CABINET FOR HEALTH AND
FAMILY SERVICES
Department for Medicaid
Services
Division of Policy and
Operations
(As Amended at ARRS,
August 11, 2015)
907 KAR 9:005. Non-outpatient level I and II
psychiatric residential treatment facility service and coverage policies.
RELATES TO: KRS 205.520, 216B.450,
216B.455, 216B.459
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 42 C.F.R. 440.160, 42 U.S.C. 1396a-d
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 Medicaid program
coverage policies regarding Level I and Level II psychiatric residential
treatment facility services that are not provided on an outpatient basis.
Section 1. Definitions. (1) "Active
treatment" means a covered Level I or II psychiatric residential treatment
facility service provided:
(a) In accordance with an individual plan
of care as specified in 42 C.F.R. 441.154; and
(b) By an individual employed or contracted
by a Level I or II PRTF including a:
1. Qualified mental health personnel;
2. Qualified mental health professional;
3. Mental health associate; or
4. Direct care staff person.
(2) "Acute care hospital" is
defined by KRS 205.639(1).
(3) "Advanced practice registered
nurse" is defined by KRS 314.011(7).
(4) "Behavioral health
professional" means:
(a) A psychiatrist;
(b) A physician licensed in Kentucky to
practice medicine or osteopathy, or a medical officer of the government of the
United States while engaged in the practice of official duties;
(c) A licensed psychologist[licensed
and practicing in accordance with KRS 319.050];
(d) A[certified psychologist with
autonomous functioning or] licensed psychological practitioner[certified
and practicing in accordance with KRS 319.056];
(e) A licensed clinical social worker[licensed
and practicing in accordance with KRS 335.100];
(f) An advanced practice registered nurse[licensed
and practicing in accordance with KRS 314.042];
(g) A licensed marriage and family
therapist[licensed and practicing in accordance with KRS 335.300];
(h) A licensed professional clinical
counselor[licensed and practicing in accordance with KRS 335.500];
(i) A licensed professional art
therapist[certified and practicing in accordance with KRS 309.130];[or]
(j) A licensed clinical[An]
alcohol and drug counselor in accordance with Section 13 of this
administrative regulation;[contingent and effective upon approval by
the Centers for Medicare and Medicaid Services; or]
(k) A certified psychologist with
autonomous functioning; or
(l) A certified alcohol and drug
counselor[certified and practicing in accordance with KRS
309.080 to 309.089].
(5)[(4)] "Behavioral
health professional under clinical supervision" means:
(a) A certified psychologist[certified
and practicing in accordance with KRS 319.056];
(b) A licensed psychological associate[licensed
and practicing in accordance with KRS 319.064];
(c) A marriage and family therapy[therapist]
associate [permitted and practicing in accordance with KRS 335.300];
(d) A certified social worker[certified
and practicing in accordance with KRS 335.080]; [or]
(e) A licensed professional counselor associate;
(f) A licensed professional art
therapist associate;[or]
(g) A physician
assistant; or
(h) A licensed clinical
alcohol and drug counselor associate in accordance with Section 13
of this administrative regulation[contingent and effective upon
approval by the Centers for Medicare and Medicaid Services][licensed
and practicing in accordance with KRS 335.500].
(6) "Certified
alcohol and drug counselor" means an individual who meets the requirements
established in KRS 309.083.
(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)[(7)]
"Certified social worker" means an individual who meets the
requirements established in KRS 335.080.
(10)[(8)][(5)]
"Child with a severe
emotional disability" is defined by KRS 200.503(2).
(11)[(9)][(6)]
"Department" means the Department for Medicaid Services or its
designee.
(12)[(10)][(7)]
"Diagnostic and assessment services" means at least one (1)
face-to-face specialty evaluation or specialty evaluation performed via
telemedicine of a recipient’s medical, social, and psychiatric status provided
by a physician or qualified mental health professional that shall:
(a) Include:
1. Interviewing and evaluating; or
2. Testing;
(b) Be documented and record all contact
with the recipient and other interviewed individuals; and
(c) Result in a:
1. Medical data code in accordance with
45 C.F.R. 162.1000; and
2. Specific treatment recommendation.
(13)[(11)]
"Enrollee" means a recipient who is enrolled with a managed care
organization.
(14)[(12)][(8)]
"Federal financial participation" is defined by 42 C.F.R. 400.203.
(15)[(13)][(9)]
"Intensive treatment services" means a program:
(a) For a child:
1. With a severe emotional disability;
and
a. An intellectual disability;
b. A severe and persistent aggressive behavior;
c. Sexually acting out behavior; or
d. A developmental disability;
2. Who requires a treatment-oriented residential
environment; and
3. Between the ages of four (4) to
twenty-one (21) years; and
(b) That provides psychiatric and behavioral
health services two (2) or more times per week to a child referenced in
paragraph (a) of this subsection:
1. As indicated by the child’s
psychiatric and behavioral health needs; and
2. In accordance with the child’s therapeutic
plan of care.
