealth services must satisfy federal
requirements of efficiency, economy and quality of care.
C. All participating providers must adhere to requirements of the Health Insurance Portability
and Accountability Act (HIPAA). The DHCFP may not participate in any medium not
deemed appropriate for protected health information by the DHCFP’s HIPAA Security
Officer.
3403.1 TELEHEALTH ORIGINATING SITE
The originating site is defined as the location where a patient is receiving telehealth services from
a provider of health care located at a distant site (via a HIPAA-compliant telecommunications
system).
A. In order to receive coverage for a telehealth facility fee, the originating site must be an
enrolled Medicaid provider.
B. If a patient is receiving telehealth services at an originating site not enrolled in Medicaid,
the originating site is not eligible for a facility fee from the DHCFP. Examples of this
include, but are not limited to, cellular devices, home computers, kiosks and tablets.
C. Facilities that are eligible for encounter reimbursement (e.g. Indian Health (IH) programs,
Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs)) may bill for
an encounter in lieu of an originating site facility fee, if the distant site is for ancillary
services (i.e. consult with specialist). If, for example, the originating site and distant site
are two different encounter sites, the originating encounter site must bill the telehealth
July 27, 2017 TELEHEALTH SERVICES Section 3403 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
originating HCFA Common Procedural Coding System (HCPCS) code and the distant
encounter site may bill the encounter code.
3403.2 TELEHEALTH DISTANT SITE
The distant site is defined as the location where a provider of health care is providing telehealth
services to a patient located at an originating site. The distant site provider must be an enrolled
Medicaid provider.
3403.3 SYNCHRONOUS TELEHEALTH SERVICES
Synchronous telehealth interactions are defined as real-time interactions between a recipient
located at an originating site and a health care provider located at a distant site. A provider has
direct visualization of the patient.
3403.4 ASYNCHRONOUS TELEHEALTH SERVICES
Asynchronous telehealth services, also known as Store-and-Forward, are defined as the
transmission of a patient’s medical information from an originating site to the health care provider
distant site without the presence of the recipient. The DHCFP reimburses for services delivered
via asynchronous telehealth, however, these services are not eligible for originating site facility
fees.
3403.5 COVERAGE AND LIMITATIONS
The following coverage and limitations pertain to telehealth services:
A. The medical examination of the patient is under the control of the health care professional
at the distant site.
B. While the distant physician or provider may request a telepresenter, a telepresenter is not
required as a condition of reimbursement.
C. Licensed Clinical Psychologist (LCP), Licensed Clinical Social Worker (LCSW) and
clinical staff employed and determined by a state mental health agency to meet established
class specification qualifications of a Mental Health Counselor, Clinical Social Worker or
Psychological Assistant may bill and receive reimbursement for psychotherapy (via a
HIPAA-compliant telecommunication system), but may not seek reimbursement for
medical evaluation and management services. Refer to MSM Chapter 400, Mental Health
and Alcohol and Substance Abuse Services, for medical coverage requirements.
September 8, 2016 TELEHEALTH SERVICES Section 3403 Page 2
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Subject:
MEDICAID SERVICES MANUAL POLICY
D. End Stage Renal Disease (ESRD)
1. ESRD visits must include at least one in-person visit to examine the vascular access
site by a provider; however, an interactive audio/video telecommunications system
may be used for providing additional visits.
2. Medical records must indicate that at least one of the visits was furnished in-person
by a provider. Refer to MSM Chapter 600, Physician Services, for medical
coverage requirements.
3403.6 NON-COVERED SERVICES
A. Telephone calls;
B. Images transmitted via facsimile machines (faxes);
C. Text messages;
D. Electronic mail (email); and
E. The following services must be provided in-person and are not considered appropriate
services to be provided via telehealth:
1. Basic skills training and peer-to-peer services provided by a Qualified Behavioral
Assistant (QBA) as identified in provider qualifications found in MSM Chapter
400, Mental Health and Alcohol and Substance Abuse Services;
2. Personal care services provided by a Personal Care Attendant (PCA) as identified
in provider qualifications found in MSM Chapter 2600, Intermediary Service
Organization and MSM Chapter 3500, Personal Care Services;
3. Home Health Services provided by a Registered Nurse (RN), Physical Therapist
(PT), Occupational Therapist, Speech Therapist, Respiratory Therapist, Dietician
or Home Health Aide as identified in provider qualifications found in MSM
Chapter 1400, Home Health Agency (HHA); and
4. Private Duty Nursing services provided by an RN as identified in provider
qualifications found in MSM Chapter 900, Private Duty Nursing.
