907 KAR 3:170. Telehealth consultation coverage and reimbursement

Link to law: http://www.lrc.ky.gov/kar/907/003/170.htm
Published: 2015

      907 KAR 3:170. Telehealth consultation coverage and reimbursement.

 

      RELATES TO: KRS 194A.060, 194A.125,

205.510(15), 205.559, 205.560, 422.317, 434.840-434.860, 42 C.F.R. 415.174,

415.184, 431.300-431.307, 440.50

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1),

205.520(3), 205.559(2), (7), 205.560

      NECESSITY, FUNCTION, AND CONFORMITY: In

accordance with KRS 194A.030(2), the Cabinet for Health and Family Services,

Department for Medicaid Services, has responsibility to administer the Medicaid

Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation,

to comply with any requirement that may be imposed or opportunity presented by

federal law to qualify for federal Medicaid funds. KRS 205.559 establishes the

requirements regarding Medicaid reimbursement of telehealth providers and KRS

205.559(2) and (7) require the cabinet to promulgate an administrative

regulation relating to telehealth consultations and reimbursement. This

administrative regulation establishes the Department for Medicaid Services'

coverage and reimbursement policies relating to telehealth consultations in

accordance with KRS 205.559.

 

      Section 1. Definitions. (1)

"Advanced practice registered nurse" or "APRN" is defined

by KRS 314.011(7).

      (2) "Certified nutritionist" is

defined by KRS 310.005(12).

      (3) "Chiropractor" is defined

by KRS 312.015(3).

      (4) "Community mental health

center" or "CMHC" means a facility that provides a comprehensive

range of mental health services to Medicaid recipients of a designated area in

accordance with KRS 210.370 to 210.485.

      (5) "Department" means the

Department for Medicaid Services or its designated agent.

      (6) "Diabetes self-management

training consultation" means the ongoing process of facilitating the

knowledge, skill, and ability necessary for diabetes self-care.

      (7) "Direct physician contact"

means that the billing physician is physically present with and evaluates,

examines, treats, or diagnoses the recipient.

      (8) "Encounter" means one (1)

visit by a recipient to a telehealth spoke site where the recipient receives a

telehealth consultation in real time, during the visit, from a telehealth

provider or telehealth practitioner at a telehealth hub site.

      (9) "Face-to-face" means,

except as established in Section 4(4)(g) of this administrative regulation:

      (a) In person; and

      (b) Not via telehealth.

      (10) "Federal financial

participation" is defined in 42 C.F.R. 400.203.

      (11) "GT modifier" means a

modifier that identifies a telehealth consultation which is approved by the

healthcare common procedure coding system (HCPCS).

      (12) "Health care provider" means a Medicaid provider who is:

      (a) Currently enrolled as a

Medicaid provider in accordance with 907 KAR 1:672; and

      (b) Currently participating

as a Medicaid provider in accordance with 907 KAR 1:671.

      (13) "Hub site"

means a telehealth site:

      (a) Where the telehealth provider or

telehealth practitioner performs telehealth; and

      (b) That is considered the place of

service.

      (14) "Legally-authorized

representative" means a Medicaid recipient's parent or guardian if a

recipient is a minor child, or a person with power of attorney for a recipient.

      (15) "Licensed clinical social

worker" means an individual meeting the licensure requirements established

in KRS 335.100.

      (16) "Licensed dietitian" is

defined by KRS 310.005(11).

      (17) "Licensed marriage and family

therapist" is defined by KRS 335.300(2).

      (18) "Licensed professional clinical

counselor" is defined by KRS 335.500(3).

      (19) "Medical necessity" or

"medically necessary" means a covered benefit is determined to be

needed in accordance with 907 KAR 3:130.

      (20) "National Provider

Identifier" or "NPI" means a standard unique health identifier

for health care providers which:

      (a) Is required by 42 C.F.R. 455.440; and

      (b) Meets the requirements of 45 C.F.R.

162.406.

      (21) "Occupational therapist"

is defined by KRS 319A.010(3).

