CABINET FOR HEALTH AND
FAMILY SERVICES
Department for Medicaid
Services
Division of Policy and
Operations
(As Amended at ARRS,
August 11, 2015)
907 KAR 9:015. Coverage provisions and requirements regarding
outpatient services provided by Level I or Level II psychiatric residential treatment
facilities.
RELATES TO: KRS 205.520, 42 U.S.C.
1396a(a)(10)(B), 1396a(a)(23)
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3)
NECESSITY, FUNCTION, AND CONFORMITY: The
Cabinet for Health and Family Services, Department for Medicaid Services, has a
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 coverage provisions
and requirements regarding Medicaid Program outpatient behavioral health
services provided by Level I or Level II psychiatric residential treatment facilities.
Section 1. Definitions. (1) "Advanced practice
registered nurse" or "APRN" is defined by KRS 314.011(7).
(2) "Approved behavioral health
services provider" means:
(a) A physician;
(b) A psychiatrist;
(c) An advanced practice registered nurse;
(d) A physician assistant;
(e) A licensed psychologist;
(f) A licensed psychological
practitioner;
(g) A certified psychologist with autonomous
functioning;
(h) A licensed clinical social worker;
(i) A licensed professional clinical
counselor;
(j) A licensed marriage and family therapist;
(k) A licensed psychological associate;
(l) A certified psychologist;
(m) A marriage and family therapy associate;
(n) A certified social worker;
(o) A licensed professional counselor associate;
(p) A licensed professional art
therapist;
(q) A licensed professional art therapist
associate;
(r) A licensed clinical alcohol and drug
counselor in accordance with Section 12 of this administrative regulation;
(s) A licensed clinical alcohol and drug
counselor associate in accordance with Section 12 of this administrative
regulation; or
(t) A certified alcohol and drug
counselor.
(3) "Behavioral health practitioner
under supervision" means an individual who is:
(a)1. A licensed professional counselor
associate;
2. A certified social worker;
3. A marriage and family therapy associate;
4. A licensed professional art therapist
associate;
5. A licensed assistant behavior analyst;
6. A physician assistant;
7. A certified alcohol and drug
counselor; or
8. A licensed clinical alcohol and drug
counselor associate in accordance with Section 12 of this administrative
regulation; and
(b) Employed by or under contract with
the same billing provider as the billing supervisor.
(4) "Billing
provider" means the
individual who, group of individual providers that, or organization that:
(a) Is authorized to bill the department
or a managed care organization for a service; and
(b) Is eligible to be reimbursed by the department
or a managed care organization for a service.
(5) "Billing
supervisor" means an individual who is:
(a)1. A physician;
2. A psychiatrist;
3. An advanced practice registered nurse;
4. A licensed psychologist;
5. A licensed clinical social worker;
6. A licensed professional clinical counselor;
7. A licensed psychological practitioner;
8. A certified psychologist with autonomous
functioning;
9. A licensed marriage and family therapist;
10. A licensed professional art
therapist; or
11. A licensed behavior analyst; and
(b) Employed by or under contract with
the same billing provider as the behavioral health practitioner under
supervision who renders services under the supervision of the billing supervisor.
(6) "Certified
alcohol and drug counselor" is defined by KRS 309.080(2).
(7) "Certified
psychologist" means an
individual who is[recognized as] a certified psychologist pursuant
to KRS 319.056[in accordance with 201 KAR Chapter 26].
(8) "Certified
psychologist with autonomous functioning" means an individual who is a
certified psychologist with autonomous functioning pursuant to KRS 319.056.
(9) "Certified
social worker" means an individual who meets the requirements established
in KRS 335.080.
(10) "Community
support associate" means a paraprofessional who meets the application,
training, and supervision requirements of 908 KAR 2:250.
(11) "Department" means
the Department for Medicaid Services or its designee.
(12) "Electronic
signature" is defined by KRS 369.102(8).
(13) "Enrollee"
means a recipient who is enrolled with a managed care organization.
(14)
"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.
(15) "Federal
financial participation" is defined by 42 C.F.R. 400.203.
(16) "Level I PRTF" means a
psychiatric residential treatment facility that meets the criteria established
in KRS 216B.450(5)(a).
(17) "Level II PRTF" means a
psychiatric residential treatment facility that meets the criteria established
in KRS 216B.450(5)(b).
(18) "Licensed
assistant behavior analyst" is defined by KRS 319C.010(7).
(19) "Licensed
behavior analyst" is defined by KRS 319C.010(6).
(20) "Licensed
clinical alcohol and drug counselor" is defined by KRS 309.080(4).
(21) "Licensed
clinical alcohol and drug counselor associate" is defined by KRS
309.080(5).
(22) "Licensed
clinical social worker" means an individual who meets the licensed
clinical social worker requirements established in KRS 335.100.
(23) "Licensed
marriage and family therapist" is defined by KRS 335.300(2).
(24) "Licensed
professional art therapist" is defined by KRS 309.130(2).
(25) "Licensed
professional art therapist associate" is defined by KRS 309.130(3).
(26) "Licensed
professional clinical counselor" is defined by KRS 335.500(3).
(27) "Licensed
professional counselor associate" is defined by KRS 335.500(4).
(28) "Licensed
psychological associate" means an individual who:
(a) Currently
possesses a licensed psychological associate license in accordance with KRS
319.010(6); and
(b) Meets the
licensed psychological associate requirements established in 201 KAR Chapter
26.
(29) "Licensed
psychological practitioner" means an individual who meets the requirements
established in KRS 319.053.
(30) "Licensed
psychologist" means an individual who:
(a) Currently
possesses a licensed psychologist license in accordance with KRS 319.010(6);
and
(b) Meets the
licensed psychologist requirements established in 201 KAR Chapter 26.
(31) "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.
(32) "Marriage
and family therapy associate" is defined by KRS 335.300(3).