September 8, 2016 TELEHEALTH SERVICES Section 3403 Page 3
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3403
Subject:
MEDICAID SERVICES MANUAL POLICY
3403.7 PRIOR AUTHORIZATION
Telehealth services follow the same prior authorization requirements as services provided in
person. Utilization of telehealth services does not require prior authorization, however, individual
services delivered via telehealth may require prior authorization. It is the provider’s responsibility
to refer to the individual medical coverage policies through the MSM for coverage requirements.
3403.8 HEARINGS
Please reference MSM Chapter 3100, Hearings, for Medicaid recipient hearing procedure.
September 8, 2016 TELEHEALTH SERVICES Section 3403 Page 4
MEDICAID SERVICES MANUAL
TRANSMITTALLETTER
September 24, 2019
TO: CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM: TAMMY MOFFITT, CHIEF OF OPERATIONS
SUBJECT: MEDICAID SERVICES MANUAL CHANGES .
CHAPTER 3500-PERSONAL CARE SERVICES PROGRAM
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 3500- Personal Care Services Program
are being proposed to add language due to the passage of the 21st Century Cures Act. In December
2016, Congress passed H.R. 34-21st Century Cures Act, mandating that all States require the use
of an Electronic Visit Verification (EVV) system for all Medicaid-funded personal care services
(PCS) that are provided under a state plan or a waiver of the plan, including services provided
under Section 1915(c).
Throughout the chapter, grammar, punctuation and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity. Renumbering and
re-arranging of sections was necessary.
Entities Financially Affected: This proposed change affects all Medicaid-enrolled providers
delivering specific personal care services. Those provider types (PT) include but are not limited
to: Personal Care Services (PT 30).
Fina9fial Impact on Local Government: Unknown at this time.
These changes are effective September 25, 2019.
MATERIAL TRANSMITTED MATERIAL SUPERSEDED
MTL21/19 MTL20/16
MSM Ch 3500 - Personal Care Services MSM Ch 3500 - Personal Care Services
Program Program
Manual Section Section Title Background and Explanation of Policy
Changes,
Clarifications and Updates
3501 AUTHORITY Added 21st Century Cures Act mandate and H.R.
6042 - 115th Congress.
Pagel of3
DIVISION OF HEALTH CARE FINANCING AND POLICY
MEDICAID SERVICES MANUAL
TABLE OF CONTENTS
PERSONAL CARE SERVICES (PCS) PROGRAM
3500 INTRODUCTION ...............................................................................................................1
3501 AUTHORITY ......................................................................................................................1
3502 DEFINITIONS .....................................................................................................................1
3503 POLICY ...............................................................................................................................1
3503.1 PERSONAL CARE SERVICES (PCS)...............................................................................1
3503.1A ELIGIBILITY CRITERIA...................................................................................................1
3503.1B COVERAGE AND LIMITATIONS ...................................................................................2
3503.1C LEGALLY RESPONSIBLE INDIVIDUAL (LRI) .............................................................5
3503.1D PERSONAL CARE REPRESENTATIVE (PCR)...............................................................5
3503.1E AUTHORIZATION PROCESS ..........................................................................................6
3503.1F FLEXIBILITY OF SERVICES DELIVERY ....................................................................10
3503.1G ELECTRONIC VISIT VERIFICATION (EVV)...............................................................11
3503.1H CONFLICT OF INTEREST STANDARDS .....................................................................12
3503.1I PROVIDER RESPONSIBILITIES ...................................................................................13
3503.1J RECIPIENT RESPONSIBILITIES AND RIGHTS ..........................................................21
3503.2 PCS TO CHILDREN .........................................................................................................24
3503.3 PCS FOR RECIPIENTS ENROLLED IN HOSPICE .......................................................24
3503.4 SUPPORTED LIVING ARRANGEMENT (SLA) ...........................................................25
3503.5 ESCORT SERVICES ........................................................................................................25
3503.5A COVERAGE AND LIMITATIONS .................................................................................25
3503.5B AUTHORIZATION PROCESS ........................................................................................26
3503.5C PROVIDER RESPONSIBILITY.......................................................................................26
3503.6 TRANSPORTATION ........................................................................................................26
3503.7 REIMBURSSEMENT .......................................................................................................26
3503.8 IMPROPER BILLING PRACTICES ................................................................................27
3503.9 QUALITY ASSURANCE .................................................................................................28
3503.10 ADVERSE ACTIONS .......................................................................................................28
3504 HEARINGS .........................................................................................................................1
MTL 20/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3500
Subject:
MEDICAID SERVICES MANUAL INTRODUCTION
3500 INTRODUCTION
PERSONAL CARE SERVICES (PCS)
The objective of the PCS Program is to assist, support and maintain recipients living independently
in their homes. PCS include a range of human assistance provided to persons with disabilities and
chronic conditions of all ages, which enables accomplishment of tasks that they would normally
do for themselves if they did not have a disability or chronic condition. These services are provided
where appropriate, medically necessary and within service limitations. Services may be provided
in settings outside the home, including employment sites.
