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.)