• Rule 72, Appendix B identifies items, which are paid at Medicaid Rates.
• Payment Amount: Payment will be at the lower of either Total Billed Charges, or Total Medicaid Allowable. This does not mean the lower of the two costs for each individual item. An example of this is as follows:

Service	CPT	$ Billed	$ Medicaid	Individual Cost
Hearing Aid	V5060	$517.38	$517.38	$517.38
Dispensing Fee	V5241	$244.06	$248.89	$244.06
Ear Mold	V5264	$40.00	$35.00	$35.00
Batteries (7)	V5266	$10.00	$7.00	$7.00
Totals		$811.44	$808.27	$803.44

• The proper amount to pay for this example is $808.27 (If the $ Billed Total is lower, pay the $ billed total. If the $ Medicaid Total is lower, pay the Medicaid Total.) The Individual Cost column is incorrect procedure; and is never to be utilized.

• Payment Attachment: A chart (e.g. Check Medicaid Rates) showing the Medicaid rate total vs. the Invoice total must be attached to each payment. Compare only the $ Invoiced total and the $ Medicaid total to arrive at the proper payment amount.
• Neuropsychological Exams: 96116 and 96118 are found in the “Physicians” Fee Schedule. These rates are allowed for both Medical Doctors and Psychologists. A total of 8 hours is allowed for a combination of the two codes as a maximum. If greater than 8 hours, medical records are required to document the added hours of testing.
• Hearing Aids: “The Hearing Aids” Fee Schedule sets a maximum rate per aid for State Fiscal Year 2012 at $708.93 per individual aid. Any amount in excess of this requires an Exception to the VR rule 72. The rate, definitions, and other important information can be found at the beginning of the Fee Schedule. Note – Medicaid will not pay Shipping & Handling for any goods.
• Prescription Drugs:

  • Each prescription has a. National Drug Code (NDC) in a numerical fashion such as XXXXXXXXX-XX
  • Metric Decimal Equivalency (MDQ) is often expressed as #120 or as a number shown as “Quan” or “Quantity”.
  • Fax (308.865.5348) or email (gil.kindsfater@nebraska.gov) a copy of the invoice asking for the proper Medicaid rate to pay. Gil will calculate the payment amount for the Medicaid rate, and provide a screen shot verifying the cost of each drug purchased. This screen shot must be attached to the payment when submitted. If Gil is unavailable, Melysa Johnson (melysa.johnson@nebraska.gov) may be contacted for the information.

• Durable Medical Goods: Note - Medicaid will not pay Shipping & Handling for any goods. When VR is the sole purchaser of the services or goods; they will be purchased at the prevailing Nebraska Medicaid Rates. If, however, Medicare or Personal Insurance is paying a portion of the cost, VR now is willing to pay the remainder, so long as the total VR payment portion does not exceed the limits imposed by the Nebraska VR Fee Schedule for the services or goods. Concurrent rules will apply as per our “Assignment Purchases Policy found below. In order to successfully carry out such an arrangement the provider must be advised, and willing to adhere to Nebraska VR’s Assignment Purchase Policy.
• Assignment Purchases:

  • Medicare as first payer: The provider must be willing to “accept assignment” for the Consumer’s share of the payment at the Medicare rate to be paid by VR. For Medicare Allowed goods and services, both Nebraska Medicaid and VR will honor the Medicare rates and co-pay the remaining amount due. Should there be Nebraska VR authorized goods or services that Medicare does not allow, or that Nebraska Medicaid does not allow, Nebraska VR will pay for them according to the lower of the Provider’s Billed amount or a negotiated amount.
  • Third Party Purchases: the provider must be willing to accept assignment of the remaining costs based on the lower of their Billed Service Total, the First Assurer’s contracted Allowed Total or the Nebraska Medicaid Rate Total. The principle for this is that the provider may not be paid more than the normal and customary charge from its contracted assurers or its normal and customary charge for other groups of people. If there are no discounts shown on the EOB, we need to ask the provider if they have an agreement with the First Assurer. Again, should there be Nebraska VR authorized goods or services that the First Assurer does not allow, or that Nebraska Medicaid does not allow, Nebraska VR will pay for them according to the lower of the Provider’s Billed amount or a negotiated amount. Otherwise Nebraska VR will use the Nebraska Medicaid Fee Schedule for its payment basis.
  • VR will need an invoice, which shows all applicable CPT Codes
  • VR will need to determine the first Assurer’s Allowed Total, and compare it with the Nebraska Medicaid Rate Total. To do this we must obtain a copy of the First Assurer’s Explanation of Benefit Statement (EOB). The EOB’s must be obtained from the provider when billing VR for the remaining portion. The remaining portion will then be limited to the lower of the First Assurer’s Allowed Total plus amounts not allowed, the Nebraska Medicaid total for all Allowed VR goods or services, or the Provider’s Billed Total for all services or goods authorized by VR. We will use an “Assignment Form - Medicare” or an “Assignment Form – 3rd Party Payer” to calculate the amount to pay.