      (22) "Optometrist" means an

individual licensed to engage in the practice of optometry in accordance with

KRS 320.210(2).

      (23) "Physical therapist" is

defined by KRS 327.010(2).

      (24) "Physician" is defined by

KRS 311.550(12).

      (25) "Physician assistant" is

defined by KRS 311.840(3).

      (26) "Psychologist" is defined

by KRS 319.010(9).

      (27) "Registered nurse" is

defined by KRS 314.011(5).

      (28) "Speech-language pathologist"

is defined by KRS 334A.020(3).

      (29) "Spoke site" means a

telehealth site where the recipient receiving the telehealth consultation is

located.

      (30) "Telehealth consultation"

is defined by KRS 205.510(15).

      (31) “Telehealth practitioner” means an individual

who is:

      (a) Authorized to perform a telehealth

consultation in accordance with this administrative regulation;

      (b) Employed by or is an agent of a

telehealth provider; and

      (c) Not the individual or entity who:

      1. Bills the department for a telehealth

consultation; or

      2. Is reimbursed by the department for a

telehealth consultation.

      (32) "Telehealth provider"

means a health care provider who:

      (a) Performs a telehealth consultation at

a hub site; or

      (b) Is the employer of or entity that

contracts with a telehealth practitioner who performs a telehealth

consultation:

      1. At a hub site; and

      2. That is billed under the telehealth

provider’s national provider identifier.

      (33) "Telehealth site" means a

hub site or spoke site that has been approved as part of a telehealth network

established in accordance with KRS 194A.125.

      (34) "Telepresenter" means an

individual operating telehealth equipment at a spoke site to enable a recipient

to receive a telehealth consultation.

      (35) "Transmission cost" means

the cost of the telephone line and related costs incurred during the time of

the transmission of a telehealth consultation.

      (36) "Two (2) way interactive

video" means a type of advanced telecommunications technology that permits

a real time telehealth consultation to take place between a recipient and a

telepresenter at the spoke site and a telehealth provider or telehealth

practitioner at the hub site.

 

      Section 2. General Policies. (1)(a) Except as provided

in paragraph (b) of this subsection, the coverage policies established in this

administrative regulation shall apply to:

      1. Medicaid services for individuals not

enrolled in a managed care organization; and

      2. A managed care organization’s coverage

of Medicaid services for individuals enrolled in the managed care organization

for the purpose of receiving Medicaid or Kentucky Children’s Health Insurance

Program services.

      (b) A managed care organization shall not

be required to reimburse the same amount for a telehealth consultation as the

department reimburses, but may reimburse the same as the department reimburses

if the managed care organization chooses to do so.

      (2) A telehealth consultation shall not be

reimbursed by the department if:

      (a) It is not medically necessary;

      (b) The equivalent service is not covered

by the department if provided in a face-to-face setting;

      (c) It requires a face-to-face contact

with a recipient in accordance with 42 C.F.R. 447.371;

      (d) The telehealth provider of the telehealth

consultation is:

      1. Not currently enrolled in the Medicaid

program pursuant to 907 KAR 1:672;

      2. Not currently participating in the Medicaid

program pursuant to 907 KAR 1:671;

      3. Not in good standing with the Medicaid

program;

      4. Currently listed on the Kentucky DMS

List of Excluded Providers, which is available at

http://chfs.ky.gov/dms/provEnr; or

      5. Currently listed on the United States

Department of Health and Human Services, Office of Inspector General List of

Excluded Individuals and Entities, which is available at https://oig.hhs.gov/exclusions/;

or

      (e) It is provided by a telehealth

practitioner or telehealth provider not recognized or authorized by the

department to provide the telehealth consultation or equivalent service in a

face-to-face setting.

      (3)(a) A telehealth provider shall:

      1. Be an approved member of the Kentucky

Telehealth Network; and

      2. Comply with the standards and protocols

established by the Kentucky Telehealth Board.

