907 KAR 9:005. Non-outpatient level I and II psychiatric residential treatment facility service and coverage policies

Link to law: http://www.lrc.ky.gov/kar/907/009/005reg.htm
Published: 2015

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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.