(33) "Medically
necessary" or "medical necessity" means that a covered benefit
is determined to be needed in accordance with 907 KAR 3:130.
(34) "Peer
support specialist" means an individual who meets the peer support
specialist qualifications established in:
(a) 908 KAR 2:220;
(b) 908 KAR 2:230;
or
(c) 908 KAR 2:240.
(35)
"Person-centered service plan" means a plan of services for a
recipient that meets the requirements established in 42 C.F.R. 441.540.
(36)
"Physician" is defined by KRS 205.510(11).
(37) "Physician
assistant" is defined by KRS 311.840(3).
(38) "Provider"
is defined by KRS 205.8451(7).
(39) "Provider
abuse" is defined by KRS 205.8451(8).
(40) "Recipient" is
defined by KRS 205.8451(9).
(41) "Recipient
abuse" is defined by KRS 205.8451(10).
(42) "Recipient’s representative"
means:
(a) For a recipient who is authorized by
Kentucky law to provide written consent, an individual acting on behalf of, and
with written consent from, the recipient; or
(b) A legal guardian.
(43) "Section
504 plan" means a plan developed under the auspices of Section 504 of the
Rehabilitation Act of 1973, as amended, 29 U.S.C. 794 (Section 504), to ensure
that a child who has a disability identified under the law and is attending an
elementary or secondary educational institution receives accommodations to
ensure the child’s academic success and access to the learning environment.
Section 2. General Coverage
Requirements. (1) For the department to reimburse for a service covered under
this administrative regulation, the service shall be:
(a) Medically necessary; and
(b) Provided:
1. Except as established in subsection
(6) or (7) of this section, to a recipient who is under twenty-two (22) years
of age; and
2. By a Level I or Level II psychiatric
residential treatment facility that meets the provider participation requirements
established in Section 3 of this administrative regulation.
(2)(a) Face-to-face contact between a
practitioner and a recipient shall be required for each service except for:
1. Collateral outpatient therapy for a recipient
under the age of twenty-one (21) years if the collateral outpatient therapy is
in the recipient’s plan of care;
2. A family outpatient therapy service in
which the corresponding current procedural terminology code establishes that
the recipient is not present;
3. A psychological testing service comprised
of interpreting or explaining results of an examination or data to family
members or others in which the corresponding current procedural terminology
code establishes that the recipient is not present; or
4. A service planning activity in which
the corresponding current procedural terminology code establishes that the
recipient is not present.
(b) A service that does not meet the requirement
in paragraph (a) of this subsection shall not be covered.
(3) A billable unit of service shall be
actual time spent delivering a service in a face-to-face encounter except
for any component of service planning that does not require the presence of the
recipient or recipient’s representative.
(4) A service shall be:
(a) Stated in the recipient’s plan of
care; and
(b) Provided in accordance with the recipient’s
plan of care.
(5)(a) A Level I or Level II psychiatric
residential treatment facility shall establish a plan of care for each
recipient receiving services from the Level I or Level II psychiatric
residential treatment facility.
(b) A plan of care shall meet the[treatment]
plan of care requirements established in 902 KAR 20:320,
Section 14.
(6)(a) Family outpatient therapy may be
provided to an individual who is over twenty-two (22) years of age if the:
1. Individual is a family member of a
recipient who is:
a. Under twenty-two (22) years of age;
and
b. Receiving outpatient behavioral health
services from the same Level I or Level II PRTF that is providing family
outpatient therapy regarding the recipient; and
2. Family outpatient therapy focuses on
the needs and treatment of the recipient who is under twenty-two (22) years of
age as identified in the recipient’s plan of care.
(b) Peer support may be provided to an individual
who is over twenty-two (22) years of age if the:
1. Individual is a family member of a
recipient who is:
a. Under twenty-two (22) years of age;
and
b. Receiving outpatient behavioral health
services from the same Level I or Level II PRTF that is providing peer support
regarding the recipient; and
2. Peer support focuses on the needs and
treatment of the recipient who is under twenty-two (22) years of age as
identified in the recipient’s plan of care.
(7)(a) A recipient may continue to
receive an outpatient behavioral health service listed in paragraph (b) of this
subsection pursuant to this administrative regulation without disruption after
reaching the age of twenty-two (22) years if the outpatient behavioral health
service continues to be medically necessary for the recipient as identified in
the recipient’s plan of care.
(b) The outpatient behavioral health services
that a recipient may receive in accordance with paragraph (a) of this subsection
may include:
1. Individual outpatient therapy;
2. Group outpatient therapy;
3. Family outpatient therapy;
4. Collateral outpatient therapy;
5. Intensive outpatient program services;
6. Day treatment;
7. Assertive community treatment;
8. Therapeutic rehabilitation services;
9. Peer support; or
10. Comprehensive community support
services.
Section 3. Provider Participation. (1)(a)
To be eligible to provide services under this administrative regulation, a Level
I or Level II psychiatric residential treatment facility shall:
1. Be currently enrolled as a provider in
the Kentucky Medicaid Program in accordance with 907 KAR 1:672;
2. Except as established in subsection
(2) of this section, be currently participating in the Kentucky Medicaid Program
in accordance with 907 KAR 1:671;
3. Be licensed as a Level I or Level II psychiatric
residential treatment facility to provide outpatient behavioral health services
in accordance with 902 KAR 20:320; and
4. Have:
a. For each service it provides, the
capacity to provide the full range of the service as established in this
administrative regulation;
b. Documented experience in serving individuals
with behavioral health disorders;
c. The administrative capacity to ensure
quality of services;
d. A financial management system that
provides documentation of services and costs; and
e. The capacity to document and maintain
individual health records.
