907 KAR 15:080.
Coverage provisions and requirements regarding outpatient chemical dependency
treatment center services.
RELATES TO: KRS 205.520, 42 U.S.C.
1396a(a)(10)(B), 1396a(a)(23)
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3)
NECESSITY, FUNCTION, AND CONFORMITY: The
Cabinet for Health and Family Services, Department for Medicaid Services, has a
responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes
the cabinet, by administrative regulation, to comply with any requirement that
may be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the coverage provisions
and requirements regarding Medicaid Program outpatient chemical dependency treatment
center services.
Section 1. General Coverage Requirements.
(1) For the department to reimburse for a service covered under this administrative
regulation, the service shall be:
(a) Medically necessary; and
(b) Provided:
1. To a recipient; and
2. By a chemical dependency treatment
center that meets the provider participation requirements established in
Section 2 of this administrative regulation.
(2)(a) Face-to-face contact between a
practitioner and a recipient shall be required for each service except for:
1. Collateral outpatient therapy for a recipient
under the age of twenty-one (21) years if the collateral outpatient therapy is
in the recipient’s plan of care;
2. A family outpatient therapy service in
which the corresponding current procedural terminology code establishes that
the recipient is not present; or
3. A psychological testing service comprised
of interpreting or explaining results of an examination or data to family
members or others in which the corresponding current procedural terminology
code establishes that the recipient is not present.
(b) A service that does not meet the
requirement in paragraph (a) of this subsection shall not be covered.
(3) A billable unit of service shall be
actual time spent delivering a service in a face-to-face encounter.
(4) A service shall be:
(a) Stated in the recipient’s plan of
care; and
(b) Provided in accordance with the recipient’s
plan of care.
(5)(a) A chemical dependency treatment
center shall establish a plan of care for each recipient receiving services
from a chemical dependency treatment center.
(b) A plan of care shall meet the treatment
plan requirements established in 902 KAR 20:160.
Section 2. Provider Participation. (1)(a)
To be eligible to provide services under this administrative regulation, a chemical
dependency treatment center shall:
1. Be currently enrolled as a provider in
the Kentucky Medicaid Program in accordance with 907 KAR 1:672;
2. Except as established in subsection
(2) of this section, be currently participating in the Kentucky Medicaid
Program in accordance with 907 KAR 1:671;
3. Be licensed as a chemical dependency
treatment center to provide outpatient behavioral health services in accordance
with 902 KAR 20:160; and
4. Have:
a. For each service it provides, the
capacity to provide the full range of the service as established in this
administrative regulation;
b. Documented experience in serving
individuals with behavioral health disorders;
c. The administrative capacity to ensure
quality of services;
d. A financial management system that
provides documentation of services and costs; and
e. The capacity to document and maintain
individual health records.
(b) The documentation referenced in
paragraph (a)4.b. of this subsection shall be subject to audit by:
1. The department;
2. The Cabinet for Health and Family
Services, Office of Inspector General;
3. A managed care organization, if the
chemical dependency treatment center is enrolled in its network;
4. The Centers for Medicare and Medicaid
Services;
5. The Kentucky Office of the Auditor of
Public Accounts; or
6. The United States Department of Health
and Human Services, Office of the Inspector General.
(2) In accordance with 907 KAR 17:015,
Section 3(3), a chemical dependency treatment center which provides a service
to an enrollee shall not be required to be currently participating in the fee-for-service
Medicaid Program.
(3) A chemical dependency treatment center
shall:
(a) Agree to provide services in compliance
with federal and state laws regardless of age, sex, race, creed, religion,
national origin, handicap, or disability; and
(b) Comply with the Americans with
Disabilities Act (42 U.S.C. 12101 et seq.) and any amendments to the act.
Section 3. Covered Services. (1) The
services covered may be provided for a substance use disorder.