PCS are available to recipients who are not inpatients or residents of a hospital, Nursing Facility
(NF), Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or
institutions for mental disease or other excluded settings.
Nevada Medicaid offers two distinct PCS delivery models: The Provider Agency Model or the
Self-Directed Model.
This Medicaid Services Manual (MSM), Chapter 3500, contains Nevada Medicaid’s policy for PCS
provided through the Provider Agency service delivery model. For policy pertaining to the Self-
Directed service delivery model, refer to MSM Chapter 2600.
All providers must be contracted with the Division of Health Care Financing and Policy (DHCFP)
in accordance with MSM Chapter 100 and meet certain qualifications and criteria as discussed later
in this chapter.
All Medicaid policies and requirements (such as prior authorization, etc.) are the same for Nevada
Check Up (NCU), with the exception of the areas where Medicaid and NCU policies differ as
documented in the NCU Manual Chapter 1000.
September 8, 2016 PERSONAL CARE SERVICES PROGRAM Section 3500 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL AUTHORITY
3501 AUTHORITY
Personal Care Services (PCS) are an optional Medicaid benefit under the Social Security Act
(SSA).
Regulatory oversight:
SSA 1905(a) (24)
Title 42, Code of Federal Regulations (CFR), Section 440.167
Nevada State Plan Attachment 3.1-A (26)
21st Century Cures Act, H.R. 34, Section 12006 – 114th Congress
H.R. 6042 – 115th Congress
September 25, 2019 PERSONAL CARE SERVICES PROGRAM Section 3501 Page 1
MTL 20/16
Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3502
Subject:
MEDICAID SERVICES MANUAL DEFINITIONS
3502 DEFINITIONS
Program definitions can be found in the MSM Addendum.
September 8, 2016 PERSONAL CARE SERVICES PROGRAM Section 3502 Page 1
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
3503 POLICY
3503.1 PERSONAL CARE SERVICES (PCS)
PCS provide assistance to support and maintain recipients living independently in their homes.
Services may be provided in the home, locations outside the home or wherever the need for the
service occurs. Assistance may be in the form of direct hands-on assistance or cueing the individual
to perform the task themselves, and related to the performance of Activities of Daily Living
(ADLs) and Instrumental Activities of Daily Living (IADLs). Services are based on the needs of
the recipient being served, as determined by a Functional Assessment Service Plan (FASP)
approved by the Division of Health Care Financing and Policy (DHCFP). All services must be
performed in accordance with the approved service plan, must be prior authorized and documented
in an approved Electronic Visit Verification (EVV) system. The time authorized for services is
intended to meet the recipient needs within program limits and guidelines, facilitate effective and
efficient service delivery, and to augment unpaid and paid supports currently in place. Services are
not intended to replace or substitute services and/or supports currently in place, or to exchange
unpaid supports for paid services.
Legally Responsible Individuals (LRIs) may not be reimbursed for providing PCS.