(b) The documentation referenced in paragraph
(a)4.b. of this subsection shall be subject to audit by:
1. The department;
2. The Cabinet for Health and Family
Services, Office of Inspector General;
3. A managed care organization, if the Level
I or Level II psychiatric residential treatment facility is enrolled in its
network;
4. The Centers for Medicare and Medicaid
Services;
5. The Kentucky Office of the Auditor of
Public Accounts; or
6. The United States Department of Health
and Human Services, Office of the Inspector General.
(2) In accordance with 907 KAR 17:015,
Section 3(3), a Level I or Level II psychiatric residential treatment facility
which provides an outpatient service to an enrollee shall not be required to be
currently participating in the fee-for-service Medicaid Program.
(3) A Level I or Level II psychiatric
residential treatment facility shall:
(a) Agree to provide services in compliance
with federal and state laws regardless of age, sex, race, creed, religion,
national origin, handicap, or disability; and
(b) Comply with the Americans with Disabilities
Act (42 U.S.C. 12101 et seq.) and any amendments to the act.
Section 4. Covered Services. (1) Except
as specified in the requirements stated for a given service, the services
covered may be provided for a:
(a) Mental health disorder;
(b) Substance use disorder; or
(c) Co-occurring mental health and substance
use disorders.
(2) The following services shall be
covered under this administrative regulation in accordance with the following
requirements:
(a) A screening, crisis intervention, or intensive
outpatient program service provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A licensed clinical alcohol and drug
counselor in accordance with Section 12 of this administrative regulation; or
14. A behavioral health practitioner under
supervision,[:
a. In accordance with Section 12
of this administrative regulation; and
b.] except for a licensed
assistant behavior analyst;
(b) An assessment provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed behavior analyst;
12. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
13. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
14. A licensed clinical alcohol and drug
counselor in accordance with Section 12 of this administrative regulation; or
15. A behavioral health practitioner
under supervision[in accordance with Section 12 of this administrative
regulation];
(c) Psychological testing provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist; or
5. A certified psychologist working under
the supervision of a board-approved licensed psychologist;
(d) Day treatment or mobile crisis
services provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A licensed clinical alcohol and drug
counselor in accordance with Section 12 of this administrative regulation;
14. A behavioral health practitioner
under supervision,[:
a.] except for a licensed
assistant behavior analyst;[and
b. In accordance with Section 12
of this administrative regulation;] or
15. A peer support specialist working under
the supervision of an approved behavioral health services provider[in
accordance with Section 12 of this administrative regulation];
(e) Peer support provided by a peer support
specialist working under the supervision of an approved behavioral health services
provider[in accordance with Section 12 of this administrative regulation];
(f) Individual outpatient therapy, group
outpatient therapy, or collateral outpatient therapy provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed behavior analyst;
12. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
13. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
14. A licensed clinical alcohol and drug
counselor in accordance with Section 12 of this administrative regulation; or
15. A behavioral health practitioner
under supervision[in accordance with Section 12 of this
administrative regulation];
(g) Family outpatient therapy provided
by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A licensed clinical alcohol and drug
counselor in accordance with Section 12 of this administrative regulation; or
14. A behavioral health practitioner
under supervision,[:
a.] except for a
licensed assistant behavior analyst;[and
b. In accordance with Section 12
of this administrative regulation;]
(h) Service planning provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed behavior analyst;
12. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
13. A certified psychologist working
under the supervision of a board-approved licensed psychologist; or
14. A behavioral health practitioner
under supervision except for:
a. A certified alcohol and drug counselor;
or
b. A licensed clinical alcohol and drug
counselor associate;
(i) A screening, brief intervention, and referral
to treatment for a substance use disorder or SBIRT provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A licensed clinical alcohol and drug
counselor in accordance with Section 12 of this administrative regulation; or
14. A behavioral health practitioner
under supervision,[:
a.] except for a
licensed assistant behavior analyst;[and
b. In accordance with Section 12
of this administrative regulation;]
(j) Assertive community treatment provided
by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A behavioral health practitioner
under supervision except for a:
a. Licensed assistant behavior analyst;
b. Certified alcohol and drug counselor;
or
c. Licensed clinical alcohol and drug counselor
associate;
14. A peer support specialist working under
the supervision of an approved behavioral health services provider except for
a:
a. Licensed clinical alcohol and drug counselor;
b. Licensed clinical alcohol and drug counselor
associate; or
c. Certified alcohol and drug counselor;
or
15. A community support associate;
(k) Comprehensive community support
services provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed behavior analyst;
12. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
13. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
14. A behavioral health practitioner
under supervision except for a:
a. Licensed clinical alcohol and drug counselor
associate; or
b. Certified alcohol and drug counselor; or
15. A community support associate; or
(l) Therapeutic rehabilitation program services
provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A behavioral health practitioner
under supervision except for a:
a. Licensed assistant behavior analyst;
b. Licensed clinical alcohol and drug counselor
associate; or
c. Certified alcohol and drug counselor;
or
14. A peer support specialist working under
the supervision of an approved behavioral health services provider except for a:
a. Licensed clinical alcohol and drug counselor;
b. Licensed clinical alcohol and drug counselor
associate; or
c. Certified alcohol and drug counselor.
(3)(a) A screening shall:
1. Determine the likelihood that an
individual has a mental health disorder, substance use disorder, or
co-occurring disorders;
2. Not establish the presence or specific
type of disorder; and
3. Establish the need for an in-depth assessment.
(b) An assessment shall:
1. Include gathering information and engaging
in a process with the individual that enables the practitioner to:
a. Establish the presence or absence of a
mental health disorder, substance use disorder, or co-occurring disorders;
b. Determine the individual’s readiness
for change;
c. Identify the individual’s strengths or
problem areas that may affect the treatment and recovery processes; and
d. Engage the individual in the development
of an appropriate treatment relationship;
2. Establish or rule out the existence of
a clinical disorder or service need;
3. Include working with the individual to
develop a plan of care; and
4. Not include psychological or
psychiatric evaluations or assessments.
