907 KAR 3:160. Specialized children’s

services clinics.

 

      RELATES TO: KRS 205.560, 620.020(4)

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

194A.050(1), 205.520(3), EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726,

effective July 9, 2004, reorganized the Cabinet for Health Services and placed

the Department for Medicaid Services and the Medicaid Program under the Cabinet

for Health and Family Services. 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

a requirement that may be imposed, or opportunity presented, by federal law for

the provision of medical assistance to Kentucky's indigent citizenry. This

administrative regulation establishes the requirements for providers and

reimbursement by the Medicaid program for services provided by a specialized

children’s services clinic.

 

      Section 1. Definitions. (1)

"Affiliation agreement" means a written agreement between a provider

and a children’s advocacy center to perform a child sexual abuse medical examination.

      (2) "Child sexual abuse medical

examination" means an examination to determine child sexual abuse that

includes:

      (a) A medical history taken from the

child and a nonimplicated parent, guardian or primary caretaker;

      (b) A physical examination with detailed

attention to the anogenital area;

      (c) If clinically indicated, a

colposcopic examination; and

      (d) A mental health screening, provided

on the same day and at the same location as the physical examination, to

determine the impact of the alleged abuse on the mental health status of the

child and the need for mental health services.

      (3) "Children’s advocacy

center" is defined in KRS 620.020(4).

      (4) "Department" means the

Department for Medicaid Services or its designated agent.

      (5) "Medically necessary" or

"medical necessity" means that a covered benefit is determined to be

needed in accordance with 907 KAR 3:130.

      (6) "Mental health

professional" means:

      (a) A psychologist as defined in KRS

319.010(8);

      (b) A licensed clinical social worker in

accordance with KRS 335.100;

      (c) An advanced registered nurse

practitioner as defined in KRS 314.011(7);

      (d) A licensed marriage and family therapist

as defined in KRS 335.300(2);

      (e) A certified professional counselor as

defined in KRS 335.500(2); or

      (f) A certified professional art

therapist as defined in KRS 309.130(2).

      (7) "Specialized children’s services

clinic" means a clinic enrolled with the Kentucky Medicaid Program that

provides child sexual abuse medical examinations and that meets the

requirements of Section 3 of this administrative regulation.

      (8) "Usual and customary

charge" means the amount a provider bills to the general public.

 

      Section 2. Covered Services. (1) A child

sexual abuse medical examination provided as a clinic service by a specialized

children’s services clinic shall be covered if medically necessary and provided

to a recipient who is under the age of eighteen (18) years.

      (2) A child sexual abuse medical

examination shall be performed by:

      (a) A licensed physician who:

      1. Completes the medical history and

physical examination;

      2. Is employed by, under contract with,

or has an affiliation agreement with a specialized children’s services clinic;

      3. Has received specialized training in

the medical examination of sexually-abused children;

      4. Has received specialized training in

the use of a colposcope and has access to a colposcope in the specialized

children’s services clinic; and

      5. Shall make reports resulting from

child sexual abuse medical examinations available for peer review and maintain

confidentiality in accordance with Section 6 of this administrative regulation;

and

      (b) A mental health professional who:

      1. Performs a mental health screening to

determine the mental health status of the child and the need for further mental

health services;

      2. Is directly supervised by the

physician who performs the medical examination;

      3. Is employed by, under contract with,

or has an affiliation agreement with a specialized children’s services clinic;

and

      4. Has received specialized training in

the mental health screening and assessment of sexually-abused children.

 

      Section 3. Provider Requirements. (1) A

provider shall be enrolled with the department as a specialized children’s

services clinic.

      (2) A specialized children’s services

clinic shall be a children’s advocacy center whose providers are employed by,

under contract with, or have a signed affiliation agreement with the clinic.

 

      Section 4. Billing for Services. (1) A

child sexual abuse medical examination shall be billed by a specialized

children’s services clinic as a comprehensive clinic service which shall

include:

      (a) The services of the physician;

      (b) Mental health screening services

provided by a mental health professional;

      (c) Services and supplies furnished as an

incidental part of the physician’s professional services in the course of

diagnosis and treatment; and

      (d) Medical services provided by other

clinic employees under the direct supervision of the physician.

      (2) Services provided by a physician or

mental health professional employed by, under contract with, or having a signed

affiliation agreement with a specialized children’s services clinic shall be

billed under the clinic’s provider number using a single reimbursement code

designated by the department.

 

      Section 5. Reimbursement. (1) The

department shall establish a statewide reimbursement rate based on a review of

cost data and a consideration of rates paid to providers for similar services.

      (2) The initial rate of reimbursement for

a child sexual abuse medical examination shall be the lesser of:

      (a) An all-inclusive statewide rate of

$538 per examination; or

      (b) The provider’s usual and customary

charge for the service.

      (3) The department shall determine the

statewide rate using updated cost data submitted on an annual cost report from

the center.

 

      Section 6. Medical Records and

Confidentiality. (1) Except to the department, duly authorized representatives

of federal or state agencies, multidisciplinary team members acting pursuant to

KRS 620.050 or a physician participating in a peer review of a specific child

sexual abuse case, a specialized children’s services clinic shall not disclose

any information concerning an eligible recipient without:

      (a) Written consent of:

      1. The recipient; or

      2. If the recipient is a minor, the

recipient’s parent, legal guardian, or attorney; or

      (b) A subpoena from a court of

appropriate jurisdiction.

      (2) A specialized children’s services

clinic shall:

      (a) Maintain a recipient’s medical

records in accordance with 907 KAR 1:672;

      (b) Maintain up-to-date recipient medical

records at the site where the medical services are provided;

      (c) Ensure that a recipient’s medical

record shall be readily retrievable, complete, organized, and legible and shall

reflect sound medical recordkeeping practices; and

      (d) Safeguard medical records against

loss, destruction, and unauthorized use.

 

      Section 7. Appeal Rights. (1) An appeal

of a negative action taken by the department regarding a Medicaid recipient

shall be in accordance with 907 KAR 1:563.

      (2) An appeal of a negative action taken

by the department regarding Medicaid eligibility of an individual shall be in accordance

with 907 KAR 1:560.

      (3) An appeal of a negative action taken

by the department regarding a Medicaid provider shall be in accordance with 907

KAR 1:671. (28 Ky.R. 207; Am. 634; eff. 9-10-2001.)