3503.1A ELIGIBILITY CRITERIA
1. The recipient must have ongoing Medicaid or Nevada Check Up (NCU) eligibility for
services;
2. The recipient is not in a hospital, Nursing Facility (NF), Intermediate Care Facility for
Individuals with Intellectual Disabilities (ICF/IID), an institution for the mentally ill or a
licensed residential facility for groups;
3. The recipient does not have an LRI who is available and capable of providing the necessary
care;
4. The recipient or Personal Care Representative (PCR) must be cooperative in establishing
the need for the provision of services and comply with the approved service plan;
5. The recipient is capable of making choices about ADLs or has a PCR who assumes this
responsibility;
6. PCS must be determined to be medically necessary as defined by the DHCFP or its
designee.
September 25, 2019 PERSONAL CARE SERVICES PROGRAM Section 3503 Page 1
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Section:
DIVISION OF HEALTH CARE FINANCING AND POLICY 3503
Subject:
MEDICAID SERVICES MANUAL POLICY
3503.1B COVERAGE AND LIMITATIONS
1. Covered Services
a. Assistance with the following ADLs is a covered service when no LRI is available
and/or capable of providing the necessary service. Services must be directed to the
individual recipient and related to their health and welfare.
1. Bathing/dressing/grooming.
2. Toileting needs and routine care of an incontinent recipient.
3. Transferring and positioning non-ambulatory recipients from one stationary
position to another, assisting a recipient out of bed, chair or wheelchair,
including adjusting/changing recipient’s position in a bed, chair or
wheelchair.
4. Mobility/Ambulation, which is the process of moving between locations,
including walking or helping the recipient to walk with support of a walker,
cane or crutches or assisting a recipient to stand up or get to his/her
wheelchair to begin ambulating.
5. Eating, including cutting up food. Specialized feeding techniques may not
be used.
b. Assistance with the following IADLs is a covered service when no LRI is available
and/or capable of providing the necessary service. Services must be directed to the
individual recipient and related to their health and welfare. See the service
limitations section of this chapter for specific eligibility criteria to be considered
eligible to receive additional time for assistance with IADLs.
1. Meal preparation, which includes storing, preparing and serving food.
2. Laundry, including washing, drying and folding the recipient’s personal
laundry and linens (sheets, towels, etc.). Ironing is not a covered service.
3. Light housekeeping, which includes changing the recipient’s bed linens,
dusting or vacuuming the recipient’s living area.
4. Essential shopping, which includes shopping for prescribed drugs, medical
supplies, groceries and other household items required specifically for the
health and nutrition of the recipient.
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Section:
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Subject:
MEDICAID SERVICES MANUAL POLICY
2. Service Limitations
To be considered eligible to receive additional time for assistance with IADLs, the recipient
must be eligible to receive PCS for ADLs and have deficits which directly preclude the
individual from completing IADLs. The FASP must demonstrate that the recipient meets
the following criteria:
a. The recipient has extensive impairments, Level 2 or higher on the FASP in two or
more areas of ADLs; and
b. The recipient has at least one of the deficits listed below:
1. Mobility deficits/impairments of an extensive nature which requires the use
of an assistive device, and directly impact the recipient’s ability to safely
perform household tasks or meal preparation independently;
2. Cognitive deficits directly impacting the recipient’s ability to safely
perform household tasks or meal preparation independently;
3. Endurance deficits directly impacting the recipient’s ability to complete a
task without experiencing substantial physical stressors;
4. Sensory deficits directly impacting the recipient’s ability to safely perform
household tasks or meal preparation independently.
Assistance with the IADLs may only be provided in conjunction with services for
ADLs, and only when no LRI is available and/or capable.
3. Non-Covered Services
Duplicative services are not considered medically necessary and will not be covered by
Nevada Medicaid. An inquiry or referral for services does not determine the medical
necessity for services.
The following are not covered under PCS and are not reimbursable:
a. A task that the DHCFP or its designee determines could reasonably be performed
by the recipient.
b. Services normally provided by an LRI.
c. Any tasks not included on the recipient’s approved service plan.