      (b) To become an approved member of the

Kentucky Telehealth Network, a provider shall:

      1. Send a written request to the Kentucky

Telehealth Board requesting membership in the Kentucky Telehealth Network; and

      2. Be approved by the Kentucky Telehealth

Board as a member of the Kentucky Telehealth Network.

      (4)(a) A telehealth consultation referenced

in Section 3 or 4 of this administrative regulation shall be provided to the same

extent and with the same coverage policies and restrictions that apply, except

as established in Section 4(4)(g) and 4(5) of this administrative regulation to

the equivalent service if provided in a face-to-face setting.

      (b) If a telehealth coverage policy or restriction

is not stated in this administrative regulation but is stated in another

administrative regulation within Title 907 of the Kentucky Administrative Regulations,

the coverage policy or restriction stated elsewhere within Title 907 of the

Kentucky Administrative Regulations shall apply.

      (5)(a) A telehealth consultation shall be

subject to utilization review for:

      1. Medical necessity;

      2. Compliance with this administrative

regulation; and

      3. Compliance with applicable state and

federal law.

      (b) If the department determines that a telehealth

consultation is not medically necessary, is not compliant with this administrative

regulation, or is not compliant with applicable state or federal law, the

department shall not reimburse for the telehealth consultation.

      (c) If the department determines that a telehealth

consultation that it has already reimbursed for was not medically necessary,

was not compliant with this administrative regulation, or was not compliant

with applicable state or federal law, the department shall recoup the reimbursement

for the telehealth consultation from the provider.

      (6) A telehealth consultation shall

require:

      (a) The use of two (2) way interactive video;

      (b) A referral by a health care provider;

and

      (c) A referral by a recipient’s lock-in

provider if the recipient is locked in pursuant to:

      1. 42 C.F.R. 431.54; and

      2. 907 KAR 1:677.

 

      Section 3. Telehealth Consultation Coverage

in a Setting That is Not a Community Mental Health Center. (1) The policies in

this section shall apply to a telehealth consultation provided in a setting

that is not a community mental health center.

      (2) The following telehealth

consultations shall be covered by the department as follows:

      (a) A physical health evaluation or

management consultation provided by:

      1. A physician including a physician:

      a. With an individual physician practice;

      b. Who belongs to a group physician

practice; or

      c. Who is employed by a

federally-qualified health center, federally-qualified health center

look-alike, rural health clinic, or primary care center;

      2. An advanced practice registered nurse

including an advanced practice registered nurse:

      a. With an individual advanced practice

registered nurse practice;

      b. Who belongs to a group advanced

practice registered nurse practice; or

      c. Who is employed by a physician,

federally-qualified health center, federally-qualified health center

look-alike, rural health clinic, or primary care center;

      3. An optometrist; or

      4. A chiropractor;

      (b) A mental health evaluation or

management service provided by:

      1. A psychiatrist;

      2. A physician in accordance with the

limit established in 907 KAR 3:005;

      3. An APRN in accordance with the limit

established in 907 KAR 1:102;

      4. A psychologist:

      a. With a license in accordance with KRS

319.010(6);

      b. With a doctorate degree in psychology;

      c. Who is directly employed by a psychiatrist;

and

      d. If:

      (i) The psychiatrist by whom the psychologist

is directly employed also interacts with the recipient during the encounter;

and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the psychologist is directly

employed;

      5. A licensed professional clinical counselor:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

professional clinical counselor is directly employed also interacts with the

recipient during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the licensed professional

clinical counselor is directly employed;

      6. A licensed clinical social worker:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

clinical social worker is directly employed also interacts with the recipient

during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the licensed clinical social

worker is directly employed; or

      7. A licensed marriage and family therapist:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

marriage and family therapist is directly employed also interacts with the recipient

during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the licensed marriage and

family therapist is directly employed;

      (c) Individual or group psychotherapy provided

by:

      1. A psychiatrist;

      2. A physician in accordance with the

limit established in 907 KAR 3:005;

