Utah Admin. Code R414-2A-7 - Limitations
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.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.