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.)