      3. An APRN in accordance with the limit

established in 907 KAR 1:102;

      4. A psychologist:

      a. With a license in accordance with KRS

319.010(6);

      b. With a doctorate degree in psychology;

      c. Who is directly employed by a psychiatrist;

and

      d. If:

      (i) The psychiatrist by whom the

psychologist is directly employed also interacts with the recipient or

recipients during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the psychologist is directly

employed;

      5. A licensed professional clinical counselor:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

professional clinical counselor is directly employed also interacts with the

recipient or recipients during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the licensed professional

clinical counselor is directly employed;

      6. A licensed clinical social worker:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

clinical social worker is directly employed also interacts with the recipient or

recipients during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the licensed clinical social

worker is directly employed; or

      7. A licensed marriage and family therapist:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

marriage and family therapist is directly employed also interacts with the

recipient or recipients during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the licensed marriage and family

therapist is directly employed;

      (d) Pharmacologic management provided by:

      1. A physician in accordance with the

limit established in 907 KAR 3:005;

      2. An APRN in accordance with the limit

established in 907 KAR 1:102; or

      3. A psychiatrist;

      (e) A psychiatric, psychological, or

mental health diagnostic interview examination provided by:

      1. A psychiatrist;

      2. A physician in accordance with the

limit established in 907 KAR 3:005;

      3. An APRN in accordance with the limit

established in 907 KAR 1:102;

      4. A psychologist:

      a. With a license in accordance with KRS

319.010(6);

      b. With a doctorate degree in psychology;

      c. Who is directly employed by a psychiatrist;

and

      d. If:

      (i) The psychiatrist by whom the psychologist

is directly employed also interacts with the recipient during the encounter;

and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the psychologist is directly

employed;

      5. A licensed professional clinical counselor:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

professional clinical counselor is directly employed also interacts with the

recipient during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the licensed professional

clinical counselor is directly employed;

      6. A licensed clinical social worker:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

clinical social worker is directly employed also interacts with the recipient

during the encounter; and

      (ii) The telehealth consultation is

billed under the NPI of the psychiatrist by whom the licensed clinical social

worker is directly employed; or

      7. A licensed marriage and family therapist:

      a. Who is directly employed by a psychiatrist;

and

      b. If:

      (i) The psychiatrist by whom the licensed

marriage and family therapist is directly employed also interacts with the recipient

during the encounter; and

      (ii) The telehealth consultation is billed

under the NPI of the psychiatrist by whom the licensed marriage and family

therapist is directly employed;

      (f) Individual medical nutrition therapy consultation

services provided by a:

      1. Licensed dietitian:

      a. Who is directly employed by a physician,

federally qualified health care center, rural health clinic, primary care

center, a hospital’s outpatient department, or the Department for Public Health;

and

      b. If the telehealth consultation is

billed under the:

      (i) NPI of the physician, federally qualified

health care center, rural health clinic, hospital’s outpatient department, or

primary care center by whom the licensed dietitian is directly employed; or

      (ii) Department for Public Health if the

licensed dietitian works for the Department for Public Health; or

      2. Certified nutritionist:

      a. Who is directly employed by a physician,

federally qualified health care center, rural health clinic, primary care

center, a hospital’s outpatient department, or the Department for Public Health;

and

      b. If the telehealth consultation is

billed under the:

      (i) NPI of the physician, federally qualified

health care center, rural health clinic, hospital’s outpatient department, or

primary care center by whom the certified nutritionist is directly employed; or

      (ii) Department for Public Health if the

certified nutritionist works for the Department for Public Health;

      (g) Individual diabetes self-management training

consultation if:

      1. Ordered by a:

      a. Physician;

      b. APRN directly employed by a physician;

or

      c. Physician assistant directly employed

by a physician;

