Federal Emergency Services Coverage for Emergency Medical Only Recipients
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Revises Nevada Medicaid Services Manual Chapter 200, Attachment A, Policy 02-02, governing Federal Emergency Services coverage for Emergency Medical Only recipients and clarifying covered, non-covered, definitional, and provider-requirement provisions.
Policy Summary
PayerNevada Health Authority
PolicyFederal Emergency Services Coverage for Emergency Medical Only Recipients
Policy CodePolicy 02-02
Change TypeModified
Effective DateOctober 29, 2025
Next Review DateN/A
Key ActionObtain QIO-like vendor authorization for all inpatient hospital admissions before seeking reimbursement.
The policy clarifies that stabilizing treatment for an acute emergency medical condition, as well as labor and delivery, is covered under the FES program.
The definition of the Federal Emergency Services Program was revised, and the federal regulatory definition of Emergency Medical Condition was added as a separate definition.
The coverage-and-limitations section was reorganized and includes a reference to EMO billing instructions.
The policy adds services to the non-covered-services list to identify additional services that are not reimbursable under EMO coverage.
The ESRD Provider Requirements section adds language regarding provider-required forms that were removed from the non-covered-services section.
2Core coverage clarifications
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FES non-covered service categories
AllInpatient admissions requiring authorization
39 weeksEarly-induction threshold
48 hoursMaximum observation duration
Coverage Criteria
Clarified FES-covered services
Covered under the FES program when the service involves qualifying emergency treatment for an EMO recipient.
Covered services
Acute emergency stabilization: Stabilizing treatment of an acute emergency medical condition is covered.
Labor and delivery are covered under the FES program.
Inpatient hospital service coverage criteria
Covered when all facility and service requirements are met.
Inpatient hospital qualification
The service is ordinarily furnished in a hospital for the care and treatment of an inpatient under the direction of a physician or dentist.
The institution is maintained primarily for care and treatment of patients with disorders other than mental disease.
The institution is licensed as a hospital by an officially designated state authority.
The institution meets Medicare hospital participation requirements.
The institution has a utilization review plan applicable to all Medicaid recipients that meets 42 CFR 482.30 and 42 CFR 456.50-456.145.42 CFR 482.30 and 42 CFR 456.50-456.145
Medical necessity
Hospital reimbursement is based on medical necessity as defined in MSM Chapter 100.
Medically necessary hospital service: The hospital service is medically necessary under the Medicaid medical-necessity definition and falls within a covered hospital service category described in Chapter 200.
Covered categories include inpatient, outpatient, ambulatory surgical, LTAC, inpatient rehabilitation, freestanding birthing-center, federal emergency, dialysis, and outpatient observation services.
Out-of-state acute inpatient services
Non-emergency out-of-state acute inpatient hospital care is covered when all requirements are met.
Out-of-state acute inpatient authorization
The care is non-emergency out-of-state acute inpatient hospital care.
Prior authorization is obtained from the QIO-like vendor.
The service involves a specialized medical procedure not available in Nevada.
Admission criteria
A recipient is considered admitted when all of the following are met.
A physician provides an admission order at admission or during the hospital stay, verified by the date and time.
Acute care services are rendered.
The recipient has been transferred to, or is awaiting transfer to, an acute care bed from the emergency department, operating room, admitting department, or another hospital service.
The admission is certified by the QIO-like vendor based on pertinent supporting documentation submitted with the admission authorization request.
Medical necessity and level-of-care review
Inpatient coverage and reimbursement require QIO-like vendor review.
Authorization review
Medical necessity is established from pertinent clinical information.
The appropriateness and location of service are established.
The service complies with Nevada Medicaid policy.
The appropriate level of care and authorized length of stay are established.
The care could not be safely, effectively, and more economically furnished on an outpatient basis, in another inpatient facility, or at a lower level of care.
Services requiring authorization
Prior authorization is required for the following specified services.
Prior-authorization categories: Non-emergency out-of-state acute inpatient care; non-emergency hospital transfers; unrelated surgery, treatment, or invasive diagnostic testing; early induction before 39 weeks; specified antepartum, dental, family-planning, psychiatric, substance-use, swing-bed, leave-of-absence, third-party-liability, Medicare-exhaustion, EPSDT, newborn/NICU, emergency, extended-stay, rollover, and behavioral-health admissions; and changes in level of care or transfers between units.
Prior authorization is generally required before service delivery; specified emergency and post-admission categories may be requested within five business days.
Limited authorization exceptions
The following inpatient services may be reimbursed without general Medicaid authorization only when the stated conditions are met.