(16)[(14)][(10)]
"Interdisciplinary team" means:
(a) For a recipient who is under the age
of eighteen (18) years:
1. A parent, legal guardian, or caregiver
of the recipient;
2. The recipient;
3. A qualified mental health
professional; and
4. A staff person, if available, who
worked with the recipient during the recipient’s most recent placement if the
recipient has previously been in a Level I or II PRTF; or
(b) For a recipient who is eighteen (18)
years of age or older:
1. The recipient;
2. A qualified mental health
professional;[and]
3. A staff person, if available, who
worked with the recipient during the recipient’s most recent placement if the
recipient has previously been in a Level I or II PRTF; and
4. If requested by the
recipient, a parent, legal guardian, or caregiver of the recipient.
(17)[(15)][(11)]
"Level I PRTF" means a psychiatric residential treatment facility
that meets the criteria established in KRS 216B.450(5)(a).
(18)[(16)][(12)]
"Level II PRTF" means a psychiatric residential treatment facility
that meets the criteria established in KRS 216B.450(5)(b).
(19)[(17)]
"Licensed clinical alcohol and drug counselor" is defined by KRS
309.080(4).
(20)[(18)]
"Licensed clinical alcohol and drug counselor associate" is defined
by KRS 309.080(5).
(21)[(19)]
"Licensed clinical social worker" means an individual who meets the
licensed clinical social worker requirements established in KRS 335.100.
(22)[(20)]
"Licensed marriage and family therapist" is defined by KRS
335.300(2).
(23)[(21)]
"Licensed professional art therapist" is defined by KRS 309.130(2).
(24)[(22)]
"Licensed professional art therapist associate" is defined by KRS
309.130(3).
(25)[(23)]
"Licensed professional clinical counselor" is defined by KRS
335.500(3).
(26)[(24)]
"Licensed professional counselor associate" is defined by KRS
335.500(4).
(27)[(25)]
"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.
(28)[(26)]
"Licensed psychological practitioner" means an individual who meets
the requirements established in KRS 319.053.
(29)[(27)]
"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.
(30)[(28)]
"Marriage and family therapy
associate" is defined by KRS 335.300(3).
(31)[(29)][(13)]
"Medicaid payment status" means a circumstance in which:
(a) The person:
1. Is eligible for and receiving Medicaid
benefits; and
2. Meets patient status criteria for
Level I or II psychiatric residential treatment facility services; and
(b) The facility is billing the Medicaid
program for services provided to the person.
(32)[(30)][(14)]
"Medically necessary" or "medical necessity" means that a
covered benefit is determined to be needed in accordance with 907 KAR 3:130.
(33)[(31)][(15)]
"Mental health associate" means:
(a)1. An individual with a minimum of a
bachelor's degree in a mental health related field;
2. A registered nurse; or
3. A licensed practical nurse with at
least one (1) year of[year's] experience in a
psychiatric inpatient or residential treatment setting for children; or
(b) An individual with:
1. A high school diploma or an equivalence
certificate; and
2. At least two (2) years of
work experience in a psychiatric inpatient or residential treatment setting for
children.
(34)[(32)]["Peer
support specialist" means an individual who meets the peer specialist
qualifications established in:
(a) 908
KAR 2:220;
(b) 908
KAR 2:230; or
(c) 908
KAR 2:240.
(33)][(16)]
"Physician" is defined by KRS 205.510(11)[311.550(12)].
(35)[(34)]
"Physician assistant" is defined by KRS 311.840(3).
(36)[(35)][(17)]
"Private psychiatric hospital" is defined by KRS 205.639(2).
(37)[(36)]
"Provider" is defined by KRS 205.8451(7).
(38)[(37)]
"Provider abuse" is defined by KRS 205.8451(8).
(39)[(38)][(18)]
"Psychiatric residential treatment facility" or "PRTF" is
defined by KRS
216B.450(5).
(40)[(39)][(19)]
"Psychiatric services" means:
(a) An initial psychiatric evaluation of
a recipient which shall include:
1. A review of the recipient’s:
a. Personal history;
b. Family history;
c. Physical health;
d. Prior treatment; and
e. Current treatment;
2. A mental status examination
appropriate to the age of the recipient;
3. A meeting with the family or any designated
significant person in the recipient’s life; and
4. Ordering and reviewing:
a. Laboratory data;
b. Psychological testing results; or
c. Any other ancillary health or mental
health examinations;
(b) Development of an initial plan of
treatment which shall include:
1. Prescribing and monitoring of psychotropic
medications; or
2. Providing and directing therapy to the
recipient;
(c) Implementing, assessing, monitoring,
or revising the treatment as appropriate to the recipient’s psychiatric status;
(d) Providing a subsequent psychiatric
evaluation as appropriate to the recipient’s psychiatric status;
(e) Consulting, if determined to be necessary
by the psychiatrist responsible for providing or overseeing the recipient’s psychiatric
services, with another physician, an attorney, or the police[,]
regarding the recipient’s care and treatment; or
(f) Ensuring that the psychiatrist
responsible for providing or overseeing the recipient’s psychiatric services
has access to the information resulting from or related to any
consultation referenced in paragraph (e) of this subsection.