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d. Services to maintain an entire household, such as cleaning areas of the house not
used solely by the recipient(s).
e. Services provided to someone other than the intended recipient.
f. Skilled care services requiring the technical or professional skill that State statute
or regulation mandates must be performed by a health care professional licensed or
certified by the State. Services include, but are not limited to, the following:
1. Insertion and sterile irrigation of catheters;
2. Irrigation of any body cavity. This includes both sterile and non-sterile
procedures such as ear irrigation, vaginal douches and enemas;
3. Application of dressings involving prescription medications and aseptic
techniques, including treatment of moderate or severe skin problems;
4. Administration of injections of fluids into veins, muscles or skin;
5. Administration of medication, including, but not limited to, the insertion of
rectal suppositories, the application of prescribed skin lotions or the
instillation of prescribed eye drops (as opposed to assisting with self-
administered medication);
6. Physical assessments;
7. Monitoring vital signs;
8. Specialized feeding techniques;
9. Rectal digital stimulation;
10. Massage;
11. Specialized range of motion (ROM);
12. Toenail cutting;
13. Medical case management, such as accompanying a recipient to a
physician’s office for the purpose of providing or receiving medical
information;
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14. Any task identified within the Nurse Practice Act as requiring skilled
nursing, including Certified Nursing Assistant (CNA) services.
g. Chore services.
h. Companion care, baby-sitting, supervision or social visitation.
i. Care of pets except in cases where the animal is a certified service animal.
j. Respite care intended primarily to relieve a member of the recipient’s household, a
family member or caregiver from the responsibility of caring for the recipient.
k. A task the DHCFP determines is within the scope of services provided to the
recipient as part of an assisted living contract, a supported living arrangement
contract or a foster care agreement.
l. Escort services for social, recreational or leisure activities.
m. Transportation of the recipient by the Personal Care Attendant (PCA).
n. Any other service not listed under Section 3503.1.B.1.
3503.1C LEGALLY RESPONSIBLE INDIVIDUAL (LRI)
LRIs are individuals who are legally responsible to provide medical support. These individuals
include spouses of recipients, legal guardians, and parents of minor recipients, including
stepparents, foster parents and adoptive parents. LRIs may not be reimbursed for providing PCS.
If the LRI is not capable of providing the necessary services/supports, he or she must provide
verification to the DHCFP’s QIO-like vendor, from a physician, that they are not capable of
providing the supports due to illness or injury. If not available, verification that they are
unavailable due to hours of employment and/or school attendance must be provided. Without this
verification, PCS will not be authorized. Additional verification may be required on a case by case
basis.
3503.1D PERSONAL CARE REPRESENTATIVE (PCR)
A recipient who is unable to provide direction in the delivery of their own care may opt to utilize
a PCR. This individual is directly involved in the day-to-day care of the recipient, is available to
direct care in the home, acts on behalf of the recipient when the recipient is unable to direct his or
her own personal care services and assumes all medical liability associated with directing the
recipient’s care. A PCR must be a responsible adult.
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The PCR must:
1. Effectuate, as much as possible, the decision the individual would make for himself/herself;
2. Accommodate the individual, to the extent necessary that they can participate as fully as
possible in all decisions that affect them;
3. Give due consideration to all information including the recommendations of other
interested and involved parties;
4. Understand that provision of services is based upon mutual responsibilities between the
PCR and the provider agency.
A PCR is not eligible to receive reimbursement from Medicaid for this activity. A recipient’s paid
PCA cannot be the recipient’s PCR. The PCR must meet all criteria outlined in Section 3503.1I of
this chapter. In addition, this individual must be present for the provision of care on a consistent
basis, as well as sign daily records. For this reason, it is not allowable for individuals such as a
paid PCA, care coordinator or case manager to assume this role.
The PCR may reside outside the home if frequent contact can be made by the recipient, the provider
agency and other care providers. The PCR must be available to the recipient, the provider agency
and other care providers as necessary to fulfill the regular elements of Section 3503.1I of this
chapter.
Additionally, if a change in PCR becomes necessary, a new personal care representative agreement
must be completed and kept in the recipient’s provider file. Contact the provider agency to make
the necessary changes and obtain necessary form(s).
3503.1E AUTHORIZATION PROCESS
PCS authorization requests must be submitted to the QIO-like vendor using the following
procedures:
1. Initial Authorization Requests
The recipient, LRI, PCR or an individual covered under the confidentiality requirements
of HIPAA may contact the QIO-like vendor to request PCS. Initial requests may not be
made by the PCS Agency provider.