      2. Provided by a:

      a. Physician;

      b. APRN directly employed by a physician;

      c. Physician assistant directly employed

by a physician;

      d. Registered nurse directly employed by

a physician; or

      e. Licensed dietitian directly employed

by a physician, federally qualified health care center, rural health clinic, primary

care center, a hospital’s outpatient department, or the Department for Public

Health; and

      3. The telehealth consultation is billed under

the:

      a. NPI of the physician, federally

qualified health care center, rural health clinic, hospital’s outpatient

department, or primary care center by whom the provider is directly employed;

or

      b. Department for Public Health if the provider

works for the Department for Public Health;

      (h) An occupational therapy evaluation or

treatment provided by an occupational therapist who is directly employed by a

physician:

      1. If direct physician contact occurs

during the evaluation;

      2. If the telehealth consultation is

billed under the physician’s NPI; and

      3. In accordance with the limits

established in 907 KAR 3:005;

      (i) An occupational therapy evaluation or

treatment provided by an occupational therapist who is directly employed by or

is an agent of a nursing facility:

      1. If the telehealth consultation is

billed under the nursing facility’s NPI; and

      2. In accordance with the limits

established in 907 KAR 1:065;

      (j) An occupational therapy evaluation or

treatment provided by an occupational therapist who is directly employed by or

is an agent of a home health agency:

      1. If the telehealth consultation is

billed under the home health agency’s NPI; and

      2. In accordance with the limits

established in 907 KAR 1:030;

      (k) A physical therapy evaluation or

treatment provided by a physical therapist who is directly employed by a

physician:

      1. If direct physician contact occurs

during the evaluation;

      2. If the telehealth consultation is

billed under the physician’s NPI; and

      3. In accordance with the limits established

in 907 KAR 3:005;

      (l) A physical therapy evaluation or

treatment provided by a physical therapist who is directly employed by or is an

agent of a hospital’s outpatient department:

      1. If the telehealth consultation is

billed under the hospital’s outpatient department’s NPI; and

      2. In accordance with the limits

established in 907 KAR 10:014;

      (m) A physical therapy evaluation or

treatment provided by a physical therapist who is directly employed by or is an

agent of a home health agency:

      1. If the telehealth consultation is

billed under the home health agency’s NPI; and

      2. In accordance with the limits

established in 907 KAR 1:030;

      (n) A physical therapy evaluation or

treatment provided by a physical therapist who is directly employed by or is an

agent of a nursing facility:

      1. If the telehealth consultation is

billed under the nursing facility’s NPI; and

      2. In accordance with the limits

established in 907 KAR 1:065;

      (o) A speech therapy evaluation or

treatment provided by a speech-language pathologist who is directly employed by

a physician:

      1. If direct physician contact occurs

during the evaluation or treatment;

      2. If the telehealth consultation is

billed under the physician’s NPI; and

      3. In accordance with the limits

established in 907 KAR 3:005;

      (p) A speech therapy evaluation or

treatment provided by a speech-language pathologist who is directly employed by

or is an agent of a hospital’s outpatient department:

      1. If the telehealth consultation is

billed under the hospital’s outpatient department’s NPI; and

      2. In accordance with the limits

established in 907 KAR 10:014;

      (q) A speech therapy evaluation or

treatment provided by a speech-language pathologist who is directly employed by

or is an agent of a home health agency:

      1. If the telehealth consultation is

billed under the home health agency’s NPI; and

      2. In accordance with the limits

established in 907 KAR 1:030;

      (r) A speech therapy evaluation or

treatment provided by a speech-language pathologist who is directly employed by

or is an agent of a nursing facility:

      1. If the telehealth consultation is

billed under the nursing facility’s NPI; and

      2. In accordance with the limits

established in 907 KAR 1:065;

      (s) A neurobehavioral status examination

provided by:

      1. A psychiatrist;

      2. A physician in accordance with the

limit established in 907 KAR 3:005; or

      3. A psychologist:

      a. With a license in accordance with KRS

319.010(6);

      b. With a doctorate degree in psychology;

and

      c. Who is directly employed by a

physician or a psychiatrist:

      (i) In accordance with the limits established

in 907 KAR 3:005;