(41)[(40)][(20)]
"Qualified mental health personnel" is defined by KRS 216B.450(6).
(42)[(41)][(21)]
"Qualified mental health professional" is defined by KRS 216B.450(7).
(43)[(42)]
"Recipient" is defined by KRS 205.8451(9).
(44)[(43)]
"Recipient abuse" is defined by KRS 205.8451(10).
(45)[(44)][(22)]
"Review agency" means, for a review, evaluation,
or authorization decision regarding an individual who is:
(a) Not enrolled with a managed care organization:
1. The department; or
2. An entity under contract with the department;
or
(b) Enrolled with a managed care organization:
1. The managed care organization with
which the enrollee is enrolled; or
2. An entity under contract with the managed
care organization with which the enrollee is enrolled.
(46)[(45)][(23)] "State
mental hospital" is defined by KRS 205.639(3).
(47)[(46)][(24)]
"Telemedicine" means two-way, real time interactive communication
between a patient and a physician or practitioner located at a distant site for
the purpose of improving a patient’s health through the use of interactive
telecommunications equipment that includes, at a minimum, audio and video
equipment.
(48)[(47)][(25)] "Treatment
plan" means a plan created for the care and treatment of a recipient that:
(a) Is developed in a face-to-face
meeting by the recipient’s interdisciplinary team;
(b) Describes a comprehensive, coordinated
plan of medically necessary behavioral health services that specifies a
modality, frequency, intensity, and duration of services sufficient to maintain
the recipient in a PRTF setting; and
(c) Identifies:
1. A program of therapies, activities,
interventions, or experiences designed to accomplish the plan;
2. A qualified mental health
professional, a mental health associate, or qualified mental health personnel
who shall manage the continuity of care;
3. Interventions by caregivers in the
PRTF and school setting that support the recipient’s ability to be maintained
in a PRTF setting;
4. Behavioral, social, and physical problems
with interventions and objective, measurable goals;
5. Discharge criteria that specifies the:
a. Recipient-specific behavioral
indicators for discharge from the service;
b. Expected service level that would be
required upon discharge; and
c. Identification of the intended provider
to deliver services upon discharge;
6. A crisis action plan that progresses
through a continuum of care that is designed to reduce or eliminate the
necessity of inpatient services;
7. A plan for:
a. Transition to a lower intensity of services;
and
b. Discharge from PRTF services;
8. An individual behavior management
plan;
9. A plan for the involvement and
visitation of the recipient with the birth family, guardian, or other
significant person, unless prohibited by a court, including therapeutic
off-site visits pursuant to the treatment plan; and
10. Services and planning, beginning at
admission, to facilitate the discharge of the recipient to an identified plan
for home-based services or a lower level of care.
Section 2. Provider Participation. (1)(a)
In order to participate, or continue to participate, in the Kentucky Medicaid
Program, a Level I PRTF shall:
1. Have a utilization review plan for
each recipient consisting of, at a minimum, a pre-admission certification
review submitted via telephone or electronically to the review agency prior to
admission of the recipient;
2. Perform and place in each recipient’s
record:
a. A medical evaluation;
b. A social evaluation; and
c. A psychiatric evaluation;
3. Establish a plan of care for each
recipient which shall be placed in the recipient’s record;
4. Appoint a utilization review committee
which shall:
a. Oversee and implement the utilization
review plan; and
b. Evaluate each Medicaid admission and
continued stay prior to the expiration of the Medicaid certification period to
determine if the admission or stay is or remains medically necessary;
5. Comply with staffing requirements established
in 902 KAR 20:320;
6. Be located in the Commonwealth of
Kentucky;
7. Maintain accreditation by the Joint
Commission on Accreditation of Health Care Organizations or the Council on
Accreditation of Services for Families and Children or any other accrediting
body with comparable standards that is recognized by the state; and
8. Comply with all conditions of Medicaid
provider participation established in 907 KAR 1:671 and 907 KAR 1:672.