The QIO-like vendor validates that the recipient meets PCS criteria, and if so, an enrolled
and trained physical or occupational therapist will then complete an in-home assessment
of the recipient’s functional abilities.
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The physical or occupational therapist contacts the recipient to schedule an appointment
for the completion of the FASP. The recipient is responsible for keeping the scheduled
appointment.
Taking into account the physical or occupational therapists’ clinical judgment, the in-home
visit may be followed by an in-clinic visit in order to accurately evaluate the recipient’s
need for PCS.
After completion, the FASP is forwarded to the QIO-like vendor to process.
If the recipient’s request for PCS is approved, the QIO-like vendor will issue a prior
authorization number to the recipient’s chosen PCS Provider Agency.
a. At Risk Recipient Requests
Upon receipt of a request for an initial FASP, the QIO-like vendor will first
complete a risk assessment over the phone to identify those recipients for whom
PCS are urgent to avoid institutionalization, or for whom the service need is the
result of an acute medical condition or loss of a primary caregiver or LRI. The intent
of the telephonic risk assessment is to determine if a recipient is at risk of losing or
being unable to return to a community setting because of the need for PCS.
When a recipient is determined “at risk,” the QIO-like vendor will provide a
temporary service authorization.
An enrolled and trained physical or occupational therapist will then complete an in-
home assessment of the recipient’s functional abilities.
The physical or occupational therapist contacts the recipient to schedule an
appointment for the completion of the FASP. The recipient is responsible for
keeping the scheduled appointment.
Taking into account the physical or occupational therapists’ clinical judgment, the
in-home visit may be followed by an in-clinic visit in order to accurately evaluate
the recipient’s need for PCS. After completion, the FASP is forwarded to the QIO-
like vendor to process.
The selected Provider Agency is notified when a recipient is at risk and agrees, by
accepting the case, to initiate needed services within 24 hours of case acceptance.
The approved service plan and authorization document are faxed to the provider
upon acceptance.
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2. Annual Update Authorization Requests
To prevent a break in service, reassessment requests for ongoing services are recommended
to be submitted to the QIO-like vendor at least 60 days, but not greater than 90 days, prior
to the expiration date of the current authorization. The request must be submitted on the
Authorization Request for PCS form (FA-24). The form must include all required recipient
and provider information, as well as the units requested and the dates of service for the
service interval requested.
The QIO-like vendor validates that the request meets PCS criteria. An enrolled and trained
physical or occupational therapist will then complete an in-home assessment of the
recipient’s functional abilities.
The physical or occupational therapist contacts the recipient to schedule an appointment
for the completion of the FASP. The recipient is responsible for keeping the scheduled
appointment.
Taking into account the physical or occupational therapists’ clinical judgment, the in-home
visit may be followed by an in-clinic visit in order to accurately evaluate the recipient’s
need for PCS. After completion, the FASP is forwarded to the QIO-like vendor to process.
If the request is approved, the QIO-like vendor will issue a prior authorization number to
the PCS Provider Agency submitting the request.
3. Significant Change in Condition or Circumstance Authorization Requests
Requests for reassessment due to significant change in the recipient’s condition or
circumstances must be submitted to the QIO-like vendor as soon as the significant change
is known. A request for reassessment due to a significant change in the recipient’s condition
or circumstances must be submitted on the Authorization Request for PCS form (FA-24)
and must be accompanied by documentation from the recipient’s physician or health care
provider. Requesting a reassessment does not guarantee an increase in previously approved
PCS.
a. Significant change in condition may be demonstrated by, for example, an
exacerbation of a previous disabling condition resulting in a hospitalization (within
past 14 days) or a physician’s visit (within past seven days) or a new diagnosis not
expected to resolve within eight weeks.
b. Significant change in circumstances may include such circumstances as absence,
illness or death of the primary caregiver or LRI.
c. Significant change in condition or circumstances would result in hospitalization or
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other institutional placement if PCS are not reassessed to meet the recipient’s
change in service needs.
The QIO-like vendor validates that the request meets PCS criteria and if so, an enrolled
and trained physical or occupational therapist will then complete an in-home assessment
of the recipient’s functional abilities.