(c) Psychological testing shall:
1. Include:
a. A psychodiagnostic assessment of
personality, psychopathology, emotionality, or intellectual disabilities; and
b. Interpretation and a written report of
testing results; and
2. Be performed by an individual who has met the
requirements of KRS Chapter 319 related to the necessary credentials to perform
psychological testing.
(d) Crisis intervention:
1. Shall be a therapeutic intervention
for the purpose of immediately reducing or eliminating the risk of physical or
emotional harm to:
a. The recipient; or
b. Another individual;
2. Shall consist of clinical intervention
and support services necessary to provide integrated crisis response, crisis
stabilization interventions, or crisis prevention activities for individuals;
3. Shall be provided:
a. On-site at the facility where the outpatient
behavioral health services are provided;
b. As an immediate relief to the
presenting problem or threat; and
c. In a face-to-face, one-on-one
encounter between the provider and the recipient;
4. Shall be followed by a referral to non-crisis
services if applicable; and
5. May include:
a. Further service prevention planning that
includes:
(i) Lethal means reduction for suicide
risk; or
(ii) Substance use disorder relapse prevention;
or
b. Verbal de-escalation, risk assessment, or
cognitive therapy.
(e) Mobile crisis services shall:
1. Be available
twenty-four (24) hours per day, seven (7) days per week, every day of the year;
2. Ensure access to
a board-certified or board-eligible psychiatrist twenty-four (24) hours a day,
seven (7) days per week, every day of the year;
3. Be provided for
a duration of less than twenty-four (24) hours;
4. Not be an
overnight service;
5. Be a multi-disciplinary
team-based intervention in a home or community setting that ensures access to
mental health and substance use disorder services and supports to:
a.[(i)]
Reduce symptoms or harm; or
b.[(ii)]
Safely transition an individual in an acute crisis to the appropriate least
restrictive level of care;
6. Involve all
services and supports necessary to provide:
a. Integrated
crisis prevention;
b. Assessment and
disposition;
c. Intervention;
d. Continuity of
care recommendations; and
e. Follow-up
services; and
7. Be provided
face-to-face in a home or community setting.
(f)1. Day treatment shall
be a non-residential, intensive treatment program for an individual under the
age of twenty-one (21) years who has:
a. A mental health
disorder, substance use disorder, or co-occurring mental health and substance
use disorders; and
b. A high risk of
out-of-home placement due to a behavioral health issue.
2. Day treatment
shall:
a. Consist of an
organized behavioral health program of treatment and rehabilitative services;
b. Include:
(i) Individual
outpatient therapy, family outpatient therapy, or group outpatient therapy;
(ii) Behavior
management and social skills training;
(iii) Independent
living skills that correlate to the age and developmental stage of the
recipient; or
(iv) Services
designed to explore and link with community resources before discharge and to
assist the recipient and family with transition to community services after discharge;
and
c. Be provided:
(i) In
collaboration with the education services of the local education authority
including those provided through 20 U.S.C. 1400 et seq. (Individuals with
Disabilities Education Act) or 29 U.S.C. 701 et seq. (Section 504 of the
Rehabilitation Act);
(ii) On school days
and on non-instructional weekdays during the school year including scheduled school
breaks;
(iii) In
coordination with the recipient’s individualized educational plan or Section
504 plan if the recipient has an individualized educational plan or Section 504
plan;
(iv) Under the
supervision of a licensed or certified approved behavioral health services
provider[in accordance with Section 12 of this administrative
regulation] or a behavioral health practitioner working under
clinical supervision[in accordance with Section 12 of this
administrative regulation]; and
(v) With a linkage
agreement with the local education authority that specifies the responsibilities
of the local education authority and the day treatment provider.
3. To provide day
treatment services, a Level I or Level II psychiatric residential treatment
facility shall have:
a. The capacity to
employ staff authorized to provide day treatment services in accordance with
this section and to coordinate the provision of services among team members;
and
b. Knowledge of
substance use disorders.
4. Day treatment
shall not include a therapeutic clinical service that is included in a child’s
individualized education plan.
(g)1. Peer support services shall:
a. Be emotional
support that is provided[to a recipient] by:
(i) An individual
who has been trained and certified in accordance with 908 KAR 2:220 and who is
experiencing or has experienced a mental health disorder, substance use disorder,
or co-occurring mental health and substance use disorders to a recipient by
sharing a similar mental health disorder, substance use disorder, or
co-occurring mental health and substance use disorders in order to bring about
a desired social or personal change;
(ii) A parent who
has been trained and certified in accordance with 908 KAR 2:230 of a child
having or who has had a mental health disorder,
substance use disorder, or co-occurring mental
health and substance use disorders[disorder] to a
parent or family member of a child sharing a similar mental health disorder,
substance use disorder, or co-occurring mental health and
substance use disorders[disorder] in order to bring
about a desired social or personal change; or
(iii) A family member who has
been trained and certified in accordance with 908 KAR 2:230 of a child having or
who has had a mental health disorder, substance use disorder,
or
co-occurring mental health and substance use disorders[disorder] to a parent or family
member of a child sharing a similar mental health disorder, substance use disorder, or co-occurring mental
health and substance use disorders[disorder] in order to bring about
a desired social or personal change;
b. Be an
evidence-based practice;
c. Be structured
and scheduled non-clinical therapeutic activities with an individual recipient
or a group of recipients;
d. Promote
socialization, recovery, self-advocacy, preservation, and enhancement of
community living skills for the recipient;
e. Be coordinated
within the context of a comprehensive, individualized plan of care developed
through a person-centered planning process;
f. Be identified in
each recipient’s plan of care; and
g. Be designed to
contribute directly to the recipient’s individualized goals as specified in the
recipient’s plan of care.