(b) In order to participate, or continue
to participate, in the Kentucky Medicaid Program, a Level II PRTF shall:
1. Have a utilization review plan for
each recipient;
2. Establish a utilization review process
which shall evaluate each Medicaid admission and continued stay prior to the
expiration of the Medicaid certification period to determine if the admission
or stay is or remains medically necessary;
3. Comply with staffing requirements established
in 902 KAR 20:320;
4. Be located in the Commonwealth of
Kentucky;
5. Maintain accreditation by the Joint
Commission on Accreditation of Health Care Organizations or the Council on
Accreditation of Services for Families and Children or any other accrediting
body with comparable standards that is recognized by the state;
6. Comply with all conditions of Medicaid
provider participation established in 907 KAR 1:671 and 907 KAR 1:672;
7. Perform and place in each recipient’s
record a:
a. Medical evaluation;
b. Social evaluation; and
c. Psychiatric evaluation; and
8. Establish a plan of care for each
recipient which shall:
a. Address in detail the intensive
treatment services to be provided to the recipient; and
b. Be placed in the recipient’s record.
(2)(a) A pre-admission certification
review for a Level I PRTF shall:
1. Contain:
a. The recipient’s valid Medicaid
identification number;
b. For a recipient who is not enrolled
with a managed care organization, a valid MAP-569, Certification of Need by
Independent Team Psychiatric Preadmission Review of Elective Admissions for
Kentucky Medicaid Recipients Under Age Twenty-One (21),
which satisfies the requirements of 42 C.F.R. 44.152 and 42 C.F.R. 441.153 for
patients age twenty-one (21) and under;
c. A DSM-IV-R[DMS-IV R]
diagnosis on all five (5) axes, except that failure to record an axis IV or V
diagnosis shall be used as the basis for a denial only if those diagnoses are
critical to establish the need for Level I PRTF treatment;
d. A description of the initial treatment
plan relating to the admitting symptoms;
e. Current symptoms requiring inpatient
treatment;
f. Information to support the medical
necessity and clinical appropriateness of the services or benefits of the
admission to a Level I PRTF in accordance with 907 KAR 3:130;
g. Medication history;
h. Prior hospitalization;
i. Prior alternative treatment;
j. Appropriate medical, social, and
family histories; and
k. Proposed aftercare placement;
2. Remain in effect for the days
certified by the review agency; and
3. Be completed within thirty (30) days.
(b) A pre-admission certification review
for a Level II PRTF for a non-emergent admission shall:
1. Contain:
a. The recipient’s valid Medicaid identification
number;
b. For a recipient who is not enrolled
with a managed care organization, a valid MAP-569, Certification of Need by
Independent Team Psychiatric Preadmission Review of Elective Admissions for
Kentucky Medicaid Recipients Under Age Twenty-One (21),
which satisfies the requirements of 42 C.F.R. 44.152 and 42 C.F.R. 441.153 for
patients age twenty-one (21) and under;
c. A DSM-IV-R diagnosis on all five (5) axes,
except that failure to record an axis IV or V diagnosis shall be used as the
basis for a denial only if those diagnoses are critical to establish the need
for Level II PRTF treatment;
d. A description of the initial treatment
plan relating to the admitting symptoms;
e. Current symptoms requiring inpatient
treatment;
f. Information to support the medical
necessity and clinical appropriateness of the services or benefits of the
admission to a Level II PRTF in accordance with 907 KAR 3:130;
g. Medication history;
h. Prior hospitalization;
i. Prior alternative treatment;
j. Appropriate medical, social, and
family histories; and
k. Proposed aftercare placement;
2. Remain in effect for the days
certified by the review agency; and
3. Be completed within thirty (30) days.
(3) Failure to admit a recipient within
the recipient’s certification period shall require a new pre-admission certification
review request.
(4) A utilization review plan for an emergency
admission to a Level II PRTF shall contain:
(a) For a recipient who is not
enrolled with a managed care organization, a completed MAP-570, Medicaid
Certification of Need for Inpatient Psychiatric Services for Individuals Under
Age Twenty-One (21):
1. Completed by the facility’s
interdisciplinary team; and
2. Placed in the recipient’s medical
record;
(b) Documentation, provided by telephone
or electronically to the review agency within two (2) days of the recipient’s
emergency admission, justifying:
1. The recipient’s emergency admission;
2. That ambulatory care resources in the
recipient’s community and placement in a Level I PRTF do not meet the
recipient’s needs;
3. That proper treatment of the
recipient’s psychiatric condition requires services provided by a Level II PRTF
under the direction of a physician; and
4. That the services can reasonably be
expected to improve the recipient’s condition or prevent further regression so
that the services are no longer needed;
(c) The recipient’s valid Medicaid
identification number;
(d) For a recipient who is not
enrolled with a managed care organization, a valid MAP-569, Certification
of Need by Independent Team Psychiatric Preadmission Review of Elective
Admissions for Kentucky Medicaid Recipients Under Age Twenty-One (21),
which satisfies the requirements of 42 C.F.R. 441.152 and 42 C.F.R. 441.153 for
recipients age twenty-one (21) and under;
(e) A DSM-IV-R[DMS-IV-R]
diagnosis on all five (5) axes, except that failure to record an axis IV or V
diagnosis shall be used as the basis for a denial only if those diagnoses are
critical to establish the need for Level II PRTF treatment;
(f)1. A description of the initial
treatment plan relating to the admitting symptom; and
2. As part of the initial treatment plan,
a full description of the intensive treatment services to be provided to the
recipient;
(g) Current symptoms requiring residential
treatment;
(h) Medication history;
(i) Prior hospitalization;
(j) Prior alternative treatment;
(k) Appropriate medical, social, and
family histories; and
(l) Proposed aftercare placement.
