Haw. Code R. § 17-1738-28 - Limitation of services

(a) Reimbursement for case assessment and case planning shall be limited to no more than one each for a recipient in a calendar year unless the recipient requires a reassessment due to a major change in level of functioning due to health, socio-emotional, or environmental factors, in which case a second assessment or case plan may be reimbursed.

(b) Reimbursement for ongoing monitoring and service coordination shall be limited to one claim for each recipient per month, and shall be only for the services rendered by or under the supervision of the recipient's designated case manager.

(c) Ongoing monitoring or service coordination shall not be available to recipients who are inpatients in acute hospitals, or residents of nursing or ICF-MR facilities.

(d) Case management services are not reimbursable when rendered to a recipient who, on the date of service, is enrolled in a health maintenance organization.

(e) Recipients receiving services under Home & Community-Based Waiver Services shall be eligible to receive non-duplicative case management services as targeted case management services under section 17-1738-5.

(f) The following activities are considered necessary for the proper and efficient administration of the medicaid state plan, and are not reimbursable:

(1) Medicaid eligibility determinations and redeterminations ;

(2) Medicaid pre-admission screening;

(3) Prior authorization for medicaid services;

(4) Medicaid utilization review;

(5) EPSDT administration; and

(6) Activities associated with the lock-in provisions of section 17-1741-8.

Notes

Haw. Code R. § 17-1738-28

[Eff 08/01/94; am 02/10/97; am 12/27/97] (Auth: HRS § 346-14; 42 C.F.R. §431.10) (Imp: 42 U.S.C. §1396 n )