The service is Medicare-covered for a dual-eligible recipient; Medicaid authorization is obtained for Medicare-noncovered services and after Medicare Part A exhaustion.
The recipient is QMB-only and the service is limited to Medicaid payment of copayments and deductibles.
The stay does not exceed two obstetric and newborn inpatient days after vaginal delivery at or after 39 weeks gestation, or four days after a medically necessary cesarean delivery.2 days after vaginal delivery; 4 days after medically necessary cesarean delivery
This exception does not apply to NICU days; all NICU days require authorization.
Newborn and NICU level of care
Newborn reimbursement is based on the highest clinically supported level of care reached during each calendar day.
Newborn level-of-care billing
The newborn's level of care is clinically evaluated daily.
The applicable InterQual or MCG level and UB revenue code are submitted through the Provider Web Portal.
The revenue code corresponding to the highest level reached during that calendar day is billed.UB Levels I-IV; revenue codes 0170-0174
UB Levels III and IV are paid at the same rate.
Inpatient medical-necessity and level-of-care review
Inpatient admission and continued inpatient services are subject to QIO-like vendor review.
Inpatient authorization review
Medical necessity, appropriateness, location of service, and level of care are supported by clinical information.
The services could not safely, effectively, and more economically be furnished in an outpatient setting, another inpatient facility, or a lower level of care.
The authorized time period for the inpatient stay is established.
Concurrent and retrospective review
Continued or retrospective inpatient coverage depends on clinical support for medical necessity and the appropriateness of the setting.
Review outcome
For concurrent review, clinical information supports continued inpatient services in the current setting.
For retrospective review, clinical information supports approval of services after delivery.
Admission certification and plan of care
Inpatient payment and care must be supported by required orders, recertification, and a written plan of care.
Inpatient documentation requirements
A physician order is written before or at admission.
An authorized physician, PA, or APRN recertifies medical necessity at least every 60 calendar days after the initial order.At least every 60 calendar days
A written plan of care is established before admission or before authorization for payment.
The plan includes diagnoses and admission indicators, functional status, treatment and service orders, continuing-care plans when appropriate, and discharge plans when appropriate.
Skilled administrative days
Covered when all authorization, level-of-care, and qualifying-circumstance requirements are met.
Skilled administrative day requirements
The recipient is in an acute inpatient hospital or critical access hospital.
The days represent a reduction from acute level of care.
At least one acute inpatient hospital day immediately precedes the initial request.
The days are authorized by the QIO-like vendor.
Qualifying circumstance: The recipient is awaiting evaluation or placement; discharge is delayed by equipment or home-based service arrangements; a medically complicated newborn is awaiting placement; non-acute medical intervention prevents discharge; or preparation is occurring for unrelated surgery that does not meet acute criteria.
Intermediate administrative days
Intermediate administrative days are covered when all of the following conditions are met.
Intermediate administrative day requirements
The services do not meet acute level-of-care criteria.
The days are authorized by the QIO-like vendor.
The recipient cannot be discharged for a qualifying social reason.
Examples include a stable newborn awaiting adoption or the mother's discharge, a recipient awaiting medically assisted transportation, or a recipient requiring evaluation after being a crime victim.
Non-covered administrative days
Administrative days are not covered when any exclusion applies.
Administrative-day exclusions
No acute inpatient day immediately preceded the initial request.
The stay is solely for the convenience of the recipient, family, or physician.
The recipient or responsible party refuses discharge planning or available placement.
A discharge order is written without comprehensive discharge planning or an acceptable documented reason and timeframe for an unavoidable delay.
Comprehensive discharge planning
Hospital reimbursement requires comprehensive discharge planning and documented compliance with discharge requirements.
Discharge planning requirements
Discharge evaluation begins as soon as practical when indicated.
Qualified personnel develop or supervise the discharge plan with input from care staff, the recipient, family, and physician as applicable.
The plan identifies goals, resolution dates, and needed discharge services and is updated after reevaluation.
The record documents placement efforts, alternatives, contacts, recipient understanding, refusals, and unavoidable delay reasons and timeframes when applicable.
A physician discharge order is documented.
Sterilization-related coverage
Sterilization-related inpatient coverage follows a split rule.
Covered inpatient days other than sterilization day
Medically necessary inpatient days within the same episode of care, other than the sterilization day, meet applicable inpatient coverage rules.
Ambulatory surgical services
Ambulatory surgical services are reimbursable only when the outpatient setting remains medically appropriate.
Ambulatory surgical coverage
The service is provided in a freestanding ambulatory surgical center or hospital-based ambulatory surgical setting.
The recipient does not require acute inpatient-level care, inpatient-only testing or interventions, or prompt inpatient intervention for likely complications.
