907 KAR 8:010. Independent occupational therapy service coverage

provisions and requirements.

 

      RELATES TO: KRS 205.520

      STATUTORY AUTHORITY: KRS 194A.030(2),

194A.050(1), 205.520(3), 42 C.F.R. 440.130, 42 U.S.C. 1396d(a)(13)(C)

      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 Medicaid Program

coverage provisions and requirements regarding occupational therapy services provided

by an independent occupational therapist or occupational therapy assistant

working under the direct supervision of an independent occupational therapist.

 

      Section 1. Provider Participation. (1)(a)

To be eligible to provide and be reimbursed for an occupational therapy service

as an independent provider, a provider shall be:

      1. Currently enrolled in the Kentucky

Medicaid Program in accordance with 907 KAR 1:672;

      2. Except as established in paragraph (b)

of this subsection, currently participating in the Kentucky Medicaid Program in

accordance with 907 KAR 1:671; and

      3. Except as provided in subsection (2)

of this section, an occupational therapist.

      (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.

      (2) Occupational therapy services provided

in accordance with Section 2 of this administrative regulation by an

occupational therapy assistant who works under the direct supervision of an

occupational therapist who meets the requirements in subsection (1) of this section

shall be reimbursable if the occupational therapist is the biller for the services.

 

      Section 2. Coverage and Limit. (1) The

department shall reimburse for an occupational therapy service if:

      (a) The service:

      1. Is provided:

      a. By an:

      (i) Occupational therapist who meets the

requirements in Section 1(1) of this administrative regulation; or

      (ii) Occupational therapy assistant who works

under the direct supervision of an occupational therapist who meets the requirements

in Section 1(1) of this administrative regulation; and

      b. To a recipient;

      2. Is ordered for the recipient by a

physician, physician assistant, or advanced practice registered nurse for:

      a. Maximum reduction of a physical or

intellectual disability; or

      b. Restoration of a recipient to the

recipient’s best possible functioning level;

      3. Is prior authorized; and

      4. Is medically necessary; and

      (b) A specific amount of visits is

requested for the recipient by an occupational therapist, physician, physician

assistant, or an advanced practice registered nurse.

      (2)(a) There shall be an annual limit of twenty

(20) occupational therapy service visits per recipient per calendar year except

as established in paragraph (b) of this subsection.

      (b) The limit established in paragraph

(a) of this subsection may be exceeded if services in excess of the limits are

determined to be medically necessary by the:

      1. Department, if the recipient is not

enrolled with a managed care organization; or

      2. Managed care organization in which the

enrollee is enrolled, if the recipient is an enrollee.

      (c) Prior authorization by the department

shall be required for each service visit that exceeds the limit established in

paragraph (a) of this subsection for a recipient who is not enrolled with a managed

care organization.

 

      Section 3. No Duplication of Service. (1)

The department shall not reimburse for an occupational therapy service provided

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

therapy services are covered during the same time period.

      (2) For example, if a recipient is

receiving an occupational therapy service from an occupational therapist

enrolled with the Medicaid Program, the department shall not reimburse for the

same occupational therapy service provided to the same recipient during the

same time period via the home health program.

 

      Section 4. Records Maintenance,

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

for each recipient.

      (2) 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.

      (3) The individual who provided the

service shall date and sign the health record on the date that the individual

provided the service.

      (4)(a) Except as established in paragraph

(b) of this subsection, a provider shall maintain a health record regarding a

recipient for at least five (5) years from the date of the service or until any

audit dispute or issue is resolved beyond five (5) years.

      (b) 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.

 

      Section 5. Medicaid Program Participation

Compliance. (1) A provider 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 provider receives any

duplicate payment or overpayment from the department, regardless of reason, the

provider shall return the payment to the department.

      (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 6. Third Party Liability. A

provider shall comply with KRS 205.622.

 

      Section 7. 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 8. Auditing Authority. The

department shall have the authority to audit any claim, medical record, or documentation

associated with any claim or medical record.

 

      Section 9. 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 10. Appeal Rights. (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. (40 Ky.R.

2038; 2765; eff. 7-7-2014.)