(2) The following services shall be
covered under this administrative regulation in accordance with the
requirements established in this subsection:
(a) A screening, crisis intervention, or
intensive outpatient program service provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A licensed clinical alcohol and drug
counselor in accordance with Section 11 of this administrative regulation; or
14. A behavioral health practitioner
under supervision, except for a licensed assistant behavior analyst;
(b) An assessment provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed behavior analyst;
12. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
13. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
14. A licensed clinical alcohol and drug
counselor in accordance with Section 11 of this administrative regulation; or
15. A behavioral health practitioner
under supervision;
(c) Psychological testing provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist; or
5. A certified psychologist working under
the supervision of a board-approved licensed psychologist;
(d) Day treatment or mobile crisis
services provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A licensed clinical alcohol and drug
counselor in accordance with Section 11 of this administrative regulation;
14. A behavioral health practitioner
under supervision, except for a licensed assistant behavior analyst; or
15. A peer support specialist working
under the supervision of an approved behavioral health services provider;
(e) Peer support provided by a peer
support specialist working under the supervision of an approved behavioral
health services provider;
(f) Individual outpatient therapy, group
outpatient therapy, or collateral outpatient therapy provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed behavior analyst;
12. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
13. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
14. A licensed clinical alcohol and drug
counselor in accordance with Section 11 of this administrative regulation; or
15. A behavioral health practitioner
under supervision;
(g) Family outpatient therapy provided
by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A licensed clinical alcohol and drug
counselor in accordance with Section 11 of this administrative regulation; or
14. A behavioral health practitioner
under supervision, except for a licensed assistant behavior analyst; or
(h) A screening, brief intervention, and
referral to treatment for a substance use disorder or SBIRT provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A certified psychologist with autonomous
functioning;
4. A licensed clinical social worker;
5. A licensed professional clinical counselor;
6. A licensed professional art therapist;
7. A licensed marriage and family therapist;
8. A physician;
9. A psychiatrist;
10. An advanced practice registered
nurse;
11. A licensed psychological associate
working under the supervision of a board-approved licensed psychologist;
12. A certified psychologist working
under the supervision of a board-approved licensed psychologist;
13. A licensed clinical alcohol and drug
counselor in accordance with Section 11 of this administrative regulation; or
14. A behavioral health practitioner
under supervision, except for a licensed assistant behavior analyst.
(3)(a) A screening shall:
1. Determine the likelihood that an
individual has a substance use disorder;
2. Not establish the presence or specific
type of disorder; and
3. Establish the need for an in-depth assessment.
(b) An assessment shall:
1. Include gathering information and
engaging in a process with the individual that enables the practitioner to:
a. Establish the presence or absence of a
substance use disorder;
b. Determine the individual’s readiness
for change;
c. Identify the individual’s strengths or
problem areas that may affect the treatment and recovery processes; and
d. Engage the individual in the
development of an appropriate treatment relationship;
2. Establish or rule out the existence of
a clinical disorder or service need;
3. Include working with the individual to
develop a plan of care; and
4. Not include psychological or
psychiatric evaluations or assessments.
(c) Psychological testing shall:
1. Include:
a. A psychodiagnostic assessment of
personality, psychopathology, emotionality, or intellectual disabilities; and
b. Interpretation and a written report of
testing results; and
2. Be performed by an individual who has met the
requirements of KRS Chapter 319 related to the necessary credentials to perform
psychological testing.
(d) Crisis intervention:
1. Shall be a therapeutic intervention
for the purpose of immediately reducing or eliminating the risk of physical or
emotional harm to:
a. The recipient; or
b. Another individual;
2. Shall consist of clinical intervention
and support services necessary to provide integrated crisis response, crisis stabilization
interventions, or crisis prevention activities for individuals;
3. Shall be provided:
a. On-site in the facility where the outpatient
behavioral health services are provided;
b. As an immediate relief to the
presenting problem or threat; and
c. In a face-to-face, one-on-one encounter
between the provider and the recipient;
4. Shall be followed by a referral to non-crisis
services if applicable; and
5. May include:
a. Further service prevention planning that
includes:
(i) Lethal means reduction for suicide
risk; or
(ii) Substance use disorder relapse prevention;
or
b. Verbal de-escalation, risk assessment, or
cognitive therapy.
