Transcription of IDAPA 16 - Department of Health and Welfare
1 IDAPA 16 IDAHO Department OF Health AND WELFARED ivision of medicaid Basic Plan BenefitsWho does this rule apply to?For those seeking medical assistance under Idaho medicaid s Basic Plan and for medicaid is the purpose of this rule?This chapter of rules contains the general provisions regarding the administration of the Medical Assistance Program ( medicaid ). All goods and services not specifically included in this chapter are excluded from coverage under the medicaid Basic Plan. A guide to covered services is found under Section 399 of these rules. These rules also contain requirements for provider procurement and provider reimbursement. (For medicaid eligibility, please see IDAPA , Eligibility for Health Care Assistance for Families and Children.)
2 What is the legal authority for the agency to promulgate this rule?This rule implements the following statutes passed by the Idaho Legislature:Public Assistance and Welfare -Public Assistance Law: Section 56-202(b), Idaho Code Duties of Director of State Department of Health & Welfare Section 56-264, Idaho Code Rulemaking AuthorityIdaho Intermediate Care Facility Assessment Act: Section 56-1610, Idaho Code Rulemaking AuthorityWhere can I find information on Administrative Appeals?Administrative appeals and contested cases are governed by the provisions of IDAPA , Contested Case Proceedings and Declaratory Rulings. How do I request public records?Unless exempted, all public records are subject to disclosure by the Department that will comply with Title 74, Chapter 1, Idaho Code, upon requests.
3 Confidential information may be restricted by state or federal law, federal regulation, and IDAPA , Use and Disclosure of Department Records. Who do I contact for more information on this rule?Idaho Department of Health and WelfareDivision of medicaid Basic Plan Benefits3232 West Elder StreetBoise, ID Box 83720 Boise, ID 83720-0036 Phone: (208) 334-5747 or 1-877-200-5441 (toll free)Fax: (208) 364-1811 Email: 2 Table of medicaid Basic Plan Benefits000. Legal Authority.. 11001. Title And Scope.. 11002. Written Interpretations.. 11003. (Reserved) ..11004. Incorporation By Reference.. 11005. -- 007. (Reserved) .. 12008. Audit, Investigation, And Enforcement.. 12009. Criminal History And Background Check Requirements.
4 12010. Definitions: A Through H.(7-1-21)T .. 14011. Definitions: I Through O.. 16012. Definitions: P Through Z.. 18013. Medical Care Advisory Committee.. 20014. -- 099. (Reserved) .. 21 GENERAL PARTICIPANT PROVISIONS100. Eligibility For Medical Assistance.. 21101. -- 124. (Reserved) .. 21125. Medical Assistance Procedures.. 21126. -- 149. (Reserved) .. 21150. Choice Of Providers.. 21151. -- 159. (Reserved) .. 22160. Responsibility For Keeping Appointments.. 22161. -- 164. (Reserved) .. 22165. Cost-Sharing.. 22166. -- 199. (Reserved) .. 22 GENERAL PROVIDER PROVISIONS200. Provider Application Process.. 22201. -- 204. (Reserved) .. 23205. Agreements With Providers.. 23206. -- 209. (Reserved) .. 24210. Conditions For Payment.. 24211. -- 214.
5 (Reserved) .. 25215. Third Party Liability.. 25216. -- 224. (Reserved) .. 27225. Reporting To The Internal Revenue Service (IRS).. 27226. -- 229. (Reserved) .. 27230. General Payment Procedures.. 27231. Handling Of Overpayments And Underpayments For Specified Providers.. 29232. -- 234. (Reserved) .. 30235. Patient Advance Directives.. 30236. -- 244. (Reserved) .. 31245. Providers Of School-Based Services.. 31246. -- 249. (Reserved) .. 31 Table of Contents (cont d) Page 3 250. Selective Contracting.. 31251. -- 299. (Reserved) .. 31 GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS300. Cost Reporting.. 31301. -- 304. (Reserved) .. 31305. Reimbursement System Audits.. 31306. -- 329. (Reserved) .. 32330. Provider's Responsibility To Maintain Records.