(5) For an individual who becomes
Medicaid eligible after admission and who is not enrolled with a managed
care organization, a Level I or II PRTF's interdisciplinary team shall
complete a MAP-570, Medicaid Certification of Need for Inpatient Psychiatric Services
for Individuals Under Age Twenty-One (21), and the form shall be placed in the
recipient's medical record.
(6) For a recipient, a Level I or II PRTF
shall maintain medical records that shall:
(a) Be:
1. Current;
2. Readily retrievable;
3. Organized;
4. Complete; and
5. Legible;
(b) Reflect sound medical recordkeeping
practice in accordance with:
1. 902 KAR 20:320;
2. KRS 194A.060;
3. KRS 434.840 through 860;
4. KRS 422.317; and
5. 42 C.F.R. 431 Subpart F;
(c) Document the need for admission and
appropriate utilization of services;
(d) Be maintained, including information
regarding payments claimed, for a minimum of six (6) years or until an audit
dispute or issue is resolved, whichever is longer; and
(e) Be made available for inspection or
copying or provided to the following upon request:
1. A representative of the United States
Department for Health and Human Services or its designee;
2. The United States Office of the
Attorney General or its designee;
3. The Commonwealth of Kentucky, Office
of the Attorney General or its designee;
4. The Commonwealth of Kentucky, Office
of the Auditor of Public Accounts or its designee;
5. The Commonwealth of Kentucky, Cabinet
for Health and Family Services, Office of the Inspector General or its
designee;
6. The department; or
7. A managed care organization with whom
the department has contracted if the recipient is enrolled with the managed
care organization.
(7)(a) If a Level I or Level II
psychiatric residential treatment facility receives any duplicate payment or
overpayment from the department or 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
issued 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[section] may be:
1. Interpreted to be fraud or abuse;
and
2. Prosecuted in accordance with
applicable federal or state law.
(8)(a) When the department or managed
care organization 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 advance of
providing the service that the:
(i) Recipient is liable for the
payment; and
(ii) Department or managed care
organization, if the recipient is enrolled with a managed care
organization, 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 or managed care
organization, if applicable, for the service; and
b. Department or managed care organization,
if applicable, 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.
(c) Except as established in
paragraph (b) of this subsection or except for a cost sharing obligation owed
by a recipient, a provider shall not bill a recipient for any part of a service
provided to the recipient.
(9)(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 3. Covered Admissions. (1) A covered
admission for a Level I PRTF:
(a) Shall be prior authorized by a review
agency; and
(b)1. Shall be limited to those for a
child age six (6) through twenty (20) years of age who meets Medicaid payment
status criteria; or
2. May continue based on medical necessity,
for a recipient who is receiving active treatment in a Level I PRTF on the
recipient’s twenty-first (21st) birthday if the recipient has not reached his
or her twenty-second (22nd) birthday.
(2) A covered admission for a Level II PRTF
shall be:
(a) Prior authorized;
(b) Limited to those for a child:
1.a. Age four (4) through twenty-one (21)
years who meets Medicaid payment status criteria; and
b. Whose coverage may continue, based on
medical necessity, if the recipient is receiving active treatment in a Level II
PRTF on the recipient’s twenty-first (21st) birthday and the recipient has not
reached his or her twenty-second (22nd) birthday;
2. With a severe emotional disability in
addition to severe and persistent aggressive behaviors, an intellectual disability,
sexually acting out behaviors, or a developmental disability; and
3.a. Who does not meet the medical necessity
criteria for an acute care hospital, private psychiatric hospital, or state
mental hospital; and
b. Whose treatment needs cannot be met in
an ambulatory care setting, Level I PRTF, or in any other less restrictive
environment; and
(c) Reimbursed pursuant to 907 KAR 9:010.
Section 4. PRTF Covered Services. (1)(a)
There shall be a treatment plan developed for each recipient.
(b) A treatment plan shall specify:
1. The amount and frequency of services
needed; and
2. The number of therapeutic pass days
for a recipient, if the treatment plan includes any therapeutic pass days.