(e) Mobile crisis services shall:
1. Be available
twenty-four (24) hours per day, seven (7) days per week, every day of the year;
2. Ensure access to
a board-certified or board-eligible psychiatrist twenty-four (24) hours per
day, seven (7) days per week, every day of the year;
3. Be provided for
a duration of less than twenty-four (24) hours;
4. Not be an
overnight service;
5. Be a multi-disciplinary
team-based intervention in a home or community setting that ensures access to
substance use disorder services and supports to:
(i) Reduce symptoms
or harm; or
(ii) Safely
transition an individual in an acute crisis to the appropriate least restrictive
level of care;
6. Involve all services
and supports necessary to provide:
a. Integrated
crisis prevention;
b. Assessment and
disposition;
c. Intervention;
d. Continuity of
care recommendations; and
e. Follow-up
services; and
7. Be provided
face-to-face in a home or community setting.
(f)1. Day treatment shall
be a non-residential, intensive treatment program for an individual under the
age of twenty-one (21) years who has:
a. A substance use
disorder; and
b. A high risk of
out-of-home placement due to a behavioral health issue.
2. Day treatment
shall:
a. Consist of an
organized, behavioral health program of treatment and rehabilitative services;
b. Include:
(i) Individual
outpatient therapy, family outpatient therapy, or group outpatient therapy;
(ii) Behavior
management and social skills training;
(iii) Independent
living skills that correlate to the age and developmental stage of the recipient;
or
(iv) Services
designed to explore and link with community resources before discharge and to
assist the recipient and family with transition to community services after discharge;
and
c. Be provided:
(i) In
collaboration with the education services of the local education authority
including those provided through 20 U.S.C. 1400 et seq. (Individuals with
Disabilities Education Act) or 29 U.S.C. 701 et seq. (Section 504 of the
Rehabilitation Act);
(ii) On school days
and on non-instructional weekdays during the school year including scheduled school
breaks;
(iii) In
coordination with the recipient’s individualized educational plan or Section
504 plan if the recipient has an individualized educational plan or Section 504
plan;
(iv) Under the
supervision of a licensed or certified approved behavioral health services
provider or a behavioral health practitioner working under clinical supervision;
and
(v) With a linkage
agreement with the local education authority that specifies the responsibilities
of the local education authority and the day treatment provider.
3. To provide day
treatment services, a chemical dependency treatment center shall have:
a. The capacity to
employ staff authorized to provide day treatment services in accordance with
this section and to coordinate the provision of services among team members;
and
b. Knowledge of
substance use disorders.
4. Day treatment shall
not include a therapeutic clinical service that is included in a child’s individualized
education plan.
(g)1. Peer support services shall:
a. Be emotional
support that is provided by:
(i) An individual
who has been trained and certified in accordance with 908 KAR 2:220 or 907 KAR
2:240 and who is experiencing or has experienced a substance use disorder to a
recipient by sharing a similar substance use disorder in order to bring about a
desired social or personal change;
(ii) A parent who
has been trained and certified in accordance with 908 KAR 2:230 of a child
having or who has had a substance use disorder to a parent or family member of a
child sharing a similar substance use disorder in order to bring about a
desired social or personal change; or
(iii) A family member who has
been trained and certified in accordance with 908 KAR 2:230 of a child having or
who has had a substance use disorder to a parent or family member of a child sharing a
similar substance use disorder in order to bring about a desired social or
personal change;
b. Be an
evidence-based practice;
c. Be structured
and scheduled non-clinical therapeutic activities with an individual recipient
or a group of recipients;
d. Promote
socialization, recovery, self-advocacy, preservation, and enhancement of
community living skills for the recipient;
e. Be coordinated
within the context of a comprehensive, individualized plan of care developed
through a person-centered planning process;
f. Be identified in
each recipient’s plan of care; and
g. Be designed to
contribute directly to the recipient’s individualized goals as specified in the
recipient’s plan of care.
2. To provide peer
support services, a chemical dependency treatment center shall:
a. Have
demonstrated:
(i) The capacity to
provide peer support services for the behavioral health population being served
including the age range of the population being served; and
(ii) Experience in
serving individuals with behavioral health disorders;
b. Employ peer
support specialists who are qualified to provide peer support services in
accordance with 908 KAR 2:220, 908 KAR 2:230, or 908 KAR 2:240;
c. Use an approved
behavioral health services provider to supervise peer support specialists;
d. Have the
capacity to coordinate the provision of services among team members; and
e. Have the
capacity to provide on-going continuing education and technical assistance to
peer support specialists.
