• RULE 72, APPENDIX B identifies Nebraska VR services which are paid at Medicaid Rates, per the Medicaid Fee Schedule(s).

• An Office Director exception is required to pay any amount that exceeds the Medicaid Fee Schedule.

• If there is no Medicaid rate for a CPT/HCPC’s code, Nebraska VR will pay as billed.

• Nebraska VR will cover what is medically necessary as determined by the medical provider; the client is responsible for anything in excess.

• Medicaid does not pay shipping and handling

Authorizing at Medicaid rates

*Before receiving quote from any medical provider, ensure Provider is aware Nebraska VR only pays at Medicaid rates.

• Obtain quote from medical provider, make sure CPT/HCPC’s codes are included.
• Go to Medicaid Provider Rates and Fee Schedules found on Nebraska DDHS website to determine Medicaid Rates for the CPT/HCPCs codes provided on the quote: https://dhhs.ne.gov/Pages/Medicaid-Provider-Rates-and-Fee-Schedules.aspx
  • Make sure the date of service is after the start date of the Medicaid fee schedule (the Fee schedule you choose covers the date of service)
  • For an explanation of fee schedule, select the Pdf file
  • For a list of codes/allowable fees at Medicaid rates, select the Excel file
• If you are unable to locate the correct fee schedule, please contact the state office          

Authorization MUST include:

1. CPT/HCPC’s Codes (per the quote) along with the description of those service/devices
2. Default Medicaid language (automatically populates in QE
3. Authorization will say “MEDICAID RATES” in Authorization amount

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Paying at Medicaid rates 

1. Obtain Provider Invoice, manufacturer invoice(s) for devices (IC – Invoice Cost), if needed, and EOB if the client DOES have insurance 

2. If the client has insurance, documentation of coverage/non coverage is required. Examples of documentation are an EOB, copy of insurance policy, written verification from the insurance company, declaration page, etc or any other verifiable documentation confirming the comparable benefit.
3. If invoice is for Prescription Drugs, forward invoice to State Office. Invoice must include name of prescription, NDC (National Drug Code), and Quantity.  State Office will contact DHHS to figure the Medicaid allowable amount for the prescription.  State office will then forward DHHS response in an email/screenshot of the allowed amount to be entered on Medicaid worksheet. (Copy of email/screenshot from State office must be attached behind Provider invoice and worksheet when sending in for payment)
4. For Physician Services, if a service is provided-

• At the Hospital, use the rate in the FACILITY RATE column
• At a Physician’s office, use the rate in the NON-FACILITY RATE column

     5. Open the appropriate Worksheet (from the FORMS ASSOCIATED TO THIS CHAPTER below) that will help calculate what Nebraska VR can pay at Medicaid rates and follow the   instructions within the worksheet.

 

• MEDICAID (NO INSURANCE):  Use this worksheet when client doesn’t have insurance.  (Amount to be paid is the lower of the TOTAL Provider BILLED or TOTAL MEDICAID ALLOWABLE, not the lower of each cost per service/device)

 

• MEDICAID (with INSURANCE/Medicare): Use this worksheet when client has insurance/Medicare (Amount to be paid will be the lower of the Total Billed, Total Medicaid or the Total of Not Covered + Insurance Allowed; less any amounts paid by client’s insurance or 3^rd party assurers, or client)

 

5.  When payment is determined:
   • If we are paying less than billed, cross through the amount on the Providers Invoice, and write/type “Pay only $_____”
   • If we are paying as billed, Circle the amount on the Providers invoice and write/type “Pay as billed”.

 

6. The Document order when sending into State Office:
   1. Provider invoice
   2. Manufacturer invoices (if any)
   3. EOB (if any)
   4. If for Prescription drug, Pdf screenshot of calculation from DHHS 
   5. Pdf of Medicaid worksheet 

Commonly used acronyms 

IC – Invoice Cost – Requires the Provider to send a copy of their Invoice cost (manufacturer invoice) for all devices except batteries or if they make them ‘in-house’ (like ear molds).

BR – By Report-Requires our Prior review and Exception to the VR Rule 72

CPT – (Current Procedural Terminology)- are for surgeries, diagnostic tests, evaluation, and management services, etc. but generally just numbers with no letters before them. 

 

HCPCS – (Healthcare Common Procedure Coding System) are for basic healthcare services like medical devices, supplies, etc.  They have 5 Characters, but the first is a letter and rest are numbers.

 

Common Modifiers on Provider invoices

R - Replacement

RA – Replacement under loss or damage coverage

RB - Repair

Medicaid Spreadsheet (No Insurance)

Medicaid Spreadsheet (With Insurance)