907 KAR 1:360. Preventive and remedial
public health services.
RELATES TO: KRS 205.520, 205.560, 42
C.F.R. 431.615
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 42 U.S.C. 1396a, b, c, d
NECESSITY, FUNCTION, AND CONFORMITY: The
Cabinet for Health 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 for the provision of
medical assistance to Kentucky's indigent citizenry. This administrative
regulation establishes the provisions relating to preventive and remedial
public health services provided through the Department for Public Health and
the method of reimbursement for these services by the Kentucky Medicaid Program.
Section 1. Definitions. (1) "Add-on
code" means a designated CPT code which may be used in conjunction with
another CPT code to denote that an adjunctive service has been performed.
(2) "CPT code" means a code
used for reporting procedures and services performed by physicians or other
licensed medical professionals which is published annually by the American
Medical Association in Current Procedural Terminology.
(3) "Department" means the
Department for Medicaid Services or its designated agent.
(4) "Incidental" means that a
medical procedure:
(a) Is performed at the same time as a
more complex primary procedure; and
(b)1. Requires few additional physician resources;
or
2. Is clinically integral to the
performance of the primary procedure.
(5) "Integral" means that a
medical procedure represents a component of a more complex procedure performed
at the same time.
(6) "KenPAC" means the Kentucky
Patient Access and Care System.
(7) "KenPAC PCP" means a
Medicaid provider who is enrolled as a primary care provider in the Kentucky
Patient Access and Care System.
(8) "Medically necessary" or
"Medical necessity" means a covered benefit is determined to be
needed in accordance with 907 KAR 3:130.
(9) "Mutually exclusive" means
that two (2) procedures:
(a) Are not reasonably performed in
conjunction with one (1) another during the same patient encounter on the same
date of service;
(b) Represent two (2) methods of performing
the same procedure;
(c) Represent medically impossible or
improbable use of CPT codes; or
(d) Are described in current procedural
terminology as inappropriate coding of procedure combinations.
(10) "Relative value unit" or
"RVU" means the Medicare-established value assigned to a CPT code
which takes into consideration the physician's work, practice expense, and
liability insurance.
(11) "Screening" means the
evaluation of a recipient by a physician to determine:
(a) The presence of a disease or medical
condition; and
(b) The necessity of further evaluation,
diagnostic tests or treatment.
Section 2. Participation Requirements.
(1) The Department for Public Health shall comply with the terms and conditions
established in the following administrative regulations:
(a) 907 KAR 1:005, Nonduplication of
payments;
(b) 907 KAR 1:671, Conditions of Medicaid
provider participation; withholding overpayments, administrative appeal
process, and sanctions; and
(c) 907 KAR 1:672, Provider enrollment,
disclosure, and documentation for Medicaid participation.
(2) The Department for Public Health
shall comply with the requirements regarding the confidentiality of personal
medical records as mandated by 42 U.S.C. 1320d to 1320d-8 and 45 C.F.R. Parts
160 and 164.
Section 3. Covered Services. The
following medically-necessary preventive, screening, diagnostic, rehabilitative
and remedial services provided by the Department for Public Health directly or
indirectly through its subcontractors shall be covered:
(1) A chronic disease service;
(2) A communicable disease service;
(3) An early and periodic screening,
diagnosis, and treatment (EPSDT) service;
(4) A family planning service;
(5) A maternity service; or
(6) A pediatric service.
Section 4. Service Limitations. (1) A
laboratory procedure shall be limited to a procedure for which the provider has
been certified in accordance with 42 C.F.R. Part 493.
(2) A service allowed in accordance with
42 C.F.R. 441, Subpart E or Subpart F shall be covered within the scope and
limitations of these federal regulations.
(3) Coverage for a fetal diagnostic
ultrasound procedure shall be limited to two (2) per nine (9) month period per
recipient unless the diagnosis code justifies the medical necessity of an
additional procedure.
(4) Except for a service specified in 907
KAR 1:320, Section 10(3)(a) through (q), a referral from the KenPAC PCP shall
be required for a recipient enrolled in the KenPAC Program.
Section 5. Reimbursement. (1) Payment for
a preventive health service specified in Section 3(1) through (6) of this
administrative regulation shall be calculated by multiplying the current
Medicare conversion factor for Kentucky by the nonfacility relative value unit
weight for the procedure code.
(2) For a service covered under Medicare
Part B, reimbursement shall be in accordance with 907 KAR 1:006.
(3) If a copayment is required in
accordance with 907 KAR 1:604, reimbursement shall be reduced by the amount of
the copayment.
(4) If performed concurrently, separate
reimbursement shall not be made for a procedure that has been determined by the
department to be incidental, integral, or mutually exclusive to another procedure.
(5) Except for an applicable add-on code,
reimbursement for an anesthesia service shall be limited to one (1) CPT code
and one (1) unit of anesthesia per operative session.
(6) Reimbursement for a surgical
procedure shall include the following:
(a) A preoperative service;
(b) An intraoperative service;
(c) A postoperative service and follow-up
care:
1. Within ninety (90) days following the
date of major surgery; or
2. Within ten (10) days following the
date of minor surgery; and
(d) A preoperative consultation performed
within two (2) days of the date of the surgery.
Section 6. Audits. (1) The Department for
Public Health or subcontracting local health departments shall provide to the
Department for Medicaid Services or a representative of an agency or office
listed in subsection (2) of this section, upon request:
(a) Information maintained by the
provider to document the service provided;
(b) Information regarding a payment
claimed by the provider for furnishing a service; or
(c) Information documenting the cost of
the service.
(2) Access to provider or subcontractor
records relating to a service provided shall be required for:
(a) A representative of the United States
Department of Health and Human Services;
(b) The United States Centers for
Medicare and Medicaid Services;
(c) The United States Attorney General’s
Office;
(d) The state Attorney General’s Office;
(e) The state Auditor’s office;
(f) The Office of the Inspector General;
or
(g) An agent or representative as may be
designated by the Secretary of the Cabinet for Health Services.
Section 7. Appeal Rights. (1) An appeal
of a department decision regarding a Medicaid provider based upon an
application of this administrative regulation shall be in accordance with 907
KAR 1:671.
(2) An appeal of a department decision
regarding a Medicaid recipient based upon an application of this administrative
regulation shall be in accordance with 907 KAR 1:563.
(3) An appeal of a department decision
regarding Medicaid eligibility of an individual shall be in accordance with 907
KAR 1:560. (15 Ky.R. 768; eff. 10-21-88; Am. 25 Ky.R. 1257; 1662; eff. 1-19-99;
28 Ky.R. 961; eff. 12-19-2001; 29 Ky.R. 1140; 1656; eff. 12-18-02; 30 Ky.R.
463; 887; eff. 10-31-03; 31 Ky.R. 2052; 32 Ky.R. 272; eff. 8-25-05.)