(h)1. Intensive outpatient program
services shall:
a. Be an
alternative to or transition from inpatient hospitalization or partial
hospitalization for a substance use disorder;
b. Offer a
multi-modal, multi-disciplinary structured outpatient treatment program that is
significantly more intensive than individual outpatient therapy, group
outpatient therapy, or family outpatient therapy;
c. Be provided at
least three (3) hours per day at least three (3) days per week; and
d. Include:
(i) Individual
outpatient therapy, group outpatient therapy, or family outpatient therapy
unless contraindicated;
(ii) Crisis
intervention; or
(iii)
Psycho-education.
2. During
psycho-education the recipient or recipient’s family member shall be:
a. Provided with
knowledge regarding the recipient’s diagnosis, the causes of the condition, and
the reasons why a particular treatment might be effective for reducing symptoms;
and
b. Taught how to
cope with the recipient’s diagnosis or condition in a successful manner.
3. An intensive
outpatient program services treatment plan shall:
a. Be
individualized; and
b. Focus on
stabilization and transition to a lesser level of care.
4. To provide
intensive outpatient program services, a chemical dependency treatment center
shall have:
a. Access to a
board-certified or board-eligible psychiatrist for consultation;
b. Access to a
psychiatrist, physician, or advanced practice registered nurse for medication
prescribing and monitoring;
c. Adequate
staffing to ensure a minimum recipient-to-staff ratio of ten (10) recipients to
one (1) staff person;
d. The capacity to
provide services utilizing a recognized intervention protocol based on
nationally accepted treatment principles; and
e. The capacity to
employ staff authorized to provide intensive outpatient program services in
accordance with this section and to coordinate the provision of services among
team members.
(i) Individual outpatient therapy shall:
1. Be provided to promote the:
a. Health and well-being of the recipient;
and
b. Recipient’s recovery from a substance use
disorder;
2. Consist of:
a. A face-to-face, one-on-one encounter
between the provider and recipient; and
b. A behavioral health therapeutic
intervention provided in accordance with the recipient’s identified plan
of care;
3. Be aimed at:
a. Reducing adverse symptoms;
b. Reducing or eliminating the presenting
problem of the recipient; and
c. Improving functioning; and
4. Not exceed three (3) hours per day
unless additional time is medically necessary.
(j)1. Group outpatient therapy shall:
a. Be a behavioral health therapeutic
intervention provided in accordance with a recipient’s identified
plan of care;
b. Be provided to promote the:
(i) Health and wellbeing of the recipient;
and
(ii) Recipient’s recovery from a
substance use disorder;
c. Consist of a face-to-face behavioral
health therapeutic intervention provided in accordance with the recipient’s
identified plan of care;
d. Be provided to a recipient in a group
setting:
(i) Of nonrelated individuals except for
multi-family group therapy; and
(ii) Not to exceed twelve (12)
individuals;
e. Focus on the psychological needs of
the recipients as evidenced in each recipient’s plan of care;
f. Center on goals including building and
maintaining healthy relationships, personal goals setting, and the exercise of
personal judgment;
g. Not include physical exercise, a
recreational activity, an educational activity, or a social activity; and
h. Not exceed three (3) hours per day per
recipient unless additional time is medically necessary.
2. The group shall have a:
a. Deliberate focus; and
b. Defined course of treatment.
3. The subject of group outpatient
therapy shall relate to each recipient participating in the group.
4. The provider shall keep individual
notes regarding each recipient of the group and within each recipient’s health
record.
(k)1. Family outpatient therapy shall
consist of a face-to-face behavioral health therapeutic intervention provided:
a. Through scheduled therapeutic visits
between the therapist and the recipient and at least one (1) member of the
recipient’s family; and
b. To address issues interfering with the
relational functioning of the family and to improve interpersonal relationships
within the recipient’s home environment.
2. A family outpatient therapy session
shall be billed as one (1) service regardless of the number of individuals
(including multiple members from one (1) family) who participate in the
session.
3. Family outpatient therapy shall:
a. Be provided to promote the:
(i) Health and well-being of the recipient;
or
(ii) Recipient’s recovery from a substance
use disorder; and
b. Not exceed three (3) hours per day per
individual unless additional time is medically necessary.