The physical or occupational therapist contacts the recipient to schedule an appointment
for the completion of the FASP. The recipient is responsible for keeping the scheduled
appointment.
Taking into account the physical or occupational therapists’ clinical judgment, the in-home
visit may be followed by an in-clinic visit in order to accurately evaluate the recipient’s
need for PCS. After completion, the FASP is forwarded to the QIO-like vendor to process.
If the request is approved, the QIO-like vendor will issue a prior authorization number to
the PCS Provider Agency submitting the request.
4. Temporary Service Authorization Requests
When the recipient has an unexpected change in condition or circumstance which requires
short-term (less than eight weeks) modification of the current authorization, a new FASP
is not required.
Such a modification is considered when additional PCS are required for a short time as the
result of an acute medical episode or during a post-hospitalization period.
The following procedure must be followed for all short-term modifications of the approved
service plan:
a. Documentation must be maintained in the recipient’s record of the circumstance(s)
that required the short term modification(s) of the approved service plan;
b. Documentation of the short-term modification(s) of the approved service plan must
be completed and sent to the Provider Agency, and if applicable, the appropriate
home and community-based waiver case manager. Documentation must include the
recipient’s name, Medicaid number and the dates during which the modified service
plan will be in effect; and
c. Upon expiration of the modified service plan, the recipient’s original approved
service plan is automatically reinstated unless a new FASP is completed due to a
significant change in the recipient’s condition or circumstance.
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5. One-Time Service Authorization Request
The recipient’s Provider Agency may submit a single-service authorization request when
the recipient requires an extra visit for an unanticipated need, such as bowel or bladder
incontinence. The Provider Agency must document the medical necessity of the service
requested and be the designated provider for the current authorization period. The request
should be submitted to the QIO-like vendor no later than seven business days after the
service is provided. A new FASP is not required in these single-service situations.
6. Mileage Authorization Request
Mileage for travel to and from a recipient’s home or for shopping is not reimbursable to
PCS Agency providers, except in hardship situations in remote or rural areas of the state
where failure to reimburse mileage expenses would severely limit available PCS Agency
providers. Mileage authorization requests must be submitted in advance to the local
DHCFP District Office for review and may be approved on a case-by-case basis. If
approved, the DHCFP District Office will notify the QIO-like vendor to issue an
authorization number for the approved mileage to the provider.
3503.1F FLEXIBILITY OF SERVICES DELIVERY
The total weekly authorized hours for PCS may be combined and tailored to meet the needs of the
recipient, as long as the plan does not alter medical necessity. The recipient will determine how to
use the weekly authorized hours on an ongoing basis. Any changes that do not increase the total
authorized hours can be made, for the recipient’s convenience, within a single week without an
additional authorization. Flexibility of services may not take place solely for the convenience of
the provider or PCA.
The following requirements must be met:
1. Upon receipt of an initial service plan from the QIO-like vendor, the provider must meet
with the recipient in person to determine how the total weekly authorized hours will be
provided to meet the individual’s needs.
2. Written documentation of the contact with the recipient regarding provision of services
must be maintained in the recipient’s file.
3. Any change to the approved service plan must be discussed between the provider and the
recipient. This may be done either in person or via the telephone in order to determine how
the hours and tasks will be provided.
4. Changes may be requested on a daily and/or weekly basis when necessary to meet a change
in circumstance or condition.
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5. The PCS provider must follow their established policies and procedures in order to timely
meet recipient requests for changes in service delivery.
6. Written documentation of the contact with the recipient regarding any change to the
approved service plan must be maintained in the recipient’s file.
3503.1G ELECTRONIC VISIT VERIFICATION (EVV)
The 21st Century Cures Act requires the use of an EVV system to document services that are
provided for all personal care services under a Medicaid state plan or waiver program. This
mandate requires provider agencies to use an EVV system to record service delivery visit
information. Nevada Medicaid utilizes the open-system model, procuring a vendor but also allows
agencies to utilize their own EVV system if it meets the 21st Century Cures Act requirements for
documentation.