The service is reasonable and medically necessary.
The service is not ordered as inpatient.
The service cannot be provided in a less restrictive setting.
LTAC medical necessity
LTAC services are covered when all medical-necessity, ordering, staffing, coordination, and authorization requirements are met.
LTAC covered services
Frequent, specialized therapeutic interventions are required on an inpatient basis.
Services are ordered and supervised by a physician or another person authorized under state licensure law.
Skilled nursing services are provided with 24-hour on-site RN availability.
Services are delivered under a multidisciplinary, coordinated plan of care.
The QIO-like vendor authorizes the services as medically necessary.
Emergency department services
Emergency department services are defined by the potential consequences of delaying treatment.
Emergency department definition: Delay in treatment of more than 24 hours could result in severe pain, loss of life, loss of limb, loss of eyesight or hearing, injury to self, or bodily harm to others.>24 hours delay could cause serious harm
Non-emergent emergency-department services are covered for recipients with full Medicaid eligibility and must be billed at the most appropriate level.
Administrative days
Administrative days require authorization and supported discharge planning.
Administrative day coverage requirements
Prior authorization is obtained.
Retrospective authorization is obtained when Medicaid eligibility is determined after inpatient admission or discharge.
Pertinent discharge-planning information is submitted to the QIO-like vendor.
The vendor is notified when the level of care is reduced to administrative days.
Comprehensive discharge-planning documentation is maintained in the medical record.
Initial inpatient rehabilitation coverage
Covered when all criteria are met.
Inpatient rehabilitation coverage
Services are medically necessary intensive inpatient rehabilitation in a freestanding rehabilitation hospital or rehabilitation unit of a general or critical access hospital.
Services are ordered and provided under the direction of a physician with specialized rehabilitation training or experience.
Services are authorized as medically necessary by the QIO-like vendor.
Admission is from an acute hospital or nursing facility within one year of the initial injury or illness or most recent related surgery or hospitalization.Within 1 year
Inpatient rehabilitation intensity exception
Covered only when all exception conditions are met.
Unexpected clinical event exception
An unexpected clinical event prevents participation in intensive therapy.
The exception occurs no more than once per admission and lasts no more than three consecutive days.Once per admission; maximum 3 consecutive days
Comprehensive documentation of the event is provided to the QIO-like vendor.
The preadmission screen, post-admission physician evaluation, and plan of care support that the recipient was initially able to participate actively.
Brain-injury trial admission
Covered when the trial criteria are met.
The recipient has a brain injury.
A comprehensive preadmission assessment supports a reasonable expectation of benefit from an interdisciplinary inpatient rehabilitation stay.
The trial admission does not exceed seven days.No longer than 7 days
Therapeutic rehabilitation leave
Covered when all leave requirements are met.
The leave is for a therapeutic reason, such as preparing for independent living.
The leave is authorized by the QIO-like vendor.
The leave does not exceed 32 hours.Maximum 32 hours
The record contains a physician order specifying the number of hours, the medically appropriate reason, and an evaluation of therapeutic effectiveness.
Freestanding birthing-center coverage
Covered when all pregnancy and service criteria are met.
Freestanding birthing-center services
The service is medically necessary natural childbirth care for labor, delivery, postpartum care, and immediate newborn care.
The prenatal course is uncomplicated and low risk and is reasonably expected to result in a normal, uncomplicated vaginal birth consistent with center protocol.
Gestational age is at least 36 weeks and no more than 42 weeks.36-42 weeks gestation
The recipient received adequate prenatal care and has a reasonable prospect of a normal uncomplicated birth.
Federal Emergency Services acute emergency coverage
Covered when the service is stabilizing treatment for a qualifying acute emergency medical condition.
FES emergency treatment
The recipient has an acute emergency medical condition meeting the FES Program definition and 42 CFR 440.255.
The service is stabilizing treatment of that emergency medical condition.
Outpatient dialysis for FES recipients with ESRD
Covered when all of the following are met.
Emergency ESRD dialysis
The recipient is an FES recipient with ESRD.
The treating physician signs and completes the required certification.
Serious consequence of absent dialysis
Absence of dialysis at least three times per week could place the recipient's health in serious jeopardy.At least 3 times per week
Absence of dialysis could cause serious impairment of bodily functions.
Hospital swing bed medical necessity
Covered when all of the following are met.
Post-acute swing bed coverage
The recipient received acute inpatient hospital services for at least three consecutive calendar days, excluding the day of discharge.At least 3 consecutive calendar days
The recipient requires post-acute skilled nursing services seven days a week.7 days per week
No nursing-facility placement is available, or the recipient or family refuses nursing-facility placement outside the rural area.