(l)1. Collateral outpatient therapy
shall:
a. Consist of a face-to-face behavioral
health consultation:
(i) With a parent or caregiver of a
recipient, household member of a recipient, recipient’s representative, school staff
person, treating professional, or other person with custodial control or
supervision of the recipient; and
(ii) That is provided in accordance with
the recipient’s plan of care; and
b. Not be reimbursable if the therapy is
for a recipient who is at least twenty-one (21) years of age.
2. Consent given to discuss a recipient’s
treatment with any person other than a parent or legal guardian shall be signed
by the recipient or recipient’s representative and filed in the recipient’s
health record.
(m) Screening, brief intervention, and
referral to treatment for a substance use disorder shall:
1. Be an evidence-based early-intervention
approach for an individual with non-dependent substance use in order to provide
an effective strategy for intervention prior to the need for more extensive or
specialized treatment; and
2. Consist of:
a. Using a standardized screening tool to
assess an individual for risky substance use behavior;
b. Engaging a recipient, who demonstrates
risky substance use behavior, in a short conversation and providing feedback
and advice to the recipient; and
c. Referring a recipient to additional
substance use disorder services if the recipient is determined to need
additional services to address the recipient’s substance use.
(4) The extent and type of a screening
shall depend upon the nature of the problem of the individual seeking or being
referred for services.
(5) A diagnosis or clinical impression
shall be made using terminology established in the most current edition of the
American Psychiatric Association Diagnostic and Statistical Manual of Mental
DisordersTM.
(6) The department shall not reimburse
for a service billed by or on behalf of an entity or individual who is not a
billing provider.
Section 4. Additional Limits and Non-covered
Services or Activities. (1)(a) Except as established in paragraph (b) of this
subsection, unless a diagnosis is made and documented in the recipient’s health
record within three (3) visits, the service shall not be covered.
(b) The requirement established in
paragraph (a) of this subsection shall not apply to:
1. Mobile crisis services;
2. Crisis intervention;
3. A screening; or
4. An assessment.
(2) The department shall not reimburse
for both a screening and an SBIRT provided to a recipient on the same date of
service.
(3) The following services or activities shall
not be covered under this administrative regulation:
(a) A service provided to:
1. A resident of:
a. A nursing facility; or
b. An intermediate care facility for
individuals with an intellectual disability;
2. An inmate of a federal, local, or
state:
a. Jail;
b. Detention center; or
c. Prison; or
3. An individual with an intellectual
disability without documentation of an additional psychiatric diagnosis;
(b) A consultation or educational service
provided to a recipient or to others;
(c) A telephone call, an email, a text
message, or other electronic contact that does not meet the requirements stated
in the definition of "face-to-face" established in 907 KAR 15:005,
Section 1(14);
(d) Travel time;
(e) A field trip;
(f) A recreational activity;
(g) A social activity; or
(h) A physical exercise activity group.
(4)(a) A consultation by one (1) provider
or professional with another shall not be covered under this administrative
regulation except as established in Section 3(3)(l)1 of this administrative regulation.
(b) A third-party contract shall not be
covered under this administrative regulation.
(5) A billing supervisor arrangement
between a billing supervisor and a behavioral health practitioner under
supervision shall not:
(a) Violate the clinical supervision
rules or policies of the respective professional licensure boards governing the
billing supervisor and the behavioral health practitioner under supervision; or
(b) Substitute for the clinical
supervision rules or policies of the respective professional licensure boards
governing the billing supervisor and the behavioral health practitioner under supervision.
Section 5. No Duplication of Service. (1)
The department shall not reimburse for a service provided to a recipient by
more than one (1) provider, of any program in which the same service is
covered, during the same time period.
(2) For example, if a recipient is
receiving a behavioral health service from an independent behavioral health
provider, the department shall not reimburse for the same service provided to
the same recipient during the same time period by a chemical dependency
treatment center.
Section 6. Records Maintenance, Documentation,
Protection, and Security. (1) A chemical dependency treatment center shall
maintain a current health record for each recipient.
(2) A health record shall document each
service provided to the recipient including the date of the service and the
signature of the individual who provided the service.
