How does a hospital determine whether a procedure subject to pre-review by ODJFS—such as elective bariatric surgery—is covered by HCAP?
Hospitals are advised to use Medicaid coverage as a proxy for determining whether a particular service would be considered medically necessary, according to OAC 5101:3-2-07.17 (A)(1) [see FAQ 6.1]. For further information regarding conditions and limitations of inpatient and outpatient coverage, please refer to OAC 5101:3-2-03 .
In general, whether an individual service or procedure is eligible for free care hinges on two factors: whether the care is medically necessary and whether Medicaid covers the service for its enrollees. When considering a service subject to Medicaid pre-certification, a hospital must make the same assessment ODJFS would have made, had it been the payer. That is, whether the care is medically necessary, versus being done for cosmetic reasons or patient convenience. If the patient’s primary physician will document that the service is medically necessary, then it is also eligible for free care. (07/01/10) PATIENT ACCOUNTING AND MEDICAID COST REPORTING Note this section is renumbered as 8 (07/01/10) 8.1 Our hospital does not maintain logs for patient accounts with family incomes above 100% of the federal poverty income limits. How should we document HCAP eligibility for these “bad debts?” You must maintain logs for all categories of entries on the Medicaid Cost Report Schedule F, including
Related Questions
- When does a covered entity have discretion to determine whether a research component of the entity is part of their covered functions, and therefore, subject to the HIPAA Privacy Rule?
- How does a hospital determine whether a procedure subject to pre-review by ODJFS—such as elective bariatric surgery—is covered by HCAP?
- Who should an employee contact to determine if a specific procedure is covered under the Total Health Plan?
