907 KAR 1:102. Advanced practice registered nurse services.
RELATES TO: KRS 205.520
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 42 C.F.R. Part 493, 42 U.S.C. 1396a, b, c, d
NECESSITY, FUNCTION, AND CONFORMITY: 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. This administrative regulation establishes the provisions
relating to advanced practice registered nurse services covered by the Medicaid
Program.
Section 1. Definitions. (1)
"Advanced practice registered nurse" or "APRN" is defined
in KRS 314.011(7).
(2) "Common practice" means an
arrangement through which a physician and an APRN jointly administer health
care services.
(3) "CPT code" means a code
used for reporting procedures and services performed by medical practitioners
and published annually by the American Medical Association in Current
Procedural Terminology.
(4) "Department" means the
Department for Medicaid Services or its designated agent.
(5) "Enrollee" means a
recipient who is enrolled with a managed care organization.
(6) "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.
(7) "Federal financial participation"
is defined by 42 C.F.R. 400.203.
(8) "Global period" means the
period of time in which related preoperative, intraoperative, and postoperative
services and follow-up care for a surgical procedure are customarily provided.
(9) "Incidental" means that a
medical procedure:
(a) Is performed at the same time as a
primary procedure; and
(b) Is clinically integral to the
performance of the primary procedure.
(10) "Injectable drug" means an
injectable, infused, or inhaled drug or biological that:
(a) Is not excluded as a non-covered immunization
or vaccine;
(b) Requires special handling, storage,
shipping, dosing, or administration; and
(c) Is a rebatable drug.
(11) "Integral" means that a
medical procedure represents a component of a more complex procedure performed
at the same time.
(12) "Locum tenens APRN" means
an APRN:
(a) Who temporarily assumes responsibility
for the professional practice of an APRN participating in the Kentucky Medicaid
Program; and
(b) Whose services are billed under the Medicaid
participating APRN’s provider number.
(13) "Locum tenens physician"
means a substitute physician:
(a) Who temporarily assumes responsibility
for the professional practice of an APRN participating in the Kentucky Medicaid
Program; and
(b) Whose services are billed under the
Medicaid participating APRN’s provider number.
(14) "Managed care organization"
means an entity for which the Department for Medicaid Services has contracted
to serve as a managed care organization as defined in 42 C.F.R. 438.2.
(15) "Medically necessary" or
"medical necessity" means that a covered benefit is determined to be
needed in accordance with 907 KAR 3:130.
(16) "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.
(17) "New patient" means a
recipient who has not received professional services from the provider within the
past three (3) years.
(18) "Provider" is defined by
KRS 205.8451(8).
(19) "Provider group" means a
group of at least:
(a) Two (2) individually licensed APRNs
who:
1. Are enrolled with the Medicaid Program
individually and as a group; and
2. Share the same Medicaid group provider
number; or
(b) One (1) APRN and at least one (1)
physician who:
1. Are enrolled with the Medicaid Program
individually and as a group; and
2. Share the same Medicaid group provider
number.
(20) "Rebatable drug" means a
drug for which the drug’s manufacturer has entered into or complied with a
rebate agreement in accordance with 42 U.S.C. 1396r-8(a).
(21) "Recipient" is defined by
KRS 205.8451(9).
(22) "Timely filing" means
receipt of a Medicaid claim by the department:
(a) Within twelve (12) months of the date
the service was provided;
(b) Within twelve (12) months of the date
retroactive eligibility was established; or
(c) Within six (6) months of the Medicare
adjudication date if the service was billed to Medicare.
Section 2. Conditions of Participation.
(1) To participate in the Medicaid program as a provider, an APRN or provider
group shall comply with:
(a) 907 KAR 1:005, 907 KAR 1:671, and 907
KAR 1:672; and
(b) The requirements regarding the
confidentiality of personal records pursuant to 42 U.S.C. 1320d to 1320d-8 and
45 C.F.R. Parts 160 and 164.
(2) A provider:
(a) Shall bill the:
1. Department rather than the recipient
for a covered service; or
2. Managed care organization in which the
recipient is enrolled if the recipient is an enrollee;
(b) May bill the recipient for a service
not covered by Medicaid if the provider informed the recipient of non-coverage
prior to providing the service; and
(c)1. Shall not bill the recipient for a
service that is denied by the department on the basis of:
a. The service being incidental,
integral, or mutually exclusive to a covered service or within the global
period for a covered service;
b. Incorrect billing procedures including
incorrect bundling of services;
c. Failure to obtain prior authorization
for the service; or
d. Failure to meet timely filing requirements;
and
2. Shall not bill the enrollee for a
service that is denied by the managed care organization in which the recipient
is enrolled if the recipient is an enrollee on the basis of:
a. The service being incidental, integral,
or mutually exclusive to a covered service or within the global period for a
covered service;
b. Incorrect billing procedures including
incorrect bundling of services;
c. Failure to obtain prior authorization
for the service if prior authorization is required by the managed care
organization; or
d. Failure to meet timely filing requirements.