(3) A health record shall:
(a) Include:
1. An identification and intake record including:
a. Name;
b. Social Security number;
c. Date of intake;
d. Home (legal) address;
e. Health insurance or Medicaid participation
information;
f. If applicable, the referral source’s name
and address;
g. Primary care physician’s name and address;
h. The reason the individual is seeking
help including the presenting problem and diagnosis;
i. Any physical health diagnosis, if a
physical health diagnosis exists for the individual, and information regarding:
(i) Where the individual is receiving
treatment for the physical health diagnosis; and
(ii) The physical health provider’s name;
and
j. The name of the informant and any
other information deemed necessary by the chemical dependency treatment center in
order to comply with the requirements of:
(i) This administrative regulation;
(ii) The chemical dependency treatment
center’s licensure board;
(iii) State law; or
(iv) Federal law;
2. Documentation of the:
a. Screening;
b. Assessment if an assessment was performed;
and
c. Disposition if a disposition was performed;
3. A complete history including mental
status and previous treatment;
4. An identification sheet;
5. A consent for treatment sheet that is
accurately signed and dated; and
6. The individual’s stated purpose for
seeking services; and
(b) Be:
1. Maintained in an organized central
file;
2. Furnished upon request:
a. To the Cabinet for Health and Family
Services; or
b. For an enrollee, to the managed care
organization in which the recipient is enrolled or has been enrolled in the
past;
3. Made available for inspection and copying
by:
a. Cabinet for Health and Family
Services’ personnel; or
b. Personnel of the managed care
organization in which the recipient is enrolled if applicable;
4. Readily accessible; and
5. Adequate for the purpose of establishing
the current treatment modality and progress of the recipient if the recipient
received services beyond a screening.
(4) Documentation of a screening shall include:
(a) Information relative to the
individual’s stated request for services; and
(b) Other stated personal or health concerns
if other concerns are stated.
(5)(a) A chemical dependency treatment
center’s notes regarding a recipient shall:
1. Be made within forty-eight (48) hours
of each service visit; and
2. Describe the:
a. Recipient’s symptoms or behavior, reaction
to treatment, and attitude;
b. Behavioral health practitioner’s
intervention;
c. Changes in the
plan of care if
changes are made; and
d. Need for continued treatment if deemed
necessary.
(b)1. Any edit to notes shall:
a. Clearly display the changes; and
b. Be initialed and dated by the person
who edited the notes.
2. Notes shall not be erased or illegibly
marked out.
(c)1. Notes recorded by a behavioral
health practitioner working under supervision shall be co-signed and dated by
the supervising professional within thirty (30) days.
2. If services are provided by a behavioral
health practitioner working under supervision, there shall be a monthly
supervisory note recorded by the supervising professional which reflects consultations
with the behavioral health practitioner working under supervision concerning
the:
a. Case; and
b. Supervising professional’s evaluation
of the services being provided to the recipient.
(6) Immediately following a screening of
a recipient, the practitioner shall perform a disposition related to:
(a) A provisional diagnosis;
(b) A referral for further consultation
and disposition, if applicable; or
(c)1. If applicable, termination of
services and referral to an outside source for further services; or
2. If applicable, termination of services
without a referral to further services.
(7) Any change to a recipient’s plan of
care shall be documented, signed, and dated by the rendering practitioner and
by the recipient or recipient’s representative.
(8)(a) Notes regarding services to a
recipient shall:
1. Be organized in chronological order;
2. Be dated;
3. Be titled to indicate the service rendered;
4. State a starting and ending time for
the service; and
5. Be recorded and signed by the rendering
practitioner and include the professional title (for example, licensed clinical
social worker) of the provider.
(b) Initials, typed signatures, or
stamped signatures shall not be accepted.
(c) Telephone contacts, family collateral
contacts not covered under this administrative regulation, or other
non-reimbursable contacts shall:
1. Be recorded in the notes; and
2. Not be reimbursable.
(9)(a) A termination summary shall:
1. Be required, upon termination of services,
for each recipient who received at least three (3) service visits; and
2. Contain a summary of the significant
findings and events during the course of treatment including the:
a. Final assessment regarding the
progress of the individual toward reaching goals and objectives established in
the individual’s plan of care;
b. Final diagnosis of clinical
impression; and
c. Individual’s condition upon
termination and disposition.