2. To provide peer
support services, a Level I or Level II psychiatric residential treatment
facility shall:
a. Have
demonstrated:
(i) The capacity to
provide peer support services for the behavioral health population being served
including the age range of the population being served; and
(ii) Experience in
serving individuals with behavioral health disorders;
b. Employ peer
support specialists who are qualified to provide peer support services in
accordance with 908 KAR 2:220, 908 KAR 2:230, or 908 KAR 2:240;
c. Use an approved
behavioral health services provider[in accordance with Section 12 of
this administrative regulation] to supervise peer support
specialists;
d. Have the
capacity to coordinate the provision of services among team members; and
e. Have the
capacity to provide on-going continuing education and technical assistance to
peer support specialists.
(h)1. Intensive outpatient program
services shall:
a. Be an
alternative to or transition from inpatient hospitalization or partial
hospitalization for a mental health disorder, substance use disorder, or
co-occurring disorders;
b. Offer a
multi-modal, multi-disciplinary structured outpatient treatment program that is
significantly more intensive than individual outpatient therapy, group
outpatient therapy, or family outpatient therapy;
c. Be provided at
least three (3) hours per day at least three (3) days per week; and
d. Include:
(i) Individual
outpatient therapy, group outpatient therapy, or family outpatient therapy
unless contraindicated;
(ii) Crisis
intervention; or
(iii)
Psycho-education.
2. During
psycho-education the recipient or recipient’s family member shall be:
a. Provided with
knowledge regarding the recipient’s diagnosis, the causes of the condition, and
the reasons why a particular treatment might be effective for reducing symptoms;
and
b. Taught how to
cope with the recipient’s diagnosis or condition in a successful manner.
3. An intensive
outpatient program services treatment plan shall:
a. Be
individualized; and
b. Focus on
stabilization and transition to a lesser level of care.
4. To provide
intensive outpatient program services, a Level I or Level II psychiatric residential
treatment facility shall have:
a. Access to a
board-certified or board-eligible psychiatrist for consultation;
b. Access to a
psychiatrist, physician, or an advanced practice registered nurse for
medication prescribing and monitoring;
c. Adequate
staffing to ensure a minimum recipient-to-staff ratio of ten (10) recipients to
one (1) staff person;
d. The capacity to
provide services utilizing a recognized intervention protocol based on
nationally accepted treatment principles; and
e. The capacity to
employ staff authorized to provide intensive outpatient program services in
accordance with this section and to coordinate the provision of services among
team members.
(i) Individual outpatient therapy shall:
1. Be provided to promote the:
a. Health and well-being of the recipient[individual];
and
b. Recipient’s recovery
from a substance use disorder, mental health disorder, or co-occurring mental
health and substance use disorders;
2. Consist of:
a. A face-to-face, one-on-one encounter
between the provider and recipient; and
b. A behavioral health therapeutic
intervention provided in accordance with the recipient’s identified plan
of care;
3. Be aimed at:
a. Reducing adverse symptoms;
b. Reducing or eliminating the presenting
problem of the recipient; and
c. Improving functioning; and
4. Not exceed three (3) hours per day unless
additional time is medically necessary.
(j)1. Group outpatient therapy shall:
a. Be a behavioral health therapeutic
intervention provided in accordance with a recipient’s identified
plan of care;
b. Be provided to promote the:
(i) Health and well-being of the recipient[individual];
and
(ii) Recipient’s recovery
from a substance use disorder, mental health disorder, or co-occurring mental
health and substance use disorders;
c. Consist of a face-to-face behavioral
health therapeutic intervention provided in accordance with the recipient’s
identified plan of care;
d. Be provided to a recipient in a group
setting:
(i) Of nonrelated individuals except for
multi-family group therapy; and
(ii) Not to exceed twelve (12)
individuals;
e. Focus on the psychological needs of
the recipients as evidenced in each recipient’s plan of care;
f. Center on goals including building and
maintaining healthy relationships, personal goals setting, and the exercise of
personal judgment;
g. Not include physical exercise, a
recreational activity, an educational activity, or a social activity; and
h. Not exceed three (3) hours per day per
recipient unless additional time is medically necessary.
2. The group shall have a:
a. Deliberate focus; and
b. Defined course of treatment.
3. The subject of group outpatient
therapy shall relate to each recipient participating in the group.
4. The provider shall keep individual
notes regarding each recipient of the group and within each recipient’s health
record.
(k)1. Family outpatient therapy shall consist
of a face-to-face behavioral health therapeutic intervention provided:
a. Through scheduled therapeutic visits
between the therapist and the recipient and at least one (1) member of the
recipient’s family; and
b. To address issues interfering with the
relational functioning of the family and to improve interpersonal relationships
within the recipient’s home environment.
2. A family outpatient therapy session
shall be billed as one (1) service regardless of the number of individuals
(including multiple members from one (1) family) who participate in the
session.
3. Family outpatient therapy shall:
a. Be provided to promote the:
(i) Health and well-being of the recipient[individual];
or
(ii) Recipient’s recovery
from a substance use disorder, mental health disorder, or co-occurring mental
health and substance use disorders; and
b. Not exceed three (3) hours per day per
individual unless additional time is medically necessary.
(l)1. Collateral outpatient therapy
shall:
a. Consist of a face-to-face behavioral
health consultation:
(i) With a parent or caregiver of a
recipient, household member of a recipient, recipient’s representative, school staff
person, treating professional, or other person with custodial control or
supervision of the recipient; and
(ii) That is provided in accordance with
the recipient’s plan of care; and
b. Not be reimbursable if the therapy is
for a recipient who is at least twenty-one (21) years of age.
2. Consent given to discuss a recipient’s
treatment with any person other than a parent or legal guardian shall be signed
by the recipient or recipient’s representative and filed in the recipient’s
health record.