(2) To be covered by the department:
(a) The following services shall be available
to a recipient covered under Section 3 of this administrative regulation and shall
meet the requirements established in paragraph (b) of this subsection:
1. Diagnostic and assessment services;
2. Treatment plan development, review, or
revision;
3. Psychiatric services;
4. Nursing services which shall be provided
in compliance with 902 KAR 20:320;
5. Medication which shall be provided in
compliance with 907 KAR 1:019;
6. Evidence-based treatment
interventions;
7. Individual therapy which shall comply
with 902 KAR 20:320;
8. Family therapy or attempted contact
with family which shall comply with 902 KAR 20:320;
9. Group therapy which shall comply with
902 KAR 20:320;
10. Individual and group interventions
that shall focus on additional and harmful use or abuse issues and relapse
prevention if indicated;
11. Substance abuse education;
12. Activities that:
a. Support the development of an
age-appropriate daily living skill including positive behavior management or
support; or
b. Support and encourage the parent’s
ability to re-integrate the child into the home;
13. Crisis intervention which shall
comply with:
a. 42 C.F.R. 483.350 through 376; and
b. 902 KAR 20:320;
14. Consultation with other professionals
including case managers, primary care professionals, community support workers,
school staff, or others;
15. Educational activities; or
16. Non-medical transportation services
as needed to accomplish objectives;
(b) A Level I PRTF service listed in
paragraph (a) of this subsection shall be:
1. Provided under the direction of a physician;
2. If included in the recipient’s
treatment plan, described in the recipient’s current treatment plan;
3. Medically necessary; and
4. Clinically appropriate pursuant to the
criteria established in 907 KAR 3:130;
(c) A Level I PRTF service listed in paragraph[subparagraph]
(a)7, 8, 9, 11, or 13 shall be provided by a qualified mental health professional,
behavioral health professional, or behavioral health professional under
clinical supervision; or
(d) A Level II PRTF service listed in
paragraph (a) of this subsection shall be:
1. Provided under the direction of a physician;
2. If included in the recipient’s
treatment plan, described in the recipient’s current treatment plan;
3. Provided at least once a week:
a. Unless the service is necessary twice
a week, in which case the service shall be provided at least twice a week; or
b. Except for diagnostic and assessment
services which shall have no weekly minimum requirement;
4. Medically necessary; and
5. Clinically appropriate pursuant to the
criteria established in 907 KAR 3:130.
(3) A Level II PRTF service listed in paragraph[subparagraph]
(a)7, 8, 9, 11, or 13 shall be provided by a qualified mental health
professional, behavioral health professional, or behavioral health professional
under clinical supervision.
Section 5. Determining Patient Status.
(1) The department shall review and evaluate the health status and care needs
of a recipient in need of Level I or II PRTF care using the criteria identified
in 907 KAR 3:130 to determine if a service or benefit is clinically appropriate.
(2) The care needs of a recipient shall
meet the patient status criteria for:
(a) Level I PRTF care if the recipient requires:
1. Long term inpatient psychiatric care
or crisis stabilization more suitably provided in a PRTF than in a psychiatric
hospital; and
2. Level I PRTF services on a continuous
basis as a result of a severe mental or psychiatric illness, including a severe
emotional disturbance; or
(b) Level II PRTF care if the recipient:
1. Is a child with a severe emotional disability;
2. Requires long term inpatient
psychiatric care or crisis stabilization more suitably provided in a PRTF than
a psychiatric hospital;
3. Requires Level II PRTF services on a
continuous basis as a result of a severe emotional disability in addition to a
severe and persistent aggressive behavior, an intellectual disability, a
sexually acting out behavior, or a developmental disability; and
4. Does not meet the medical necessity
criteria for an acute care hospital or a psychiatric hospital and has treatment
needs which cannot be met in an ambulatory care setting, Level I PRTF, or other
less restrictive environment.
Section 6. Durational Limit,
Re-evaluation, and Continued Stay. (1) A recipient’s stay, including the
duration of the stay, in a Level I or II PRTF shall be subject to the department’s
approval.
(2)(a) A recipient in a Level I PRTF
shall be re-evaluated at least once every thirty (30) days to determine if the
recipient continues to meet Level I PRTF patient status criteria established in
Section 5(2) of this administrative regulation.
(b) A Level I PRTF shall complete a
review of each recipient’s treatment plan at least once every thirty (30) days.
(c) The review referenced in paragraph
(b) of this subsection shall include:
1. Dated signatures of:
a. Appropriate staff; and
b. If present for the treatment plan
meeting, a parent,
guardian, legal custodian, or conservator;
2. An assessment of progress toward each
treatment plan goal and objective with revisions indicated; and
3. A statement of justification for the
level of services needed including:
a. Suitability for treatment in a
less-restrictive environment; and
b. Continued services.
(d) If a recipient no longer meets Level
I PRTF patient status criteria, the department shall only reimburse through the
last day of the individual’s current approved stay.
(e) The re-evaluation referenced in
paragraph (a) of this subsection shall be performed by a review agency.
