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907 KAR 1:044. Coverage provisions and requirements regarding community mental health center services


Published: 2015

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      907 KAR 1:044. Coverage

provisions and requirements regarding community mental health center behavioral

health services.

 

      RELATES TO: KRS

194A.060, 205.520(3), 205.8451(9), 422.317, 434.840-434.860, 42 C.F.R. 415.208,

431.52, 431 Subpart F

      STATUTORY AUTHORITY:

KRS 194A.030(2), 194A.050(1), 205.520(3), 210.450, 42 U.S.C. 1396a-d

      NECESSITY,

FUNCTION, AND CONFORMITY: The Cabinet for Health and Family 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. This administrative regulation establishes the Medicaid Program

coverage provisions and requirements regarding community mental health center

(CMHC) behavioral health services provided to Medicaid recipients.

 

      Section 1.

Definitions. (1) "Community mental health center" or "CMHC"

means a facility which meets the community mental health center requirements

established in 902 KAR 20:091.

      (2)

"Department" means the Department for Medicaid Services or its

designee.

      (3)

"Enrollee" means a recipient who is enrolled with a managed care

organization.

      (4)

"Face-to-face" means occurring:

      (a) In person; or

      (b) If authorized

by 907 KAR 3:170, via a real-time, electronic communication that involves two

(2) way interactive video and audio communication.

      (5) "Federal

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

      (6)

"Medically necessary" means that a covered benefit is determined to

be needed in accordance with 907 KAR 3:130.

      (7) "Mental

health associate" means an individual who meets the mental health

associate requirements established in the Community Mental Health Center

Behavioral Health Services Manual.

      (8)

"Professional equivalent" means an individual who meets the

professional equivalent requirements established in the Community Mental Health

Center Behavioral Health Services Manual.

      (9)

"Provider" is defined by KRS 205.8451(7).

      (10) "Qualified

mental health professional" means an individual who meets the requirements

established in KRS 202A.0011(12).

      (11)

"Recipient" is defined by KRS 205.8451(9).

 

      Section 2.

Requirements for a Psychiatric Nurse. A registered nurse employed by a

participating community mental health center shall be considered a psychiatric

or mental health nurse if the individual:

      (1) Possesses a

Master of Science in nursing with a specialty in psychiatric or mental health

nursing;

      (2)(a) Is a

graduate of a four (4) year nursing educational program with a Bachelor of

Science in nursing; and

      (b) Possesses at

least one (1) year of experience in a mental health setting;

      (3)(a) Is a

graduate of a three (3) year nursing educational program; and

      (b) Possesses at

least two (2) years of experience in a mental health setting; or

      (4)(a) Is a

graduate of a two (2) year nursing educational program with an associate degree

in nursing; and

      (b) Possesses at

least three (3) years of experience in a mental health setting.

 

      Section 3. Community

Mental Health Center Behavioral Health Services Manual. The conditions for

participation, services covered, and limitations for the community mental

health center behavioral health services component of the Medicaid Program

shall be as specified in:

      (1) This

administrative regulation; and

      (2) The Community

Mental Health Center Behavioral Health Services Manual.

 

      Section 4. Covered

Services. (1) Behavioral health services covered pursuant to this

administrative regulation and pursuant to the Community Mental Health Center

Behavioral Health Services Manual shall be rehabilitative mental health and

substance use disorder services including:

      (a) Individual

outpatient therapy;

      (b) Group

outpatient therapy;

      (c) Family

outpatient therapy;

      (d) Collateral

outpatient therapy;

      (e) Therapeutic

rehabilitation services;

      (f) Psychological

testing;

      (g) Screening;

      (h) An assessment;

      (i) Crisis

intervention;

      (j) Service

planning;

      (k) A screening,

brief intervention, and referral to treatment;

      (l) Mobile crisis

services;

      (m) Assertive

community treatment;

      (n) Intensive

outpatient program services;

      (o) Residential

crisis stabilization services;

      (p) Partial

hospitalization;

      (q) Residential

services for substance use disorders;

      (r) Day treatment;

      (s) Comprehensive

community support services;

      (t) Peer support

services; or

      (u) Parent or

family peer support services.