(m)1. Service planning shall:
a. Involve assisting a recipient in
creating an individualized plan for services needed for maximum reduction of the
effects of a mental health disorder;
b. Involve restoring a recipient's
functional level to the recipient's best possible functional level; and
c. Be performed using a person-centered
planning process.
2. A service plan:
a. Shall be directed by the:
(i) Recipient; or
(ii) Recipient’s representative if the
recipient is under the age of eighteen (18) years or is unable to provide
direction;
b. Shall include practitioners of the
recipient’s choosing; and
c. May include:
(i) A mental health advance directive
being filed with a local hospital;
(ii) A crisis plan; or
(iii) A relapse prevention strategy or
plan.
(n) Screening, brief intervention, and
referral to treatment for a substance use disorder shall:
1. Be an evidence-based early
intervention approach for an individual with non-dependent substance use in
order to provide an effective strategy for intervention prior to the need for more
extensive or specialized treatment; and
2. Consist of:
a. Using a standardized screening tool to
assess an individual for risky substance use behavior;
b. Engaging a recipient, who demonstrates
risky substance use behavior, in a short conversation and providing feedback
and advice to the recipient; and
c. Referring a recipient to additional
mental health disorder, substance use disorder, or co-occurring disorders
services if the recipient is determined to need additional services to address the
recipient’s substance use.
(o)1. Assertive community treatment
shall:
a. Be an
evidence-based psychiatric rehabilitation practice which provides a
comprehensive approach to service delivery for individuals with a severe mental
illness; and
b. Include:
(i) Assessment;
(ii) Treatment
planning;
(iii) Case
management;
(iv) Psychiatric
services;
(v) Medication prescribing
and monitoring;
(vi) Individual
outpatient therapy;
(vii) Group
outpatient therapy;
(viii) Mobile
crisis services;
(ix) Mental health consultation;
(x) Family support
and basic living skills; or
(xi) Peer support.
2.a. Mental health
consultation shall involve brief, collateral interactions with other treating
professionals who may have information for the purpose of treatment planning
and service delivery.
b. Family support
shall involve the assertive community treatment team’s working with the
recipient’s natural support systems to improve family relations in order to:
(i) Reduce
conflict; and
(ii) Increase the
recipient’s autonomy and independent functioning.
c. Basic living
skills shall be rehabilitative services focused on teaching activities of daily
living necessary to maintain independent functioning and community living.
3. To provide
assertive community treatment services, a psychiatric residential treatment
facility shall:
a. Employ at least
one (1) team of multidisciplinary professionals:
(i) Led by an
approved behavioral health services provider except for a licensed clinical
alcohol and drug counselor, a licensed clinical alcohol and drug counselor
associate, or a certified alcohol and drug counselor; and
(ii) Comprised of
at least four (4) full-time equivalents including a psychiatrist, a nurse, a
case manager, a peer support specialist, or an approved behavioral health
services provider except for a licensed clinical alcohol and drug counselor, a
licensed clinical alcohol and drug counselor associate, or a certified alcohol
and drug counselor;
b. Have adequate
staffing to ensure that no team’s caseload size exceeds ten (10) participants
per team member (for example, if the team includes five (5) individuals, the
caseload for the team shall not exceed fifty (50) recipients);
c. Have the
capacity to:
(i) Employ staff
authorized to provide assertive community treatment services in accordance with
this paragraph;
(ii) Coordinate the
provision of services among team members;
(iii) Provide the
full range of assertive community treatment services as stated in this
paragraph; and
(iv) Document and
maintain individual health records; and
d. Demonstrate
experience in serving individuals with persistent and severe mental illness who
have difficulty living independently in the community.
(p)1. Comprehensive
community support services shall:
a. Be activities necessary to allow an
individual to live with maximum independence in the community;
b. Be intended to ensure successful community
living through the utilization of skills training as identified in the
recipient’s plan of care; and
c. Consist of using a variety of psychiatric
rehabilitation techniques to:
(i) Improve daily living skills;
(ii) Improve self-monitoring of symptoms
and side effects;
(iii) Improve emotional regulation
skills;
(iv) Improve crisis coping skills; and
(v) Develop and enhance interpersonal skills.
2. To provide comprehensive community
support services, a psychiatric residential treatment facility shall:
a. Have the capacity to employ staff authorized
pursuant to 908 KAR 2:250 to provide comprehensive community support services
in accordance with subsection (2)(k) of this section and to coordinate the
provision of services among team members; and
b. Meet the requirements for comprehensive
community support services established in 908 KAR 2:250.
(q)1. Therapeutic rehabilitation program
services shall be:
a. A rehabilitative service for an individual
under the age of twenty-one (21) years who has a severe emotional disability; and
b. Designed to maximize the reduction of the
effects of a mental health disorder and the restoration of the individual’s
functional level to the individual’s best possible functional level.
2. A recipient in a therapeutic
rehabilitation program shall establish the recipient’s own rehabilitation goals
within the person-centered service plan.
3. A therapeutic rehabilitation program
shall:
a. Be delivered using a variety of
psychiatric rehabilitation techniques;
b. Focus on:
(i) Improving daily living skills;
(ii) Self-monitoring of symptoms and side
effects;
(iii) Emotional regulation skills;
(iv) Crisis coping skills; and
(v) Interpersonal skills; and
c. Be delivered individually or in a
group.
(4) The extent and type of a screening
shall depend upon the nature of the problem of the individual seeking or being
referred for services.
(5) A diagnosis or clinical impression
shall be made using terminology established in the most current edition of the
American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.
(6) The department shall not reimburse
for a service billed by or on behalf of an entity or individual who is not a
billing provider.
Section 5. Additional Limits and Non-covered
Services or Activities. (1)(a) Except as established in paragraph (b) of this
subsection, unless a diagnosis is made and documented in the recipient’s health
record within three (3) visits, the service shall not be covered.