(3) A Level II PRTF shall complete by no
later than the third (3rd) business day following an admission, an initial
review of services and treatment provided to a recipient which shall include:
(a) Dated signatures of appropriate staff,
parent, guardian, legal custodian, or conservator;
(b) An assessment of progress toward each
treatment plan goal and objective with revisions indicated; and
(c) A statement of justification for the
level of services needed including:
1. Suitability for treatment in a
less-restrictive environment; and
2. Continued services.
(4)(a) For a recipient aged four (4) to
five (5) years, a Level II PRTF shall complete a review of the recipient’s
treatment plan of care at least once every fourteen (14) days after the initial
review referenced in subsection (3) of this section.
(b) The review referenced in paragraph
(a) of this subsection shall include:
1. Dated signatures of appropriate staff,
parent, guardian, legal custodian, or conservator;
2. An assessment of progress toward each
treatment plan goal and objective with
revisions indicated; and
3. A statement of justification for the
level of services needed including:
a. Suitability for treatment in a
less-restrictive environment; and
b. Continued services.
(5)(a) For a recipient aged six (6) to
twenty-two (22) years, a Level II PRTF shall complete a review of the
recipient’s treatment plan of care at least once every thirty (30) days after
the initial review referenced in subsection (3) of this section.
(b) The review referenced in paragraph
(a) of this subsection shall include:
1. Dated signatures of appropriate staff,
parent, guardian, legal custodian, or conservator;
2. An assessment of progress toward each
treatment plan goal and objective with revisions indicated; and
3. A statement of justification for the
level of services needed including:
a. Suitability for treatment in a
less-restrictive environment; and
b. Continued services.
Section 7. Exclusions and Limitations in
Coverage. (1) The following shall not be covered as Level I or II PRTF services
under this administrative regulation:
(a)[1. Chemical dependency treatment
services if the need for the services is the primary diagnosis of the
recipient, except chemical dependency treatment services shall be covered as
incidental treatment if minimal chemical dependency treatment is necessary for
successful treatment of the primary diagnosis;
(b)] Outpatient services,
which shall be covered in accordance with 907 KAR 9:015;
(b)[(c)] Pharmacy services,
which shall be covered in accordance with 907 KAR 1:019;
(c)[(d)] Durable medical
equipment, which shall be covered in accordance with 907 KAR 1:479;
(d)[(e)] Hospital emergency
room services, which shall be covered in accordance with 907 KAR 10:014;
(e)[(f)] Acute care
hospital inpatient services, which shall be covered in accordance with 907 KAR
10:012;
(f)[(g)] Laboratory and
radiology services, which shall be covered in accordance with 907 KAR 10:014 or
907 KAR 1:028;
(g)[(h)] Dental services,
which shall be covered in accordance with 907 KAR 1:026;
(h)[(i)] Hearing and vision
services, which shall be covered in accordance with 907 KAR 1:038; or
(i)[(j)] Ambulance
services, which shall be covered in accordance with 907 KAR 1:060.
(2) A Level I or II PRTF shall not charge
a recipient or responsible party representing a recipient any difference
between private and semiprivate room charges.
(3) The department shall not reimburse
for Level I or II PRTF services for a recipient if appropriate alternative
services are available for the recipient in the community.
(4) The following shall not qualify as
reimbursable in a PRTF setting:
(a) An admission that is not medically necessary;
or
(b) Services for an individual:
1. With a major medical problem or minor
symptoms;
2. Who might only require a psychiatric
consultation rather than an admission to a PRTF; or
3. Who might need only adequate living
accommodations, economic aid, or social support services.
Section 8. Reserved Bed and Therapeutic
Pass Days. (1)(a) The department shall cover a bed reserve day for an acute
hospital admission, a state mental hospital admission, a private psychiatric
hospital admission, or an admission to a psychiatric bed in an acute care
hospital for a recipient’s absence from a Level I or II PRTF if the recipient:
1. Is in Medicaid payment status in a
Level I or II PRTF;
2. Has been in the Level I or II PRTF overnight
for at least one (1) night;
3. Is reasonably expected to return requiring
Level I or II PRTF care; and
4.a. Has not exceeded the bed reserve day
limit established in paragraph (b) of this subsection; or
b. Received an exception to the limit in
accordance with paragraph (c) of this subsection.
(b) The annual bed reserve day limit per
recipient shall be five (5) days per calendar year in aggregate for any
combination of bed reserve days associated with an acute care hospital
admission, a state mental hospital admission, a private psychiatric hospital admission,
or an admission to a psychiatric bed in an acute care hospital.
(c) The department shall allow a
recipient to exceed the limit established in paragraph (b) of this subsection,
if the department determines that an additional bed reserve day is in the best
interest of the recipient.
