IDAPA 16 – IDAHO 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.

2 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. )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?

3 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. 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?

4 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.

5 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.

6 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. (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.

7 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.. 32331.

8 -- 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.

9 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.. 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.

10 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.. 51434. Surgical Procedures For Weight Loss: Provider Qualifications And Duties.