(b) The requirement established in
paragraph (a) of this subsection shall not apply to:
1. Mobile crisis services;
2. Crisis intervention;
3. A screening; or
4. An assessment.
(2) For a recipient who is receiving
assertive community treatment, the following shall not be billed or reimbursed
for the same period of time in which the recipient receives assertive community
treatment[date of service for the recipient]:
(a) An assessment;
(b) Case management;
(c) Individual outpatient therapy;
(d) Group outpatient therapy;
(e) Peer support services; or
(f) Mobile crisis services.
(3) The department shall not reimburse
for both a screening and an SBIRT provided to a recipient on the same date of
service.
(4) The following services or activities shall
not be covered under this administrative regulation:
(a) A service provided to:
1. A resident of:
a. A nursing facility; or
b. An intermediate care facility for
individuals with an intellectual disability;
2. An inmate of a federal, local, or
state:
a. Jail;
b. Detention center; or
c. Prison; or
3. An individual with an intellectual
disability without documentation of an additional psychiatric diagnosis;
(b) Psychiatric or psychological testing
for another agency, including a court or school, that does not result in the
individual receiving psychiatric intervention or behavioral health therapy from
the psychiatric residential treatment facility;
(c) A consultation or educational service
provided to a recipient or to others;
(d) A telephone call, an email, a text
message, or other electronic contact that does not meet the requirements stated
in the definition of "face-to-face" established in Section 1(14) of
this administrative regulation;
(e) Travel time;
(f) A field trip;
(g) A recreational activity;
(h) A social activity; or
(i) A physical exercise activity group.
(5)(a) A consultation by one (1) provider
or professional with another shall not be covered under this administrative
regulation except as established in Section 4(3)(l)1 of this administrative regulation.
(b) A third party contract shall not be
covered under this administrative regulation.
(6) A billing supervisor arrangement
between a billing supervisor and a behavioral health practitioner under
supervision shall not:
(a) Violate the clinical supervision rules
or policies of the respective professional licensure boards governing the
billing supervisor and the behavioral health practitioner under supervision; or
(b) Substitute for the clinical
supervision rules or policies of the respective professional licensure boards
governing the billing supervisor and the behavioral health practitioner under supervision.
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 same service is
covered, during the same time period.
(2) For example, if a recipient is
receiving a behavioral health service from an independent behavioral health
provider, the department shall not reimburse for the same service provided to
the same recipient during the same time period by a Level I or Level II psychiatric
residential treatment facility.
Section 7. Records Maintenance, Documentation,
Protection, and Security. (1) A Level I or Level II psychiatric residential
treatment facility shall maintain a current health record for each recipient.
(2)(a) 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.
(b) 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.
(3) 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 or Medicaid participation
information;
f. If applicable, the referral
source’s name and address;
g. Primary care physician’s name 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 regarding:
(i) Where the individual is receiving
treatment for the physical health diagnosis; and
(ii) The physical health provider’s name;
and
j. The name of the informant and any
other information deemed necessary by the Level I or Level II psychiatric
residential treatment facility in order to comply with the requirements of:
(i) This administrative regulation;
(ii) The Level I or Level II psychiatric
residential treatment facility’s licensure board;
(iii) State law; or
(iv) Federal law;
2. Documentation of the:
a. Screening;
b. Assessment if an assessment was performed;
and
c. Disposition if a disposition was performed;
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; and
(b) Be:
1. Maintained in an organized central
file;
2. Furnished upon request:
a. To the Cabinet for Health and Family
Services; or
b. For an enrollee, to the managed care
organization in which the recipient is enrolled or has been enrolled in the
past;
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 if the recipient
received services beyond a screening.
(4) 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.
(5)(a) A Level I or Level II psychiatric
residential treatment facility’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. Behavioral health practitioner’s[Therapist’s]
intervention;
c. Changes in the
plan of care if
changes are made; and
d. Need for continued treatment if deemed
necessary.
(b)1. Any edit to notes shall:
a. Clearly display the changes; and
b. Be initialed and dated by the person
who edited the notes.
2. Notes shall not be erased or illegibly
marked out.
(c)1. Notes recorded by a behavioral
health practitioner working under supervision shall be co-signed and dated by
the supervising professional within thirty (30) days.
2. If services are provided by a behavioral
health practitioner working under supervision, there shall be a monthly
supervisory note recorded by the supervising professional which reflects consultations
with the behavioral health practitioner working under supervision concerning
the:
a. Case; and
b. Supervising professional’s evaluation
of the services being provided to the recipient.
(6) Immediately following a screening of
a recipient, the practitioner 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.
(7) Any change to a recipient’s plan of
care shall be documented, signed, and dated by the rendering practitioner and
by the recipient or recipient’s representative.
(8)(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 practitioner 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
non-reimbursable contacts shall:
1. Be recorded in the notes; and
2. Not be reimbursable.
(9)(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
c. Individual’s condition upon
termination and disposition.
(b) A health record relating to an
individual who has been terminated from receiving services shall be fully
completed within ten (10) days following termination.
(10) 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.
(11)(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
Level I or Level II psychiatric residential treatment facility shall, within ten
(10) business days of awareness of the transfer or referral, transfer the recipient’s
records in a manner that complies with the 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, an acute care hospital, or to the
residential setting of a Level I or Level II PRTF for care or treatment, the
transferring outpatient Level I or Level II psychiatric residential treatment facility
shall, within forty-eight (48) hours of the transfer or referral, transfer the
recipient’s records in a manner that complies with the 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.
(12)(a) If a Level I or Level II
psychiatric residential treatment facility’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 an owner or deaths of owners, the health records of the Level I or
Level II psychiatric residential treatment facility shall:
1. Remain the property of the Level I or
Level II psychiatric residential treatment facility; and
2. Be subject to the retention
requirements established in subsection (13) of this section.
