Kan. Admin. Regs. § 30-5-81 - Scope of hospital services
(a) Each hospital
shall be medicare-certified and shall annually update medicaid enrollment
information.
(b) Outpatient
services shall be covered with the following limitations.
(1) Services shall be ordered by an attending
physician who is not serving as an emergency room physician, except for those
services related to emergency situations. Orders shall be related specifically
to the present diagnosis of the recipient.
(2) A prosthetic device shall replace all or
part of an internal body organ or shall replace one of these devices.
(3)
(A) Rehabilitative therapies shall be
restorative in nature.
(B)
Rehabilitative therapies shall be provided following physical debilitation due
to acute physical trauma or physical illness.
(C) Rehabilitative therapies shall be
prescribed by the attending physician.
(4) Services provided in the emergency
department shall be emergency services.
(5) Elective surgery shall not be covered,
except for sterilization operations or operations for Kan Be Healthy program
participants.
(6) Ambulance
services shall not be covered.
(7)
Nonemergency visits in place of physician office visits shall be considered
physician office visits and shall be counted against the physician office visit
limitation.
(8) Outpatient
hospital assessment of the need for emergency service shall not be covered.
(c) Inpatient services
shall be covered, subject to the following limitations.
(1) Services shall be ordered by a physician
and shall be related specifically to the present diagnosis of the recipient.
(2) Transplant surgery shall be
limited to the following:
(A) Liver
transplants, which shall be performed only at a hospital designated by the
secretary unless the medical staff of that hospital recommends another
location; and
(B) corneal, kidney,
and bone marrow transplants and related services.
(3) A recipient of general hospital inpatient
services shall not be billed for those days determined to be medically
unnecessary. If a recipient refuses to leave a hospital after the recipient's
physician writes a discharge order, the days after discharge that the recipient
remains in the hospital may be billed to the recipient.
(4) A provider shall not be reimbursed for
services provided on the day of discharge.
(5) Long-term care services in swing beds
shall be provided pursuant to 42 CFR part 482, subpart E, revised October 1,
1999, which is adopted by reference.
(6) A provider shall not be reimbursed on an
inpatient basis for therapeutic and diagnostic surgical services, and related
services that can be performed on an outpatient basis. A provider shall not be
reimbursed on an inpatient basis unless the service provider documents medical
necessity.
(7) Inpatient services
shall be subject to utilization review, which shall determine the following:
(A) Whether services are medically necessary;
(B) whether services are furnished
at the appropriate level of care;
(C) whether services are of a quality that
meets professionally recognized standards;
(D) whether a discharge is premature;
(E) whether a transfer is
necessary; and
(F) whether the
procedure coding and the diagnosis coding on a claim are correct.
(8) Psychotherapy, directed by a
psychiatrist or approved hospital staff under the direction of a psychiatrist,
shall be provided to each psychiatric patient on a daily basis.
(9) Substance abuse treatment services shall
be limited to three treatment admissions per recipient's lifetime, regardless
of the type of provider.
(10)
Inpatient acute care related to substance abuse treatment services shall be
limited to those patients who are in need of acute detoxification.
(11) Elective surgery shall not be covered,
except for sterilization operations or operations for Kan Be Healthy program
participants.
Notes
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No prior version found.