      (ii) If the physician or psychiatrist by

whom the psychologist is directly employed also interacts with the recipient

during the encounter; and

      (iii) If the telehealth consultation is

billed under the NPI of the physician or psychiatrist by whom the psychologist

is directly employed; or

      (t) End-stage renal disease monitoring,

assessment, or counseling consultations for a home dialysis recipient provided

by:

      1. A physician directly employed by a

hospital’s outpatient department if the telehealth consultation is billed under

the hospital’s outpatient department’s NPI; or

      2. An APRN directly employed by a

hospital’s outpatient department if the telehealth consultation is billed under

the hospital’s outpatient department’s NPI.

 

      Section 4. Telehealth Consultation Coverage

in a Community Mental Health Center.

      (1) The policies in this section shall

apply to a tele-health consultation provided via a community mental health

center.

      (2) The limits, restrictions, exclusions,

or policies:

      (a) Which apply to a service provided

face-to-face in a community mental health center shall apply to a telehealth

consultation or service provided via telehealth via a community mental health

center; and

      (b) Established in 907 KAR 1:044 shall

apply to a telehealth consultation or service provided via:

      1. Telehealth; and

      2. A community mental health center.

      (3) The department shall not reimburse

for a telehealth consultation provided via a community mental health center if:

      (a) The consultation is not billed under

the community mental health center’s national provider identifier; or

      (b) The person who delivers the

telehealth consultation is not:

      1. Directly employed by the community

mental health center; or

      2. An agent of the community mental

health center.

      (4) The following telehealth

consultations provided via a community mental health center shall be covered by

the department as follows:

      (a) A psychiatric diagnostic interview examination

provided:

      1. In accordance with 907 KAR 1:044; and

      2. By:

      a. A psychiatrist; or

      b. An APRN who:

      (i) Is certified in the practice of

psychiatric mental health nursing; and

      (ii) Meets the requirements established

in 201 KAR 20:057;

      (b) A psychological diagnostic interview

examination provided:

      1. In accordance with 907 KAR 1:044; and

      2. By:

      a. A psychiatrist; or

      b. A psychologist with a license in

accordance with KRS 319.010(6);

      (c) Pharmacologic management provided:

      1. In accordance with 907 KAR 1:044; and

      2. By:

      a. A physician;

      b. A psychiatrist; or

      c. An APRN who:

      (i) Is certified in the practice of psychiatric

mental health nursing; and

      (ii) Meets the requirements established

in 201 KAR 20:057;

      (d) Group psychotherapy provided:

      1. In accordance with 907 KAR 1:044; and

      2. By:

      a. A psychiatrist;

      b. A psychologist with a license in

accordance with KRS 319.010(6);

      c. A licensed professional clinical

counselor;

      d. A licensed marriage and family therapist;

      e. A licensed clinical social worker;

      f. A psychiatric registered nurse; or

      g. An APRN who:

      (i) Is certified in the practice of psychiatric

mental health nursing; and

      (ii) Meets the requirements established

in 201 KAR 20:057;

      (e) Mental health evaluation or

management emergency services provided:

      1. In accordance with 907 KAR 1:044; and

      2. By:

      a. A psychiatrist;

      b. A psychologist with a license in

accordance with KRS 319.010(6);

      c. A licensed professional clinical

counselor;

      d. A licensed marriage and family therapist;

      e. A licensed clinical social worker;

      f. A psychiatric medical resident;

      g. A psychiatric registered nurse; or

      h. An APRN who:

      (i) Is certified in the practice of psychiatric

mental health nursing; and

      (ii) Meets the requirements established

in 201 KAR 20:057;

      (f) A mental health assessment provided:

      1. In accordance with 907 KAR 1:044; and

      2. By a psychologist with a license in

accordance with KRS 319.010(6); or

      (g) Individual psychotherapy provided:

      1. In accordance with 907 KAR 1:044

except that “face-to-face” shall include two (2) way interactive video for the

purposes of individual psychotherapy provided via a community mental health center;

and

      2. By:

      a. A psychiatrist;

      b. A psychologist with a license in

accordance with KRS 319.010(6);

      c. A licensed professional clinical

counselor;

      d. A licensed marriage and family

therapist;

      e. A licensed clinical social worker;

      f. A psychiatric registered nurse; or

      g. An APRN who:

      (i) Is certified in the practice of

psychiatric mental health nursing; and

      (ii) Meets the requirements established

in 201 KAR 20:057.