(b) A Level I or Level II psychiatric
residential treatment facility shall have a written plan addressing how to
maintain health records in the event of death of an owner or deaths of owners.
(13)(a) Except as established in
paragraph (b) or (c) of this subsection, a Level I or Level II psychiatric
residential treatment facility shall maintain a health record regarding a recipient
for at least six (6) years from the last 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 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.
(14)(a) A Level I or Level II psychiatric
residential treatment facility shall comply with 45 C.F.R. Part 164.
(b) All information contained in a health
record shall:
1. Be treated as confidential;
2. Not be disclosed to an unauthorized individual;
and
3. Be disclosed to an authorized representative
of:
a. The department;
b. Federal government; or
c. For an enrollee, the managed
care organization in which the enrollee is enrolled.
(c)1. Upon request, a Level I or Level II
psychiatric residential treatment facility shall provide to an authorized
representative of the department, federal government, or managed care
organization if applicable, information requested to substantiate:
a. Staff notes detailing a service that
was rendered;
b. The professional who rendered a service;
and
c. The type of service rendered and any
other requested information necessary to determine, on an individual basis,
whether the service is reimbursable by the department or managed care organization.
2. Failure to provide information
referenced in subparagraph 1 of this paragraph shall result in denial of
payment for any service associated with the requested information.
Section 8. Medicaid Program Participation
Compliance. (1) A Level I or Level II psychiatric residential treatment
facility 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 Level I or Level II
psychiatric residential treatment facility receives any duplicate payment or
overpayment from the department or a managed care organization, regardless of
reason, the Level I or Level II psychiatric residential treatment facility
shall return the payment to the department or managed care organization that
made the duplicate payment or overpayment in accordance with 907 KAR 1:671.
(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.
(3)(a) When the department makes payment
for a covered service and the Level I or Level II psychiatric residential
treatment facility accepts the payment:
1. The payment shall be considered payment
in full;
2. A bill for the same service shall not be
given to the recipient; and
3. Payment from the recipient for the
same service shall not be accepted by the Level I or Level II psychiatric
residential treatment facility.
(b)1. A Level I or Level II psychiatric
residential treatment facility may bill a recipient for a service that is not
covered by the Kentucky Medicaid Program if the:
a. Recipient requests the service; and
b. Level I or Level II psychiatric
residential treatment facility makes the recipient aware in writing in advance
of providing the service that the:
(i) Recipient is liable for the payment;
and
(ii) Department is not covering the
service.
2. If a recipient makes payment for a service
in accordance with subparagraph 1 of this paragraph, the:
a. Level I or Level II psychiatric
residential treatment facility shall not bill the department for the service;
and
b. Department shall not:
(i) Be liable for any part of the payment
associated with the service; and
(ii) Make any payment to the Level I or
Level II psychiatric residential treatment facility regarding the service.
(4)(a) A Level I or Level II psychiatric
residential treatment facility shall attest[attests]
by the Level I or Level II psychiatric residential treatment facility’s staff’s
or representative’s signature that any claim associated with a service is valid
and submitted in good faith.
(b) Any claim and substantiating record
associated with a service shall be subject to audit by the:
1. Department or its designee;
2. Cabinet for Health and Family
Services, Office of Inspector General, or its designee;
3. Kentucky Office of Attorney General or
its designee;
4. Kentucky Office of the Auditor for
Public Accounts or its designee;
5. United States General Accounting Office
or its designee; or
6. For an enrollee, managed care
organization in which the enrollee is enrolled.
(c)1. If a Level I or Level II
psychiatric residential treatment facility receives a request from the:
a. Department to provide a claim, related
information, related documentation, or record for auditing purposes, the Level
I or Level II psychiatric residential treatment facility shall provide the requested
information to the department within the timeframe requested by the department;
or
b. Managed care organization in which an
enrollee is enrolled to provide a claim, related information, related
documentation, or record for auditing purposes, the Level I or Level II
psychiatric residential treatment facility shall provide the requested
information to the managed care organization within the timeframe requested by
the managed care organization.
2.a. The timeframe requested by the
department or managed care organization for a Level I or Level II psychiatric
residential treatment facility to provide requested information shall be:
(i) A reasonable amount of time given the
nature of the request and the circumstances surrounding the request; and
(ii) A minimum of one (1) business day.
b. A Level I or Level II psychiatric
residential treatment facility may request a longer timeframe to provide
information to the department or a managed care organization if the Level I or
Level II psychiatric residential treatment facility justifies the need for a
longer timeframe.
(d)1. All services provided shall be
subject to review for recipient or provider abuse.
2. Willful abuse by a Level I or Level II
psychiatric residential treatment facility shall result in the suspension or
termination of the Level I or Level II psychiatric residential treatment
facility from Medicaid Program participation in accordance with 907 KAR 1:671.
Section 9. Third Party Liability. A Level
I or Level II psychiatric residential treatment facility shall comply with KRS
205.622.
Section 10. 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 Level I or Level II psychiatric
residential treatment facility 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 Level I
or Level II psychiatric residential treatment facility'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 Level I or Level II
psychiatric residential treatment facility's electronic signature policy;
2. The signed consent form; and
3. The original filed signature.
Section 11. Auditing Authority. The
department or 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 any
claim or health record.
Section 12. 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 13. Appeals. (1) An appeal of an
adverse action by the department regarding a service and 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.
LISA LEE, Commissioner
AUDREY TAYSE HAYNES, Secretary
APPROVED BY AGENCY: July 7, 2015
FILED WITH LRC: July 9, 2015 at 11 a.m.
CONTACT
PERSON: Tricia Orme, Office of Legal Services, 275 East Main Street 5 W-B,
Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502) 564-7573,
tricia.orme@ky.gov.
