Utah Admin. Code R414-2A-7 - Limitations

Current through Bulletin 2022-07, April 1, 2022

Inpatient hospital care is limited to medical treatment of symptoms that lead to medical stabilization of the member. This medical stabilization care is irrespective of any underlying psychiatric diagnosis.

(1) Detoxification for a substance use disorder in a hospital shall meet the criteria in the Department's evidence-based criteria tool for inpatient detoxification. The Department does not cover any lesser level of detoxification in an inpatient hospital. The standards for the evidence-based criteria tool shall be in accordance with Section R414-1-12.
(2) Abortion procedures require prior authorization. Refer to Rule R414-1B.
(3) Sterilization and hysterectomy procedures require prior authorization and must meet the requirements of 42 CFR 441, Subpart F.
(4) Organ transplant services are governed by Rule R414-10A.
(5) Take-home supplies, dressings, non-rental durable medical equipment, and drugs are included in the inpatient reimbursement.
(6) Coverage of sleep studies requires sleep center accreditation through one of the following nationally recognized accreditation organizations:
(a) American Academy of Sleep Medicine (AASM);
(b) Accreditation Commission for Health Care (ACHC); or
(c) The Joint Commission (TJC).
(7) Hyperbaric oxygen therapy is limited to service in a facility in which the hyperbaric unit is accredited by the Undersea and Hyperbaric Medical Society. Hyperbaric oxygen therapy is therapy that places the member in an enclosed pressure chamber for medical treatment.
(8) Medicaid does not cover inpatient services solely for pain management. Pain management is adjunct to other Medicaid services.
(9) Inpatient rehabilitation services require prior authorization.
(10) Observation services are limited to cases where observation and evaluation is required to establish a diagnosis and determine the appropriateness of an inpatient admission or discharge. Observation is used to monitor the member's condition, complete diagnostic testing to establish a definitive diagnosis and formulate the treatment plan.
(a) Medicaid covers observation services with a physician's written order that outlines specific medically necessary reasons for the service, such as the member requires more evaluation to determine the severity of illness through laboratory, imaging, or other diagnostic test, and an order to continue monitoring for clinical signs and symptoms to determine improving or declining health status.
(b) Outpatient procedures include an uneventful recovery period.
(i) Observation is used to monitor complications of outpatient procedures beyond an uneventful recovery period.
(c) Medicaid does not cover observation services for convenience of the hospital, member or family, or when awaiting transfer to another facility.
(d) When an ordered hospital inpatient admission improves to the point of discharge with a stay less than 24 hours, the admission is covered as inpatient when documentation supports the medical necessity.
(e) Inpatient admissions solely for observation or diagnostic evaluation do not qualify for reimbursement under the diagnosis-related group (DRG) system.
(11) Medicaid does not cover admission solely for the treatment of eating disorders.
(12) Medicaid does not cover non-physician psychosocial counseling outside of the DRG.
(13) An undocumented immigrant who does not meet United States residency requirements may only receive emergency services, including emergency labor and delivery, to treat an emergency medical condition.
(a) Medicaid does not cover prenatal and post-partum services for undocumented immigrants.
(b) Medicaid does not cover prescriptions for a member who is eligible to receive emergency services only.
(14) Inpatient hospital intensive physical rehabilitation services are not covered when the condition and prognosis meet the requirements of placement into a long-term facility, skilled nursing facility, or outpatient rehabilitation service.
(15) Medicaid does not cover admission for deconditioning in an inpatient hospital intensive physical rehabilitation facility.
(16) Inpatient hospital intensive physical rehabilitation services for a member who has suffered a stroke or other cerebral vascular accident may be provided only when admission and therapy is initiated within the first 60 days after onset of the incident.


Utah Admin. Code R414-2A-7
Amended by Utah State Bulletin Number 2017-14, effective 7/1/2017 Amended by Utah State Bulletin Number 2018-1, effective 12/12/2017 Amended by Utah State Bulletin Number 2018-11, effective 5/8/2018 Amended by Utah State Bulletin Number 2019-20, effective 9/17/2019 Amended by Utah State Bulletin Number 2020-19, effective 10/1/2020 Amended by Utah State Bulletin Number 2021-17, effective 8/13/2021

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