The swing bed placement is temporary rather than long-term.
Swing bed covered services and reimbursement
Covered swing bed services are reimbursed at a per diem rate, with specified services separately reimbursable when their own policy requirements are met.
Swing bed covered services
Medically necessary post-acute nursing-facility level-of-care services are provided on an inpatient basis.
The per diem includes routine room, dietary, nursing, social, activity, supply, oxygen, equipment, and facility services.
Separately reimbursable services: Prescription drugs, tube-feeding nutritional supplements, physician-recommended appliances and devices, customized DME, emergency transportation, therapies, physician services, laboratory, portable x-ray, diagnostic services, or repair of recipient-owned equipment meet their applicable policy requirements.
Covered outpatient observation
Outpatient observation is covered when ordered by an authorized clinician, medically necessary, and within the permitted duration.
Observation is ordered by a physician or other clinician authorized by state licensure law and hospital bylaws.
Observation is medically necessary.
Observation is provided for no more than 48 continuous hours.Up to 48 continuous hours
Qualifying clinical circumstance
The recipient is clinically unstable for discharge because of abnormal laboratory values, abnormal signs or symptoms requiring monitoring, vague symptoms without a definitive diagnosis, or uncertain severity requiring possible intervention.
Hospital swing bed authorization
Swing bed services require authorization and supporting documentation.
Swing bed authorization documentation
The provider submits the initial or concurrent authorization request to the QIO-like vendor.
The initial request includes a history and physical or acute inpatient discharge summary showing skilled nursing need.
The physician acute-hospital discharge order and swing-bed admission order are submitted.
Nursing-facility placement efforts and bed unavailability or refusal of placement outside the rural area are documented.
For concurrent review, ongoing placement efforts and a monthly nursing assessment showing continued skilled level of care are submitted no less frequently than monthly when applicable.
Coding and Operational Thresholds
Covered Newborn UB Revenue CodesRevenueCovered
0170
General
0171
Newborn - UB Level I: routine care of apparently normal full-term or preterm neonates; newborn nursery
0172
Newborn - UB Level II: low-birth-weight neonates who are not sick but require frequent feeding, or neonates requiring more nursing than normal neonates; continuing care
0173
Newborn - UB Level III: sick neonates who do not require intensive care but require six to 12 hours of nursing daily; intermediate care
0174
Newborn - UB Level IV: newborns needing constant nursing and continuous cardiopulmonary and other support for severe illness; intensive care
Covered InterQual and MCG to UB Editor Level-of-Care Crosswalk CodesmixedCovered
0170 / 0171
UB Level I; crosswalk from Newborn Nursery / Level I
0172
UB Level II; crosswalk from InterQual I / MCG Level I / Transitional Care
0173
UB Level III; crosswalk from InterQual II / MCG Level II
0174
UB Level IV; crosswalk from InterQual III & IV / MCG Level III & IV
Authorization, Documentation, and Denial Risks
Prior Authorization
Out-of-State Acute Inpatient Authorization
Obtain prior authorization from the QIO-like vendor for non-emergency out-of-state acute inpatient care for Medicaid recipients. The referral must come from the referring or transferring Nevada physician and/or hospital and generally concerns specialized services unavailable in Nevada.
Document the clinical reason for the out-of-state referral and supporting evidence that the service is unavailable in Nevada.
Maintain the referral, authorization number, and related planned-admission records.
Prior Authorization
Authorize Acute Hospital Transfers
The attending physician transferring a Medicaid recipient from an acute hospital to another acute hospital must request authorization before the transfer, including transfers to general, psychiatric, LTAC, or inpatient rehabilitation hospitals.
Submit clinical information supporting the transfer and requested level of care.
Record the transferring physician's order, planned transfer date, destination, and authorization number.
Policy Summary
PayerNevada Health Authority
PolicyFederal Emergency Services Coverage for Emergency Medical Only Recipients
Policy CodePolicy 02-02
Change TypeModified
Effective DateOctober 29, 2025
Next Review DateN/A
Key ActionObtain QIO-like vendor authorization for all inpatient hospital admissions before seeking reimbursement.
Required level-of-care and PASRR documentation is completed before nursing-facility placement.
Active, ongoing interventions from multiple therapy disciplines are required on an inpatient basis.
Physical and/or occupational therapy is included.
The recipient is capable of significant, measurable functional improvement in activities of daily living within a specified period.
Rehabilitative services are provided at least three hours per day, five days per week, or 15 hours within each seven-consecutive-day period beginning on admission.3 hours/day for 5 days/week or 15 hours/7 consecutive days
Absence of dialysis could cause serious dysfunction of a bodily organ or part.