• Eye Glasses: Note - Medicaid will not pay Shipping & Handling for any goods.

  • Purchase of eyewear can be extremely complicated, when the Consumer desires options. VR payment options, which will require an Exception to Rule 72, are

    • Anti-reflective and mirror lens coating
    • Blended and progressive multi-focal lenses (AKA “No Line Bifocals”)
    • Drilling, notching, grooving, and faceting of lenses
    • Edging or beveling of lenses for cosmetic reasons
    • Engraving
    • High index lenses when correction is less than +/- 10.00 diopters
    • Photo chromatic and transition tints (AKA “Transition Lenses”)
    • Polycarbonate lenses for correction of less than +/- 8 diopters
    • Rolled or polished edges
    • Additional scratch resistance (some is already included for plastic lenses)
    • Ultraviolet (UV) unless prescribed for Chronic UV Disorder Otherwise, if the Consumer is willing to pay for any of these options, you must provide a clear understanding of this in the authorization text. If determined at the point of Consumer fitting, after authorization, provide verbal understanding of what will be payable by VR.

• Partial Costs: Sometimes the costs of services are broken down into components, such as this. Note the modifiers in column B:

93990		$105.84
93990	26	$15.12
93990	TC	$90.72

• If the practitioner is a member of the facility where this service is provided, it will be billed for $105.84. If not, the individual practitioner will get $15.12 for the “Professional Component” (26), and the facility will get $90.72 for the “Technical Component” (TC). The facility generally will hire all necessary technicians to assist with any Technical Components, but occasionally there may be another added charge (80) for an assistant.

• Facility Charges verses Non-Facility Charges: There is now a lower allowable cost for Physicians Services, which are provided in a Hospital setting. This is because they have no equipment cost:

  • Use the “Facility Rate” for any service provided by a physician at the Hospital.
  • Use the “Non-Facility Rate” for any service provided by a physician at their clinic.

To provide guidelines regarding the use of Medicaid rates.

Commonly used Terms – Some require Rule 72 Exception Approval:

• Prior Authorize – Requires our prior review and an Exception to the VR Rule 72
• IC - Invoice Cost – Requires the Provider to send a copy of their Invoice cost for the items which have this designation, except for dispensing fees.
• BR – By Report – Requires our prior review and an Exception to the VR Rule 72
• R – Replacement (example - RA = Replacement Hearing Aid)
• RR – Monthly Rental
• KR – Daily Rental
• RA – Replacement under loss or damage coverage (We usually don’t purchase loss or damage coverage for Durable Medical Goods)
• RB – Repair – We do pay for repair at times
• RNE – Relative Value Not Established - requires our close attention to price
• CPT – Current Procedural Terminology – Required to apply the rates Not Covered - Requires our prior review and an Exception to the VR Rule 72.

Commonly used Health Professional Abbreviations:

• RN - Registered Nurse
• APRN - Advanced Practice Registered Nurse
• DO - Doctor of Osteopathy
• LADC - Licensed Alcohol and Drug Abuse Counselor
• PLADC - Provisionally Licensed Alcohol and Drug Abuse Counselor
• LMHP - Licensed Mental Health Practitioner
• LIMHP - Licensed Individual Mental Health Practitioner
• PLMHP - Provisionally Licensed Mental Health Practitioner
• MD - Medical Doctor (Includes Psychiatrists)
• PA - Physicians Assistant
• PhD (67) - Doctor of Philosophy (Includes Psychologists)
• PhD Cand (38) Candidate - Needs to complete Internship and Dissertation
• PhD Prov (57) Provisional PhD - Needs to complete the PhD Dissertation
• PhD S (64) PhD with differing course work - Grandfathered In
• Note: 90792 are only for Physicians and APRN’s. PhD’s use 90791.

INACTIVE FORM: Check Medicaid Rates

INACTIVE FORM: Check 3rd Party Medicaid Rates