6 32331. -- 339. (Reserved) .. 32340. Draft Audit Report.. 32341. Final Audit Report.. 33342. -- 359. (Reserved) .. 33360. Related Party Transactions.. 33361. Application.. 33362. Exception To The Related Organization Principle.. 33363. -- 389. (Reserved) .. 34 EXCLUDED SERVICES390. Services, Treatments, And Procedures Not Covered By Medical Assistance. 34391. -- 398. (Reserved) .. 35399. Covered Services Under Basic Plan Benefits.. 35 COVERED SERVICESSUB AREA: HOSPITAL SERVICES400. Hospital Services Definitions.. 38401. Hospital Reimbursement Prospective Payment Systems.. 41402. Inpatient Hospital Services: Coverage And Limitations.. 41403. Inpatient Hospital Services: Procedural Requirements.. 41404. Inpatient Hospital Services: Provider Qualifications And Duties.
7 42405. Hospital Services Provider Reimbursement.. 42406. Inpatient Hospital Services: Quality Assurance.. 48407. -- 409. (Reserved) .. 48410. Outpatient Hospital Services: Definitions.. 48411. (Reserved) .. 48412. Outpatient Hospital Services: Coverage And Limitations.. 49413. Outpatient Hospital Services: Procedural Requirements.. 49414. (Reserved) .. 49415. Outpatient Hospital Services: Provider Reimbursement.. 49416. -- 421. (Reserved) .. 50422. Reconstructive Surgery: Coverage And Limitations.. 50423. -- 430. (Reserved) .. 50431. Surgical Procedures For Weight Loss: Participant Eligibility.. 50432. Surgical Procedures For Weight Loss: Coverage And Limitations.. 51433. Surgical Procedures For Weight Loss: Procedural Requirements.
8 51434. Surgical Procedures For Weight Loss: Provider Qualifications And Duties.. 51 Table of Contents (cont d) Page 4 435. -- 442. (Reserved) .. 51443. Investigational Procedures Or Treatments: Procedural Requirements.. 51444. -- 449. (Reserved) .. 52 SUB AREA: AMBULATORY SURGICAL CENTERS450. -- 451. (Reserved) .. 52452. Ambulatory Surgical Center Services: Coverage And Limitations.. 52453. (Reserved) .. 52454. Ambulatory Surgical Center Services: Provider Qualifications And Duties.. 52455. Ambulatory Surgical Center Services: Provider Reimbursement.. 53456. -- 499. (Reserved) .. 54 SUB AREA: PHYSICIAN SERVICES AND ABORTION PROCEDURES500. Physician Services.. 54501. (Reserved) .. 54502. Physician Services: Coverage And Limitations.
9 54503. (Reserved) .. 54504. Physician Services: Provider Qualifications And Duties.. 54505. Physician Services: Provider Reimbursement.. 55506. -- 510. (Reserved) .. 55511. Abortion Procedures: Participant Eligibility.. 56512. -- 513. (Reserved) .. 56514. Abortion Procedures: Provider Qualifications And Duties.. 56515. -- 519. (Reserved) .. 56 SUB AREA: OTHER PRACTITIONER SERVICES520. -- 521. (Reserved) .. 56522. Non-Physician Practitioner Services: Coverage And Limitations.. 56523. (Reserved) .. 56524. Non-Physician Practitioner Services: Provider Qualifications And Duties.. 56525. Non-Physician Practitioner Services: Provider Reimbursement.. 56526. -- 529. (Reserved) .. 57530. Chiropractic Services: Definitions.. 57531. (Reserved).
10 57532. Chiropractic Services: Coverage And Limitations.. 57533. (Reserved) .. 57534. Chiropractic Services: Provider Qualifications.. 57535. -- 539. (Reserved) .. 57540. Podiatrist Services: Definitions.. 57541. Podiatrist Services: Participant Eligibility.. 57542. Podiatrist Services: Coverage And Limitations.. 57543. (Reserved) .. 58544. Podiatrist Services: Provider Qualifications.. 58545. (Reserved) .. 58546. Licensed Midwife (LM) Services.. 58547. LM Services: Definitions.. 58548. LM Services: Participant Eligibility.. 58 Table of Contents (cont d) Page 5 549. LM Services: Coverage and Limitations.. 58550. LM Services: Provider Qualifications And Duties.. 58551. LM Services: Provider Reimbursement.. 58552. LM Services: Provider Quality Assurance Activities.