A significant adverse reaction occurs after a therapeutic service such as blood or chemotherapy administration or dialysis.
Observation criteria are met, inpatient admission is denied because acute inpatient criteria are not met, a physician orders observation status, and applicable patient-rights and federal utilization-review requirements are satisfied.
At least monthly
Documentation Required
Verify Transfer Authorization Before Acceptance
Before agreeing to accept or admit a recipient for a non-emergent transfer, the receiving hospital must confirm with the QIO-like vendor that the transferring physician or hospital obtained authorization before the transfer.
Verify the authorization directly with the QIO-like vendor.
Document the verification, authorization number, accepting physician, and planned admission or transfer records.
Unsupported block type: prior_auth
Prior Authorization
Authorize Before Non-Emergency Transfer
The transferring physician or facility must obtain authorization before a non-emergency transfer between in-state or out-of-state facilities and provide the authorization number to the receiving hospital.
Do not transfer until authorization is obtained.
Include the admission order, transfer order, planned destination, and transfer admission records.
Prior Authorization
Obtain General Inpatient Authorization
All inpatient hospital admissions must be authorized by the QIO-like vendor for Nevada Medicaid reimbursement. The vendor evaluates medical necessity, appropriateness, location, and compliance and certifies level of care and length of stay.
Submit the admission order and admission date.
Provide the physician's clinical information, written plan of care, and all pertinent medical information in the required format and timeframe.
Authorization does not guarantee payment; eligibility and other coverage requirements still apply.
Prior Authorization
Request Additional Inpatient Days
Request additional inpatient review days within five business days of the last day of the current or existing authorization period.
Submit updated clinical information supporting continued medical necessity, level of care, and requested length of stay.
Track authorization end dates and submit concurrent-review requests before the deadline.
Prior Authorization
Authorize Specified Non-Emergency Services
Providers must submit pertinent clinical information and obtain prior authorization for specified non-emergent services and admissions, including unrelated procedures, early induction, dental, family-planning procedures, non-emergency admissions, psychiatric admissions, level-of-care changes, detoxification, swing beds, therapeutic leave, TPL admissions, Medicare-noncovered days, and EPSDT admissions.
Submit the admission order, planned procedure or transfer records, and clinical information supporting authorization.
Obtain a new or updated authorization for every change in level of care or transfer between units.
Prior Authorization
Coordinate Dental and Inpatient Authorization
Dental admissions require two approvals: the Medicaid dental consultant must authorize the dental procedure, and the QIO-like vendor must authorize the medical necessity of inpatient hospitalization.
Obtain both authorizations before the planned admission or procedure.
Maintain the dental treatment authorization and inpatient medical-necessity authorization in the record.
Prior Authorization
Submit Authorization Within Five Business Days
Providers must submit pertinent clinical information and request QIO-like vendor authorization within five business days for emergency inpatient admissions, emergency transfers or level-of-care changes, specified obstetric and newborn stays, NICU admissions or transfers, and qualifying rollover admissions.
For emergency admissions, transfers, or level-of-care changes, submit the request within five business days.
For obstetric and newborn stays, count from delivery: authorization is required after two days for vaginal delivery or four days for medically necessary cesarean delivery.
All NICU days require authorization; maintain the admission order and admission date.
Prior Authorization
Authorize Obstetric and NICU Care
Obstetric and newborn admissions exceeding the applicable two-day vaginal or four-day medically necessary cesarean threshold require authorization within five business days after the threshold is exceeded. Every newborn or neonate admission or transfer to a NICU requires authorization.
Document delivery type, delivery date, admission date, and authorized days.
Maintain newborn level-of-care documentation and NICU clinical information.
All NICU days require authorization, even when the ordinary obstetric/newborn day exception applies.
Prior Authorization
Authorize Emergency Transfers
The receiving hospital must obtain authorization for an emergency transfer within five business days of the inpatient admission.
Submit the emergency transfer record, admission order, admission date, and pertinent clinical information.
Document the receiving hospital's authorization request and authorization number.
Prior Authorization
Authorize After Medicare Exhaustion
After Medicare Part A benefits are exhausted, obtain Medicaid QIO-like vendor authorization for non-Medicare-covered inpatient days within 30 days of receiving the Medicare EOB. Providers must notify the vendor when exhaustion is suspected and submit the EOB or equivalent proof.
Medicare/Medicaid dual eligibles generally do not need Medicaid authorization for Medicare-covered services.
Follow Medicaid authorization rules for Medicare-noncovered days; QMB-only claims denied by Medicare are also denied by Medicaid.