      (2)(a) To be

covered under this administrative regulation, a service listed in subsection

(1) of this section shall be:

      1. Provided by a

community mental health center that is:

      a. Currently

enrolled in the Medicaid Program in accordance with 907 KAR 1:672; and

      b. Except as

established in paragraph (b) of this subsection, currently participating in the

Medicaid Program in accordance with 907 KAR 1:671;

      2. Provided in

accordance with:

      a. This

administrative regulation; and

      b. The Community

Mental Health Center Behavioral Health Services Manual; and

      3. Medically

necessary.

      (b) In accordance

with 907 KAR 17:015, Section 3(3), a provider of a service to an enrollee shall

not be required to be currently participating in the fee-for-service Medicaid

Program.

 

      Section 5.

Electronic Documents and Signatures. (1) The creation, transmission, storage,

or other use of electronic signatures and documents shall comply with

requirements established in KRS 369.101 to 369.120 and all applicable state and

federal laws and regulations.

      (2) A CMHC

choosing to utilize electronic signatures shall:

      (a) Develop and

implement a written security policy which shall:

      1. Be complied

with by each of the center's employees, officers, agents, and contractors; and

      2. Stipulate which

individuals have access to which electronic signatures and password

authorization;

      (b) Ensure that

electronic signatures are created, transmitted, and stored securely;

      (c) Develop a

consent form that shall:

      1. Be completed

and executed by each individual utilizing an electronic signature;

      2. Attest to the

signature's authenticity; and

      3. Include a

statement indicating that the individual has been notified of his or her

responsibility in allowing the use of the electronic signature; and

      (d) Provide the

department, immediately upon request, with:

      1. A copy of the

provider's electronic signature policy;

      2. The signed

consent form; and

      3. The original

filed signature.

 

      Section 6. No

Duplication of Service. (1) The department shall not reimburse for a service

provided to a recipient by more than one (1) provider, of any program in which

the service is covered, on the same day of service.

      (2) For example,

if a recipient is receiving a behavioral health service from an independently

enrolled behavioral health service provider, the department shall not reimburse

for the same service provided to the same recipient by a community mental health

center on the same day of service.

 

      Section 7. Records

Maintenance, Protection, and Security. (1) A provider shall maintain a current

health record for each recipient.

      (2)

A health record shall:

      (a)

Include:

      1.

An identification and intake record including:

      a.

Name;

      b.

Social Security number;

      c.

Date of intake;

      d.

Home (legal) address;

      e.

Health insurance information;

      f.

Referral source and address of referral source;

      g.

Primary care physician and address;

      h.

The reason the individual is seeking help including the presenting problem and

diagnosis;

      i.

Any physical health diagnosis, if a physical health diagnosis exists for the

individual, and information, if available, regarding:

      (i)

Where the individual is receiving treatment for the physical health diagnosis;

and

      (ii)

The physical health provider; and

      j.

The name of the informant and any other information deemed necessary by the

independent provider to comply with the requirements of:

      (i)

This administrative regulation;

      (ii)

The provider’s licensure board;

      (iii)

State law; or

      (iv)

Federal law;

      2.

Documentation of the:

      a.

Screening if the community mental health center performed the screening;

      b.

Assessment; and

      c.

Disposition;

      3.

A complete history including mental status and previous treatment;

      4.

An identification sheet;

      5.

A consent for treatment sheet that is accurately signed and dated; and

      6.

The individual’s stated purpose for seeking services;

      (b)

Be:

      1.

Maintained in an organized central file;

      2.

Furnished to the:

      a.

Cabinet for Health and Family Services upon request; or

      b.

Managed care organization in which the recipient is enrolled if the recipient

is enrolled with a managed care organization;

      3.

Made available for inspection and copying by:

      a.

Cabinet for Health and Family Services’ personnel; or

      b.

Personnel of the managed care organization in which the recipient is enrolled

if applicable;

      4.

Readily accessible; and

      5.

Adequate for the purpose of establishing the current treatment modality and

progress of the recipient; and

      (c) Document each

service provided to the recipient including the date of the service and the

signature of the individual who provided the service.

      (3) The individual

who provided the service shall date and sign the health record within

forty-eight (48) hours of the date that the individual provided the service.