All service information must be recorded in an electronic system that interfaces with either a
telephone or an electronic device that generates a timestamp. The provider agency must verify the
EVV record, including any visit maintenance, prior to submitting a claim associated with the EVV
record. All claims must be supported by an EVV entry into an EVV system prior to claim
submission.
Provider Agencies must ensure each personal care attendant (PCA) has a unique identifier
(National Provider Identification – NPI) associated with their worker profile in the EVV system.
1. STATE OPTION
a. The EVV system electronically captures:
1. The type of service performed, based on procedure code;
2. The individual receiving the service;
3. The date of the service;
4. The location where service is provided;
5. The individual providing the service;
6. The time the service begins and ends.
b. The EVV system must utilize one or more of the following:
1. The agency/PCA’s smartphone;
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2. The agency/PCA’s tablet;
3. The recipient’s landline telephone;
4. The recipient’s cellular phone (for Interactive Voice Response (IVR)
purposes only);
5. Another GPS-based device as approved by the DHCFP.
2. DATA AGGREGATOR OPTION
a. All Provider Agencies that utilize a different EVV system (as approved by the
DHCFP) must comply with all documentation requirements of this chapter and
must utilize the data aggregator to report encounter or claim data.
1. Appropriate form must be approved by the DHCFP before use of the system
to ensure all data requirements are being collected to meet the 21st Century
Cures Act.
2. At a minimum, data uploads must be completed monthly into data
aggregator.
3503.1H CONFLICT OF INTEREST STANDARDS
The DHCFP assures the independence of contracted providers completing the FASPs. Physical
and occupational therapists who complete the FASPs must be an independent third party and may
not be:
1. Related by blood or marriage to the individual or to any paid caregiver of the individual;
2. Financially responsible for the individual;
3. Empowered to make financial or health-related decisions on behalf of the individual;
4. Related by blood or marriage to the Provider who provides PCS to the individual.
The therapist completing the FASP must not have an interest in or employment by a Provider.
Note: To ensure the independence of individuals completing the FASP, providers are prohibited
from contacting the physical or occupational therapists directly.
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3503.1I PROVIDER RESPONSIBILITIES
PCS providers shall furnish PCAs to assist eligible Medicaid and NCU recipients with ADLs and
IADLs, as identified on the individual recipient’s approved service plan and in accordance with
the conditions specified in this Chapter and the Medicaid Provider Contract.
Additionally, all PCS providers have the following responsibilities:
1. Licensure
In order to enroll as a Nevada Medicaid PCS Provider, a provider must be licensed by the
Division of Public and Behavioral Health (DPBH) as an Agency to Provide Personal Care
Services in the Home (personal care agency).
Providers must comply with licensing requirements and maintain an active certification
and/or license at all times.
2. Provider Enrollment
To become a Nevada Medicaid PCS provider, the provider must enroll with the QIO-like
vendor as a Personal Care Services – Provider Agency (PT 30).
3. Electronic Visit Verification (EVV)
Utilize an EVV system that meets the requirements of the 21st Century Cures Act, to
electronically document the personal care services provided to Medicaid recipients served
by a Medicaid provider.
4. Time Parameters
The Provider will implement PCS in a timely manner. The Provider agrees to furnish
qualified staff to provide PCS to eligible Medicaid recipients within five working days of
an accepted referral and within 24 hours of an accepted referral if the recipient is identified
as “at risk” by the DHCFP or its designee.
PCS providers must meet the conditions of participation as stated in the MSM Chapter 100.
The Provider must comply with all local, state and federal regulations, and applicable
statutes, including, but not limited to, Nevada Revised Statutes Chapter 449, Nevada
Administrative Code Chapter 449, the Internal Revenue Service (IRS), Federal Insurance
Contributions Act (FICA), Occupational Safety and Health Act (OSHA), the Health
Insurance Portability and Accountability Act (HIPAA) and the 21st Century Cures Act.
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5. 24-Hour Accessibility
The Provider shall maintain an available telephone line 24 hours per day, seven days per
week for recipient contact.
6. Backup Mechanism.
The Provider shall have a backup mechanism to provide a recipient with his or her
authorized service hours in the absence of a regular caregiver due to sickness, vacation or
any unscheduled event.
7. Referral Source Agreement
The Provider shall maintain, and utilize as necessary, written referral source agreements
with other DHCFP co
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