Prior Authorization
Apply Inpatient Admission Authorization Rules
All inpatient admissions require QIO-like vendor authorization except specified exceptions, including qualifying Medicare-covered dual-eligible services and limited obstetric/newborn stays. Non-Medicare-covered admissions or days must follow Medicaid authorization requirements.
Obtain authorization for Medicare-noncovered admissions and days.
All NICU days require authorization.
Maintain the admission order, admission date, and applicable Medicare documentation.
Prior Authorization
Document Obstetric and Newborn Medical Necessity
Early induction before 39 weeks must be medically necessary and authorized. Obstetric and newborn stays beyond the applicable delivery-day thresholds and all NICU days require authorization within the specified timeframe.
Maintain newborn level-of-care documentation and delivery records.
Submit clinical information supporting medical necessity and the authorized length of stay.
Elective or non-medically necessary cesarean admissions are not covered.
Prior Authorization
Authorize Leave of Absence
Obtain prior authorization for an acute-hospital leave of absence expected to exceed eight hours and for rehabilitation therapeutic leave exceeding eight hours or involving an overnight stay. Rehabilitation therapeutic leave may not exceed 32 hours.
Maintain a physician order specifying the duration, the medically appropriate reason, and an evaluation of therapeutic effectiveness.
Document the leave in the medical record and obtain vendor authorization before the leave when required.
Prior Authorization
Authorize Elective Procedures and Admissions
The physician or staff must obtain QIO-like vendor prior authorization for all non-emergency, elective, planned hospital procedures and admissions. Dental, oral, and maxillofacial surgeons must also obtain dental consultant authorization for covered procedures.
An unauthorized elective procedure or admission is automatically denied and cannot be appealed.
Do not rebill an authorized inpatient service as outpatient merely because the inpatient stay was denied, except for truly prior outpatient services.
Prior Authorization
Coordinate Crossover Authorization
For Medicare/Medicaid crossover admissions, notify the QIO-like vendor when Medicare coverage is exhausted, provide the Medicare EOB or other supporting proof, and obtain Medicaid authorization for acute or administrative days.
Concurrent review is generally not conducted until Medicare acute days or benefits are exhausted.
Medicaid authorization covers acute and administrative days only under the crossover process.
Prior Authorization
Authorize Non-Emergency Facility Transfers
The transferring physician or facility must obtain prior authorization for non-emergency transfers between facilities before transfer and provide the authorization number to the receiving hospital.
Maintain planned and transfer admission records, including orders, destination, date, and authorization number.
The receiving hospital must verify authorization before accepting or admitting the recipient.
Prior Authorization
Request Emergency Transfer Authorization
For an emergency transfer, the receiving hospital must request authorization within five business days of inpatient admission.
Submit the emergency transfer documentation, admission order and date, and clinical information supporting the receiving level of care.
Retain the request and authorization confirmation.
Prior Authorization
Authorize Administrative Days
Administrative days require prior authorization, and retrospective authorization is required when Medicaid eligibility is established after admission to or discharge from an inpatient bed.
Apply the inpatient prior-authorization and utilization-review rules.
Notify the QIO-like vendor when the recipient's level of care is reduced to administrative days.
Documentation Required
Submit Administrative-Day Request Records
Submit all pertinent discharge-planning information with the administrative-day request and obtain authorization within the QIO-like vendor's required timeframe.
Provide placement efforts, contacts and results, social-work/case-management/nursing notes, physician orders or progress notes, modified plans, and acceptable reasons and timeframes for unavoidable delays.
Maintain administrative-day documentation and discharge-planning records in the medical record.
Unsupported block type: denial_risk
Prior Authorization
Submit Ambulatory Surgery Preapproval
Contact the QIO-like vendor 48 hours before an ambulatory surgery procedure and submit the required authorization form, Medicaid eligibility card, and all supporting medical documentation.
Requests cannot be accepted from facility or hospital personnel.
Allow up to two working days for processing.
The date of service must fall within 30 days of the authorization issue date.
Documentation Required
Request Retroactive Ambulatory Authorization
For retroactively eligible recipients, contact the QIO-like vendor for retrospective ambulatory surgery authorization after services are rendered. The vendor reviews medical necessity, appropriateness, and benefit compliance and sends written notice within 30 days after receiving complete documentation.
Submit the complete authorization packet and eligibility information.
Retain the written determination for the physician and facility.
Prior Authorization
Identify Procedures Requiring Authorization
Prior authorization is required when listed procedures are performed in a higher or non-listed setting, on an inpatient basis, out of state, with another authorized procedure, or during a rollover from ambulatory or observation status.
Obtain authorization for MD Office procedures performed outside the office, emergency department, or clinic.