      (4)(a) Except as

established in paragraph (b) or (c) of this subsection, a provider shall

maintain a health record regarding a recipient for at least six (6) years from

the date of the service or until any audit dispute or issue is resolved beyond

six (6) years.

      (b) After

a recipient’s death or discharge from services, a provider shall maintain the

recipient’s health record for the longest of the following periods:

      1. Six (6) years

unless the recipient is a minor; or

      2. If the

recipient is a minor, three (3) years after the recipient reaches the age of

majority under state law.

      (c) If the

Secretary of the United States Department of Health and Human Services requires

a longer document retention period than the period referenced in paragraph (a)

of this subsection, pursuant to 42 C.F.R. 431.17, the period established by the

secretary shall be the required period.

      (5) A provider

shall comply with 45 C.F.R. Part 164.

      (6)

Documentation of a screening shall include:

      (a)

Information relative to the individual’s stated request for services; and

      (b)

Other stated personal or health concerns if other concerns are stated.

      (7)(a)

A provider’s notes regarding a recipient shall:

      1.

Be made within forty-eight (48) hours of each service visit; and

      2.

Describe the:

      a.

Recipient’s symptoms or behavior, reaction to treatment, and attitude;

      b.

Therapist’s intervention;

      c.

Changes in the plan of care if changes are made; and

      d.

Need for continued treatment if continued treatment is needed.

      (b)1.

Any edit to notes shall:

      a.

Clearly display the changes; and

      b.

Be initialed and dated.

      2.

Notes shall not be erased or illegibly marked out.

      (c)

If services are provided by a practitioner working under supervision, there

shall be a monthly supervisory note recorded by the supervising professional

reflecting consultations with the practitioner working under supervision

concerning the:

      1.

Case; and

      2.

Supervising professional’s evaluation of the services being provided to the

recipient.

      (8)

Immediately following a screening of a recipient, the provider shall perform a

disposition related to:

      (a)

A provisional diagnosis;

      (b)

A referral for further consultation and disposition, if applicable; or

      (c)1.

If applicable, termination of services and referral to an outside source for

further services; or

      2.

If applicable, termination of services without a referral to further services.

      (9)

Any change to a recipient’s plan of care shall be documented, signed, and dated

by the:

      (a)

Rendering practitioner; and

      (b)

Recipient or recipient’s representative.

      (10)(a)

Notes regarding services to a recipient shall:

      1.

Be organized in chronological order;

      2.

Be dated;

      3.

Be titled to indicate the service rendered;

      4.

State a starting and ending time for the service; and

      5.

Be recorded and signed by the rendering provider and include the professional

title (for example, licensed clinical social worker) of the provider.

      (b)

Initials, typed signatures, or stamped signatures shall not be accepted.

      (c)

Telephone contacts, family collateral contacts not covered under this

administrative regulation, or other nonreimbursable contacts shall:

      1.

Be recorded in the notes; and

      2.

Not be reimbursable.

      (11)(a)

A termination summary shall:

      1.

Be required, upon termination of services, for each recipient who received at

least three (3) service visits; and

      2.

Contain a summary of the significant findings and events during the course of

treatment including the:

      a.

Final assessment regarding the progress of the individual toward reaching goals

and objectives established in the individual’s plan of care;

      b.

Final diagnosis of clinical impression; and

      3.

Individual’s condition upon termination and disposition.

      (b)

A health record relating to an individual who was terminated from receiving

services shall be fully completed within ten (10) days following termination.

      (12)

If an individual’s case is reopened within ninety (90) days of terminating

services for the same or related issue, a reference to the prior case history

with a note regarding the interval period shall be acceptable.

      (13)(a)

Except as established in paragraph (b) of this subsection, if a recipient is

transferred or referred to a health care facility or other provider for care or

treatment, the transferring CMHC shall, if the recipient gives the CMHC written

consent to do so, within ten (10) business days of the transfer or referral, transfer

the recipient’s health records in a manner that complies with the health

records’ use and disclosure requirements as established in or required by:

      1.a. The Health

Insurance Portability and Accountability Act;

      b. 42 U.S.C.