      (5) If a provision established in 907 KAR

1:044 or the material incorporated by reference into 907 KAR 1:044 is in

contrast with subsection (4)(g)1. of this section, the policy established in

subsection (4)(g)1 of this section shall supersede the contrary statement.

 

      Section 5. Reimbursement. (1)(a) The

department shall reimburse a telehealth provider who is eligible for

reimbursement from the department for a telehealth consultation an amount equal

to the amount paid for a comparable in-person service in accordance with:

      1. 907 KAR 3:010 if the service was

provided:

      a. By a physician; and

      b. Not in the circumstances described in

subparagraphs 3., 4., 5., or 6. of this paragraph;

      2. 907 KAR 1:104 if the service was

provided:

      a. By an advanced practice registered

nurse; and

      b. Not in the circumstances described in

subparagraphs 3., 4., 5., or 6. of this paragraph;

      3. 907 KAR 1:055 if the service was

provided and billed through a federally-qualified health center,

federally-qualified health center look-alike, rural health clinic, or primary

care center;

      4. 907 KAR 1:015 if the service was

provided and billed through a hospital outpatient department;

      5. 907 KAR 1:031 if the service was

provided and billed through a home health agency; or

      6. 907 KAR 1:065 if the service was

provided and billed through a nursing facility.

      (b)1. Reimbursement for a telehealth

consultation provided by a practitioner who is employed by a provider or is an

agent of a provider shall be a matter between the provider and the

practitioner.

      2. The department shall not be liable for

reimbursing a practitioner who is employed by a provider or is an agent of a provider.

      (c) A managed care organization shall not

be required to reimburse the same amount for a telehealth consultation as the

department reimburses, but may reimburse the same amount as the department

reimburses if the managed care organization chooses to do so.

      (2) A telehealth provider shall bill for

a telehealth consultation using the appropriate two (2) letter "GT"

modifier.

      (3) The department shall not require the

presence of a health care provider requesting a telehealth consultation at the

time of the telehealth consultation unless it is requested by a telehealth provider

or telehealth practitioner at the hub site.

      (4) The department shall not reimburse

for transmission costs.

 

      Section 6. Confidentiality and Data

Integrity. (1) A telehealth consultation shall be performed on a secure

telecommunications line or utilize a method of encryption adequate to protect

the confidentiality and integrity of the telehealth consultation information.

      (2) Both a hub site and a spoke site

shall use authentication and identification to ensure the confidentiality of a

telehealth consultation.

      (3) A telehealth provider or telehealth

practitioner of a telehealth consultation shall implement confidentiality

protocols that include:

      (a) Identifying personnel who have access

to a telehealth transmission;

      (b) Usage of unique passwords or

identifiers for each employee or person with access to a telehealth

transmission; and

      (c) Preventing unauthorized access to a

telehealth transmission.

      (4) A telehealth provider’s or telehealth

practitioner's protocols and guidelines shall be available for inspection by

the department upon request.

 

      Section 7. Informed Consent. (1) Before

providing a telehealth consultation to a recipient, a telehealth provider or

telehealth practitioner shall document written informed consent from the recipient

and shall ensure that the following written information is provided to the

recipient in a format and manner that the recipient is able to understand:

      (a) The recipient shall have the option

to refuse the telehealth consultation at any time without affecting the right

to future care or treatment and without risking the loss or withdrawal of a

Medicaid benefit to which the recipient is entitled;

      (b) The recipient shall be informed of

alternatives to the telehealth consultation that are available to the

recipient;

      (c) The recipient shall have access to

medical information resulting from the telehealth consultation as provided by

law;

      (d) The dissemination, storage, or

retention of an identifiable recipient image or other information from the

telehealth consultation shall comply with 42 U.S.C. 1301 et seq., 45 C.F.R.