Obtain authorization for Amb Surgical procedures performed inpatient and for procedures unrelated to the admitting diagnosis.
Include the ambulatory surgery authorization packet and supporting medical necessity evidence.
Prior Authorization
Authorize Behavioral Health Transfer or Admission
Behavioral-health-related admissions and transfers require psychiatric assessment to determine medically necessary treatment in the appropriate setting and QIO-like vendor authorization for the transfer or admission.
Stabilize the recipient first when services begin in the emergency department.
Maintain the assessment, physician order, admission order, and clinical information supporting the setting.
Hospitals without a psychiatric or substance-use unit must document comprehensive efforts to transfer promptly to an appropriate alternate setting.
Prior Authorization
Authorize LTAC Services
LTAC services must be medically necessary, require frequent specialized inpatient interventions, include skilled nursing with 24-hour RN availability, be physician-ordered and supervised, follow a multidisciplinary plan of care, and be authorized by the QIO-like vendor.
Maintain the admission order, plan of care, clinical information, and medical-necessity evaluation.
Retrospective authorization is required when Medicaid eligibility is established after LTAC admission or discharge.
Prior Authorization
Authorize Higher-Setting Procedures
Authorization is required when services are performed above the setting recommended by the surgical-procedure list. The physician or office staff must contact the QIO-like vendor before the procedure.
Document the recommended setting, requested higher setting, and clinical justification.
Failure to obtain required setting authorization risks non-reimbursement.
Prior Authorization
Complete LTAC Prior Authorization
LTAC prior authorization is required except for qualifying dual eligibles while Medicare benefits remain available. Retrospective authorization is required when eligibility is established after LTAC admission or discharge.
Follow inpatient prior-authorization and utilization-review requirements.
Maintain eligibility, admission, discharge, clinical, and plan-of-care records.
Prior Authorization
Authorize Inpatient Rehabilitation
Inpatient rehabilitation requires prior authorization except for qualifying dual eligibles while Medicare benefits are not exhausted. Retrospective authorization is required when eligibility is established after admission or discharge.
Prior authorization is also required for therapeutic leave exceeding eight hours, overnight leave, or an intensity-of-service exception.
Maintain preadmission screening, post-admission physician assessment, therapy intensity evidence, and the rehabilitation plan of care.
Unsupported block type: documentation
Prior Authorization
Document Brain-Injury Trial Authorization
A brain-injury recipient may receive a trial rehabilitation admission of no more than seven days when a comprehensive preadmission assessment supports likely benefit. Request additional days when trial assessments show continued benefit.
Submit the preadmission assessment and trial-period clinical findings.
Document the request for additional days and the expected rehabilitation benefit.
Documentation Required
Document Therapeutic Leave
Therapeutic rehabilitation leave may not exceed 32 hours and requires QIO-like vendor authorization.
Maintain a physician order specifying hours, the medically appropriate reason, and an evaluation of therapeutic effectiveness.
Record the leave and return in the medical record.
Prior Authorization
Apply FES Authorization Rules
FES emergency services must follow Chapter 200 authorization requirements. Prior authorization is not required for ESRD services, but treating physicians must complete the required ESRD certification forms.
Maintain the FA 100 Initial Emergency Dialysis Case Certification and FA 101 Monthly Emergency Dialysis Case Certification in the medical record.
Follow the applicable emergency-service authorization process for non-ESRD FES services.
Prior Authorization
Authorize Swing-Bed Admissions
Swing-bed admissions require prior authorization except for qualifying dual eligibles while Medicare benefits are not exhausted. Retrospective authorization is required when eligibility is established after admission or discharge.
Services outside the per diem may require separate authorization.
Maintain initial swing-bed authorization records, including the admission order and supporting clinical documentation.
Note
Apply Observation Authorization Exception
Hourly outpatient observation does not require prior authorization, although medically necessary ancillary services may require authorization under the applicable policy.
Maintain a signed and dated observation order and medical-record support.
Track the observation start and stop times.
Documentation Required
Complete Swing-Bed Authorization Review
Swing-bed authorization requires initial, concurrent, and retrospective review when applicable. Notify the QIO-like vendor and submit required documentation when a recipient is retroactively eligible.
Initial records: history and physical or acute discharge summary showing skilled need, acute discharge order, swing-bed admission order, and NF placement efforts.
Monthly concurrent records: ongoing NF placement efforts and reasons for unavailable beds or refusal outside the rural area, plus a monthly nursing assessment showing continued skilled level of care.
Maintain the initial swing-bed authorization documentation and concurrent review documentation.
Denial Risk
Avoid Non-Covered EMO Services
Emergency medical coverage does not reimburse services that are not emergency services, services after stabilization, follow-up or routine care, or otherwise excluded EMO services.
