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
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
(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
(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
(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
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
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.)