Iowa Admin. Code r. 441-78.57 - Child care medical services
Payments will be made to licensed child care centers that provide medical services in addition to child care. Medically necessary services are provided under a plan of care that is developed by licensed professionals within their scope of practice and authorized by the member's physician. The services include and implement a comprehensive protocol of care that is developed in conjunction with the parent or guardian and specifies the medical, nursing, personal care, psychosocial and developmental therapies required by the medically dependent or technologically dependent child served.
(1) Nursing services are
services which are provided by a registered nurse or a licensed practical nurse
under the direction of the member's physician to a member in a licensed child
care center. Nursing services shall be provided according to a written plan of
care authorized by a physician. Payment for nursing services may be approved if
the services are determined to be medically necessary as defined in subrule
78.57(5). Nursing services include activities that require the expertise of a
nurse, such as physical assessment, tracheostomy care, medication
administration, and tube feedings.
(2) Personal care services are those services
which are provided by an aide but are delegated and supervised by a registered
nurse under the direction of the member's physician. Payment for personal care
services may be approved if the services are determined to be medically
necessary as defined in subrule 78.57(5). Personal care services shall be in
accordance with the member's plan of care and authorized by a physician.
Personal care services include the activities of daily living, oral hygiene,
grooming, toileting, feeding, range of motion and positioning, and training the
member in necessary self-help skills, including teaching prosocial skills and
reinforcing positive interactions.
(3) Psychosocial services are those services
that focus at decreasing or eliminating maladaptive behaviors. Payment for
psychosocial services may be approved if the services are determined to be
medically necessary as defined in subrule 78.57(5). Psychosocial services shall
be in accordance with the member's plan of care and authorized by a physician.
Psychosocial services include implementing a plan using clinically accepted
techniques for decreasing or eliminating maladaptive behaviors. Psychosocial
intervention plans must be developed and reviewed by licensed mental health
providers.
(4) Developmental
therapies are those services which are provided by an aide but are delegated
and supervised by a licensed therapist under the direction of the member's
physician. Payment for developmental therapies may be approved if the services
are determined to be medically necessary as defined in subrule 78.57(5).
Developmental therapies shall be in accordance with the member's plan of care
and authorized by a physician. Developmental therapies include activities based
on the individual's needs such as fine motor, gross motor, and receptive
expressive language.
(5) "Medically
necessary" means the service is reasonably calculated to prevent, diagnose,
correct, cure, alleviate or prevent the worsening of conditions that endanger
life, cause pain, result in illness or infirmity, or threaten to cause or
aggravate a disability or chronic illness and is an effective course of
treatment for the member requesting a service.
(6) Requirements.
a. Nursing, psychosocial, developmental
therapies and personal care services shall be ordered in writing.
b. Nursing, psychosocial, developmental
therapies and personal care services shall be authorized by the department or
the department's designated review agent prior to payment.
c. Prior authorization shall be requested at
the time of initial submission of the plan of care or at any time the plan of
care is substantially amended and shall be renewed with the department or the
department's designated review agent. Initial request for and request for
renewal of prior authorization shall be submitted to the department's
designated review agent. The provider of the service is responsible for
requesting prior authorization and for obtaining renewal of prior
authorization. The request for prior authorization shall include a nursing
assessment, the plan of care, and supporting documentation. A treatment plan
shall be completed prior to the start of care and at a minimum reviewed every
180 days thereafter. The plan of care shall support the medical necessity and
intensity of services to be provided by reflecting the following information:
(1) Place of service.
(2) Type of service to be rendered and the
treatment modalities being used.
(3) Frequency of the services.
(4) Assistance devices to be used.
(5) Date on which services were
initiated.
(6) Progress of member
in response to treatment.
(7)
Medical supplies to be furnished.
(8) Member's medical condition as reflected
by the following information, if applicable:
1. Dates of prior hospitalization.
2. Dates of prior surgery.
3. Date last seen by a primary care
provider.
4. Diagnoses and dates of
onset of diagnoses for which treatment is being rendered.
5. Prognosis.
6. Functional limitations.
7. Vital signs reading.
8. Date of last episode of acute recurrence
of illness or symptoms.
9.
Medications.
(9)
Discipline of the person providing the service.
(10) Certification period.
(11) Physician's signature and date. The
treatment plan must be signed and dated by the physician before the claim for
service is submitted for reimbursement.
(12) Form 470-5686 is utilized during the
prior authorization review.
(7) Nursing, personal care, and psychosocial
services do not include:
a. Services provided
to members aged 21 and older.
b.
Services that require prior authorizations that are provided without regard to
the prior authorization process.
c.
Nursing services provided simultaneously with other Medicaid services (e.g.,
home health aide, physical, occupational, or speech therapy services,
etc.).
d. Services that exceed the
services that are approvable under the private duty nursing and personal care
program pursuant to subrule 78.9(10).
e. Transportation services.
f. Services provided to a member while the
member is in institutional care.
This rule is intended to implement Iowa Code chapter 249A.
Notes
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