Confirm that the primary diagnosis meets the emergency medical condition definition.
Do not separately bill post-stabilization services as FES coverage.
Denial Risk
Missing Out-of-State Authorization
Out-of-state acute inpatient care without required prior authorization is not reimbursable and may be denied.
Obtain authorization before non-emergency services and retain referral support from the Nevada physician or hospital.
An out-of-state admission may be denied when the service is available in Nevada.
Denial Risk
Do Not Transfer Without Authorization
A transfer performed without required prior authorization is subject to denial, including a non-emergency transfer between acute hospitals.
The transferring physician or facility must obtain authorization before transfer.
Provide the authorization number to the receiving hospital.
Denial Risk
Receiving Hospital Must Verify Authorization
A receiving hospital that fails to verify authorization before accepting or admitting a recipient for a non-emergency transfer risks denial and non-reimbursement.
Verify authorization with the QIO-like vendor before acceptance and before transfer.
Document the verification and authorization number.
Denial Risk
Meet Hospital Qualification Requirements
Inpatient hospital services are reimbursable only when furnished in a qualifying hospital licensed by the state, meeting Medicare participation requirements, maintaining a compliant utilization-review plan, and primarily treating disorders other than mental disease.
A hospital does not include an IMD, NF, or ICF/IID merely because it is licensed or named as a hospital.
SNF or ICF services furnished under swing-bed approval are not inpatient hospital services.
Denial Risk
Submit Complete Clinical Documentation
Failure to submit pertinent medical information in the QIO-like vendor's required format and timeframe results in authorization denial.
Submit clinical information supporting medical necessity, appropriateness, severity of illness, intensity of services, level of care, and requested length of stay.
Include all information requested with the initial authorization request or reconsideration request.
Denial Risk
Avoid Unauthorized Inpatient Services
Services requiring authorization that were not authorized are not covered or reimbursed. Unauthorized elective inpatient procedures and related concurrent services are rejected, except services needed to stabilize an emergency condition.
Do not perform a planned elective admission or procedure before authorization.
Do not rebill a denied authorized inpatient stay as outpatient, except for truly prior outpatient services.
Denial Risk
Update Authorization Dates
Authorization is valid only for the authorized dates of service. If services cannot be provided during those dates, obtain a new or updated authorization for the corresponding dates.
Monitor authorization periods when a recipient's condition or treatment schedule changes.
Document the revised admission, service, or discharge dates.
Denial Risk
Use In-State Services When Available
An out-of-state inpatient admission may be denied when an appropriate service is available in Nevada, subject to the out-of-state service rules.
Document the lack of an available in-state service or why out-of-state resources are geographically or fiscally more appropriate.
Maintain referral support and the clinical rationale.
Denial Risk
Avoid Non-Medically Necessary Cesarean Admissions
An obstetric admission for an elective or non-medically necessary cesarean section, including one performed for convenience, is not covered.
Maintain documentation supporting medical necessity and accepted diagnosis criteria when a cesarean is performed.
Early induction before 39 weeks also requires medical necessity and prior authorization.
Denial Risk
Support Medical Necessity and Level of Care
If clinical information does not support medical necessity, appropriateness, or the requested setting, the QIO-like vendor may deny or reduce services and level of care.
Maintain physician assessments, medical-care evaluation studies, severity and intensity evidence, and level-of-care documentation.
Submit peer-review or reconsideration evidence by the decision date.
Documentation Required
Submit Form 3058
All hospitals must submit Form 3058 to the local DWSS District Office whenever an admission, discharge, or death occurs.
Retain evidence of timely submission in the facility's financial and statistical records.
Failure to submit Form 3058 may delay or deny payment.
Unsupported block type: denial_risk
Unsupported block type: denial_risk
Billing Rule
Apply Discharge-Day Payment Rule
The day of discharge is not reimbursed except when discharge or death occurs on the day of admission.
Maintain the physician discharge order, discharge date, and comprehensive discharge record.
A readmission after discharge is a new and separate admission.
Denial Risk
Avoid Medicare-Denied QMB Claims
Qualified Medicare Beneficiary claims denied by Medicare are also denied by Nevada Medicaid.
Submit the Medicare EOB and crossover documentation when applicable.
Do not assume Medicaid will pay a Medicare-denied QMB claim.
Denial Risk
Validate Sterilization Consent
The inpatient day on which sterilization is performed without a valid federally compliant consent form is not covered.
Obtain and retain the valid sterilization consent form before the procedure.
Other medically necessary inpatient days in the same episode, excluding the sterilization day, may be reimbursable under applicable coverage rules.