1320d-2 to 1320d-8; and

      c. 45 C.F.R. Parts

160 and 164; or

      2.a. 42 U.S.C.

290ee-3; and

      b. 42 C.F.R. Part

2.

      (b) If a recipient

is transferred or referred to a residential crisis stabilization unit, a

psychiatric hospital, a psychiatric distinct part unit in an acute care

hospital, or an acute care hospital for care or treatment, the transferring

CMHC shall, within forty-eight (48) hours of the transfer or referral, transfer

the recipient’s health records in a manner that complies with the health

records’ use and disclosure requirements as established in or required by:

      1.a. The Health

Insurance Portability and Accountability Act;

      b. 42 U.S.C.

1320d-2 to 1320d-8; and

      c. 45 C.F.R. Parts

160 and 164; or

      2.a. 42 U.S.C.

290ee-3; and

      b. 42 C.F.R Part

2.

      (14)(a)

If a CMHC's Medicaid Program participation status changes as a result of

voluntarily terminating from the Medicaid Program, involuntarily terminating

from the Medicaid Program, a licensure suspension, or death of a provider, the

health records regarding recipients to whom the CMHC has provided services

shall:

      1.

Remain the property of the CMHC; and

      2.

Be subject to the retention requirements established in subsection (4) of this

section.

      (b)

A CMHC shall have a written plan addressing how to maintain health records in

the event of a provider’s death.

 

      Section 8.

Medicaid Program Participation Compliance. (1) A CMHC shall comply with:

      (a) 907 KAR 1:671;

      (b) 907 KAR 1:672;

and

      (c) All applicable

state and federal laws.

      (2)(a) If a CMHC receives any duplicate payment or

overpayment from the department or managed care organization, regardless of

reason, the CMHC shall return the

payment to the department or managed care organization that issued the

duplicate payment or overpayment.

      (b) Failure to

return a payment to the department in accordance with paragraph (a) of this

subsection may be:

      1. Interpreted to

be fraud or abuse; and

      2. Prosecuted in

accordance with applicable federal or state law.

 

      Section 9. Third

Party Liability. A provider shall comply with KRS 205.622.

 

      Section 10. Auditing Authority. The department or

the managed care organization in which an enrollee is enrolled shall have the authority to audit any:

      (1)

Claim;

      (2)

Health record; or

      (3)

Documentation associated with the claim or health record.

 

      Section 11. Federal Approval and Federal

Financial Participation. (1) The department’s

coverage of services pursuant to this administrative regulation shall be

contingent upon:

      (a) Receipt of

federal financial participation for the coverage; and

      (b) Centers for

Medicare and Medicaid Services’ approval for the coverage.

      (2) The coverage

of services provided by a licensed clinical alcohol and drug counselor or

licensed clinical alcohol and drug counselor associate shall be contingent and

effective upon approval by the Centers for Medicare and Medicaid Services.

      Section 12. Appeal Rights. (1) An appeal

of an adverse action by the department regarding a recipient who is not

enrolled with a managed care organization shall be in accordance with 907 KAR

1:563.

      (2) An appeal of

an adverse action by a managed care organization regarding a service and an

enrollee shall be in accordance with 907 KAR 17:010.

 

      Section 13.

Incorporation by Reference. (1) The "Community Mental Health Center

Behavioral Health Services Manual", May 2015, is incorporated by

reference.

      (2) This material may

be inspected, copied, or obtained, subject to applicable copyright law, at the

Department for Medicaid Services, 275 East Main Street, 6th Floor West,

Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. or online

at the department’s Web site at

http://www.chfs.ky.gov/dms/incorporated.htm. (Recodified from 904 KAR 1:044, 5-2-1986; 15

Ky.R. 2461; eff. 8-5-1989; 18 Ky.R. 915; eff. 10-16-1991; 20 Ky.R. 663; eff.

10-21-1993; 32 Ky.R. 1801; 2039; 2276; eff. 7-7-2006; 34 Ky.R. 1825; 2313; 2404;

eff. 6-6-2008; 40 Ky.R. 1955; 2487; 2718; eff. 7-7-2014; 41 Ky.R. 1910; 2261;

2553; eff. 7-6-2015.)