(3)(a) If a
provider receives any duplicate payment or overpayment from the department or
managed care organization, regardless of reason, the provider 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 or managed care organization 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.
(4)(a) A provider
shall maintain a current health record for each recipient.
(b)1. A health
record shall document each service provided to the recipient including the date
of the service and the signature of the individual who provided the service.
2. The individual
who provided the service shall date and sign the health record within
seventy-two (72) hours from the date that the individual provided the service.
(5)(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
record for the longer 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) or
(b) of this subsection, pursuant to 42 C.F.R. 431.17, the period established by
the secretary shall be the required period.
(6) If a provider
fails to maintain a health record pursuant to subsection (4) or (5) of this
section, the department shall:
(a) Not reimburse
for any claim associated with the health record; or
(b) Recoup from the
provider any payment made associated with the health record.
(7) A provider
shall comply with 45 C.F.R. Part 164.
(8)(a) A service provided by an APRN to a
recipient shall be substantiated by health records signed by the APRN which
correspond to the date and service reported on the claim submitted for payment
to the:
1. Department if the claim is for a
service to a recipient who is not an enrollee; or
2. Managed care organization in which the
recipient is enrolled if the recipient is an enrollee.
(b) If rendering services to a recipient
in a hospital, an APRN shall document in the health record of the hospitalized
recipient that the APRN performed one (1) or more of the following:
1. A personal review of the recipient’s
medical history;
2. A physical examination;
3. A confirmation or revision of the recipient’s
diagnosis;
4. A visit with the recipient; or
5. A discharge service for the recipient.
Section 3. APRN Covered Services. (1)(a)
An APRN covered service shall be:
1. A medically-necessary service
furnished by an APRN through face-to-face interaction between the APRN and the
recipient except as established in paragraph (c) of this subsection; and
2. A service which is:
a. Within the legal scope of practice of
the APRN as specified in:
(i) 201 KAR 20:057; and
(ii) 201 KAR 20:059; and
b. Eligible for reimbursement by Kentucky
Medicaid.
(b) Any service covered pursuant to 907
KAR 3:005 shall be covered under this administrative regulation if it meets the
requirements established in paragraph (a) of this subsection.
(c) Face-to-face interaction between the APRN
and recipient shall not be required for:
1. A radiology service;
2. An imaging service;
3. A pathology service;
4. An ultrasound study;
5. An echographic study;
6. An electrocardiogram;
7. An electromyogram;
8. An electroencephalogram;
9. A vascular study;
10. A telephone analysis of an emergency
medical system or a cardiac pacemaker if provided under APRN direction;
11. A sleep disorder service;
12. A laboratory service; or
13. Any other service that is customarily
performed without face-to-face interaction between the APRN and the recipient.
(2) The prescribing of drugs by an APRN
shall be in accordance with 907 KAR 1:019.
(3) A covered delivery service provided
in a:
(a) Hospital shall include:
1. Admission to the hospital;
2. Admission history;
3. Physical examination;
4. Anesthesia;
5. Management of uncomplicated labor;
6. Vaginal delivery; and
7. Postpartum care; or
(b) Freestanding birth center shall
include:
1. Delivery services in accordance with
907 KAR 1:180, Section 3(3); and
2. Postnatal visits in accordance with
907 KAR 1:180, Section 3(4).
(4) An EPSDT screening service shall be
covered if provided in compliance with the periodicity schedule established in
907 KAR 11:034.
(5) Behavioral health services established
in 907 KAR 15:010 that are provided by an APRN or provider group that is the
billing provider for the services shall be:
(a) Provided in accordance with 907 KAR
15:010; and
(b) Covered in accordance with 907 KAR
15:010.
(6) An injectable drug that is listed on
the Physician Injectable Drug List and that is administered by an APRN or
provider group shall be covered.
Section 4. Service Limitations and Exclusions.
(1)(a) A limitation on a service provided by a physician in accordance with 907
KAR 3:005 shall apply to services covered under this administrative regulation.
(b) A service that is not covered
pursuant to 907 KAR 3:005 shall not be covered under this administrative
regulation.
(2) The same service performed by an APRN
and a physician on the same day within a common practice shall be considered as
one (1) covered service.