(2)(a) The department shall cover a
therapeutic pass day for a recipient’s absence from a Level I or II PRTF if the
recipient:
1. Is in Medicaid payment status in a Level I
or II PRTF;
2. Has been in the Level I or II PRTF overnight
for at least one (1) night;
3. Is reasonably expected to return requiring
Level I or II PRTF care; and
4.a. Has not exceeded the therapeutic pass day
limit established in paragraph (b) of this subsection; or
b. Received an exception to the limit in
accordance with paragraph (c) of this subsection.
(b) The annual therapeutic pass day limit
per recipient shall be fourteen (14) days per calendar year.
(c) The department shall allow a recipient
to exceed the limit established in paragraph (b) of this subsection, if the
department determines that an additional therapeutic pass day is in the best interest
of the recipient.
(3)[(a) The bed reserve day and
therapeutic pass day count for each recipient shall be zero (0) upon the
effective date of this administrative regulation.
(b) For subsequent calendar
years,] The bed reserve day and therapeutic pass day count for each
recipient shall begin at zero[(0)] on January 1 of each[the]
calendar year.
(4) An authorization decision regarding a
bed reserve day or therapeutic pass day in excess of the limits established in
this section shall be performed by a review agency.
(5)(a) An acute care hospital bed reserve
day shall be a day when a recipient is temporarily absent from a Level I or II
PRTF due to an admission to an acute care hospital.
(b) A state mental hospital bed reserve
day, private psychiatric hospital bed reserve day, or psychiatric bed in an
acute care hospital bed reserve day, respectively, shall be a day when a
recipient is temporarily absent from a Level I or II PRTF due to receiving psychiatric
treatment in a state mental hospital, private psychiatric hospital, or
psychiatric bed in an acute care hospital respectively.
(c) A therapeutic pass day shall be a day
when a recipient is temporarily absent from a Level I or II PRTF for a
therapeutic purpose that is:
1. Stated in the recipient’s treatment
plan; and
2. Approved by the recipient’s treatment
team.
(6)(a) A Level I or II PRTF’s occupancy
percent shall be based on a midnight census.
(b) An absence from a Level I or II PRTF that
is due to a bed reserve day for an acute hospital admission, a state mental
hospital admission, a private psychiatric hospital admission, or an admission
to a psychiatric bed in an acute care hospital shall count as an absence for
census purposes.
(c) An absence from a Level I or II PRTF
that is due to a therapeutic pass day shall not count as an absence for census
purposes.
Section 9. Outpatient Services
Requirements Established in 907 KAR 9:015. The department’s coverage provisions
and requirements regarding outpatient behavioral health services provided by a
Level I or II PRTF shall be as established in 907 KAR 9:015.
Section 10. Third Party Liability. A Level
I or Level II PRTF shall comply with KRS 205.622.
Section 11. 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 PRTF or Level II PRTF
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 PRTF’s or Level II PRTF’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 PRTF’s or
Level II PRTF’s electronic signature policy;
2. The signed consent form; and
3. The original filed signature.
Section 12. Auditing Authority. The
department or the managed care organization in which an enrollee is enrolled
shall have the authority to audit any:
(1) Claim;
(2) Medical record; or
(3) Documentation associated with any
claim or medical record.
Section 13. Federal Financial
Participation. (1) The department’s coverage of services pursuant to this
administrative regulation shall be contingent upon[A policy established
in this administrative regulation shall be null and void if the Centers for
Medicare and Medicaid Services]:
(a) Receipt of[(1) Denies or
does not provide] federal financial participation for the coverage[policy];
and[or]
(b) Centers for Medicare and Medicaid
Services’ approval of the coverage[(2) Disapproves the policy].
(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 14.[10.] Appeal
Rights. (1)(a) An appeal of an adverse[a negative] action by
the department regarding a service and a recipient who is not enrolled
with a managed care organization[Medicaid beneficiary] shall be in
accordance with 907 KAR 1:563.
(b) 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.
(2) An appeal of a negative action regarding
Medicaid eligibility of an individual shall be in accordance with 907 KAR
1:560.
(3) An appeal of a negative action
regarding a Medicaid provider shall be in accordance with 907 KAR 1:671.
Section 15.[11.] Incorporation
by Reference. (1) The following material is incorporated by reference:
(a) "MAP-569, Certification of Need
by Independent Team Psychiatric Preadmission Review of Elective Admissions for
Kentucky Medicaid Recipients Under Age Twenty-One (21)", revised 5/90; and
(b) "MAP-570, Medicaid Certification
of Need for Inpatient Psychiatric Services for Individuals Under Age Twenty-one
(21)", revised 5/90.
(2) This material may be inspected,
copied, or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, Cabinet for Health and Family Services, 275 East Main
Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m.
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, tricia.orme@ky.gov, Office of Legal Services, 275 East Main Street 5 W-B,
Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502) 564-7573.