Parts 160, 162, 164, KRS 205.566, 216.2927, and any other federal law or regulation

or state law establishing individual health care data confidentiality policies;

      (e) The recipient shall have the right to

be informed of the parties who will be present at the spoke site and the hub

site during the telehealth consultation and shall have the right to exclude

anyone from either site; and

      (f) The recipient shall have the right to

object to the video taping of a telehealth consultation.

      (2) A copy of the signed informed consent

shall be retained in the recipient's medical record and provided to the

recipient or the recipient's legally-authorized representative upon request.

      (3) The requirement to obtain informed

consent before providing a telehealth consultation shall not apply to an

emergency situation if the recipient is unable to provide informed consent and

the recipient's legally-authorized representative is unavailable.

 

      Section 8. Medical Records. (1) A request

for a telehealth consultation from a health care provider and the medical

necessity for the telehealth consultation shall be documented in the recipient's

medical record.

      (2) A health care provider shall keep a

complete medical record of a telehealth consultation provided to a recipient

and follow applicable state and federal statutes and regulations for medical

recordkeeping and confidentiality in accordance with KRS 194A.060, 422.317,

434.840 - 434.860, 42 C.F.R. 431.300 to 431.307, and 45 C.F.R. 164.530(j).

      (3)(a) A medical record of a telehealth consultation

shall be maintained in compliance with 907 KAR 1:672 and 45 C.F.R. 164.530(j).

      (b) A health care provider shall have the

capability of generating a hard copy of a medical record of a telehealth consultation.

      (4) Documentation of a telehealth consultation

by the referring health care provider shall be included in the recipient's

medical record and shall include:

      (a) The diagnosis and treatment plan

resulting from the telehealth consultation and a progress note by the referring

health care provider if present at the spoke site during the telehealth consultation;

      (b) The location of the hub site and

spoke site;

      (c) A copy of the document signed by the

recipient indicating the recipient's informed consent to the telehealth

consultation;

      (d) Documentation supporting the medical necessity of the telehealth consultation;

and

      (e) The referral order and complete

information from the referring health care provider who requested the telehealth

consultation for the recipient.

      (5)(a) A telehealth provider's or

telehealth practitioner's diagnosis and recommendations resulting from a

telehealth consultation shall be documented in the recipient's medical record

at the office of the health care provider who requested the telehealth

consultation.

      (b) Except as established in paragraph

(c) of this subsection, a telehealth provider or telehealth practitioner shall

send a written report regarding a telehealth consultation within thirty (30)

days of the consultation to the referring health care provider.

      (c) If a community mental health center

was the referring health care provider and the provider of the telehealth consultation

for a recipient, the requirement in paragraph (b) of this subsection shall not

apply.

 

      Section 9. Federal Financial

Participation. A policy established in this administrative regulation shall be

null and void if the Centers for Medicare and Medicaid Services:

      (1) Denies federal financial

participation for the policy; or

      (2) Disapproves the policy.

 

      Section 10. Appeal Rights. (1) An appeal

of a department determination regarding a Medicaid beneficiary shall be in accordance

with 907 KAR 1:563.

      (2) An appeal of a department

determination regarding Medicaid eligibility of an individual shall be in

accordance with 907 KAR 1:560.

      (3) A provider may appeal a department-written

determination as to the application of this administrative regulation in

accordance with 907 KAR 1:671. (28 Ky.R. 150; Am. 1430; eff. 12-19-2001; 30 Ky.R. 1861;

2055; eff. 3-18-2004; 32 Ky.R. 1934; 2279; eff. 7-7-2006; 35 Ky.R. 1923; 2456;

2757; eff. 7-6-2009; 39 Ky.R. 1070; 1738; 2036; eff. 5-3-2013.)
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