(3)(a) Except as established in paragraph
(b) of this subsection, coverage of a psychiatric service provided by an APRN
shall be limited to four (4) psychiatric services per APRN, per recipient, per
twelve (12) months.
(b) A service designated as a psychiatry
service CPT code that is provided by an APRN with a specialty in psychiatry shall
not be subject to the limit established in paragraph (a) of this subsection.
(4) The department shall not cover more
than one (1) of the following evaluation and management services per recipient per
provider per date of service:
(a) A consultation service;
(b) A critical care service;
(c) An emergency department evaluation
and management service;
(d) A home evaluation and management
service;
(e) A hospital inpatient evaluation and
management service;
(f) A nursing facility service;
(g) An office or other outpatient
evaluation and management service; or
(h) A preventive medicine service.
(5) Except for any cost sharing
obligation pursuant to 907 KAR 1:604, a:
(a) Recipient shall not be liable for
payment of any part of a Medicaid-covered service provided to the recipient;
and
(b) Provider shall not bill or charge a
recipient for any part of a Medicaid-covered service provided to the recipient.
(6)(a) In accordance with 42 C.F.R.
455.410, to prescribe medication, order a service for a recipient, or refer a
recipient for a service, a provider shall be currently enrolled and
participating in the Medicaid Program.
(b) The department shall not reimburse
for a:
1. Prescription prescribed by a provider
that is not currently:
a. Participating in the Medicaid Program
pursuant to 907 KAR 1:671; and
b. Enrolled in the Medicaid Program
pursuant to 907 KAR 1:672; or
2. Service:
a. Ordered by a provider that is not
currently:
(i) Participating in the Medicaid Program
pursuant to 907 KAR 1:671; and
(ii) Enrolled in the Medicaid Program
pursuant to 907 KAR 1:672; or
b. Referred by a provider that is not
currently:
(i) Participating in the Medicaid Program
pursuant to 907 KAR 1:671; and
(ii) Enrolled in the Medicaid Program
pursuant to 907 KAR 1:672.
Section 5. Prior Authorization
Requirements. The prior authorization requirements established in 907 KAR 3:005
shall apply to services provided under this administrative regulation.
Section 6. Locum Tenens. The department
shall cover services provided by a locum tenens APRN or locum tenens physician
under this administrative regulation:
(1) If the service meets the requirements
established in this administrative regulation; and
(2) In accordance with:
(a) 201 KAR 20:056; and
(b) 201 KAR 20:057.
Section 7. 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 during the same time period.
(2) For example, if
a recipient is receiving a speech-language pathology service from a
speech-language pathologist enrolled with the Medicaid Program under 907 KAR
8:030, the department shall not reimburse for the same service provided to the
same recipient on the same day by another provider enrolled with the Medicaid
Program.
Section 8. Third Party
Liability. A provider shall comply with KRS 205.622.
Section 9. Use of Electronic
Signatures. (1) The creation, transmission, storage, and other use of
electronic signatures and documents shall comply with the requirements established
in KRS 369.101 to 369.120.
(2) A provider that
chooses to use electronic signatures shall:
(a) Develop and
implement a written security policy that shall:
1. Be adhered to by
each of the provider's employees, officers, agents, or contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each
electronic signature is created, transmitted, and stored in a secure fashion;
(b) Develop a
consent form that shall:
1. Be completed and
executed by each individual using 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
(c) 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 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. The department’s
coverage of services pursuant to this administrative regulation shall be
contingent upon:
(1) Receipt of
federal financial participation for the coverage; and
(2) Centers for
Medicare and Medicaid Services’ approval for the coverage.
Section 12. Appeal Rights. An appeal
of a department decision regarding:
(1) A recipient who is not enrolled with
a managed care organization based upon an application of this administrative
regulation shall be in accordance with 907 KAR 1:563; or
(2) An enrollee based upon an application
of this administrative regulation shall be in accordance with 907 KAR 17:010.
Section 13. Incorporation
by Reference. (1) "Physicians Injectable Drug List", February 16,
2015, is incorporated by reference.
(2) This material
may be inspected, copied, or obtained, subject to applicable copyright law:
(a) At the
Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky, Monday
through Friday, 8 a.m. to 4:30 p.m.; or
(b) Online at the
department’s Web site at www.chfs.ky.gov/dms/incorporated.htm. (17
Ky.R. 2365; eff. 5-3-1991; Am. 19 Ky.R. 1453; eff. 1-27-1993; 27 Ky.R. 245;
811; eff. 9-11-2000; TAm eff. 4-28-2011; 41 Ky.R. 1920; 2268; 2556; eff.
7-6-2015.)