(b) A health record relating to an
individual who has been terminated from receiving services shall be fully
completed within ten (10) days following termination.
(10) If an individual’s case is reopened
within ninety (90) days of terminating services for the same or related issue,
a reference to the prior case history with a note regarding the interval period
shall be acceptable.
(11)(a) Except as established in
paragraph (b) of this subsection, if a recipient is transferred or referred to
a health care facility or other provider for care or treatment, the
transferring chemical dependency treatment center shall, within ten (10)
business days of awareness of the transfer or referral, transfer the
recipient’s records in a manner that complies with the records’ use and
disclosure requirements as established in or required by:
1.a. The Health Insurance Portability and
Accountability Act;
b. 42 U.S.C. 1320d-2 to 1320d-8; and
c. 45 C.F.R. Parts 160 and 164; or
2.a. 42 U.S.C. 290ee-3; and
b. 42 C.F.R. Part 2.
(b) If a recipient is transferred or
referred to a residential crisis stabilization unit, a psychiatric hospital, a psychiatric
distinct part unit in an acute care hospital, a Level I psychiatric residential
treatment facility, a Level II psychiatric residential treatment facility, or
an acute care hospital for care or treatment, the transferring chemical dependency
treatment center shall, within forty-eight (48) hours of the transfer or
referral, transfer the recipient’s records in a manner that complies with the
records’ use and disclosure requirements as established in or required by:
1.a. The Health Insurance Portability and
Accountability Act;
b. 42 U.S.C. 1320d-2 to 1320d-8; and
c. 45 C.F.R. Parts 160 and 164; or
2.a. 42 U.S.C. 290ee-3; and
b. 42 C.F.R. Part 2.
(12)(a) If a chemical dependency treatment
center’s Medicaid Program participation status changes as a result of
voluntarily terminating from the Medicaid Program, involuntarily terminating
from the Medicaid Program, a licensure suspension, or death of an owner or deaths
of owners, the health records of the chemical dependency treatment center
shall:
1. Remain the property of the chemical
dependency treatment center; and
2. Be subject to the retention
requirements established in subsection (13) of this section.
(b) A chemical dependency treatment
center shall have a written plan addressing how to maintain health records in
the event of death of an owner or deaths of owners.
(13)(a) Except as established in
paragraph (b) or (c) of this subsection, a chemical dependency treatment center
shall maintain a health record regarding a recipient for at least six (6) years
from the last date of the service or until any audit dispute or issue is
resolved beyond six (6) years.
(b) After a recipient’s death or
discharge from services, a provider shall maintain the recipient’s record for
the longest of the following periods:
1. Six (6) years unless the recipient is
a minor; or
2. If the recipient is a minor, three (3)
years after the recipient reaches the age of majority under state law.
(c) If the Secretary of the United States
Department of Health and Human Services requires a longer document retention
period than the period referenced in paragraph (a) of this subsection, pursuant
to 42 C.F.R. 431.17, the period established by the secretary shall be the required
period.
(14)(a) A chemical dependency treatment
center shall comply with 45 C.F.R. Part 164.
(b) All information contained in a health
record shall:
1. Be treated as confidential;
2. Not be disclosed to an unauthorized individual;
and
3. Be disclosed to an authorized representative
of:
a. The department;
b. Federal government; or
c. For an enrollee, the managed care
organization in which the enrollee is enrolled.
(c)1. Upon request, a chemical dependency
treatment center shall provide to an authorized representative of the
department, federal government, or managed care organization if applicable,
information requested to substantiate:
a. Staff notes detailing a service that
was rendered;
b. The professional who rendered a service;
and
c. The type of service rendered and any
other requested information necessary to determine, on an individual basis,
whether the service is reimbursable by the department or the managed care
organization, if applicable.
2. Failure to provide information
referenced in subparagraph 1 of this paragraph shall result in denial of
payment for any service associated with the requested information.
Section 7. Medicaid Program Participation
Compliance. (1) A chemical dependency treatment center shall comply with:
(a) 907 KAR 1:671;
(b) 907 KAR 1:672; and
(c) All applicable state and federal
laws.
(2)(a) If a chemical dependency treatment
center receives any duplicate payment or overpayment from the department or a
managed care organization, regardless of reason, the chemical dependency
treatment center shall return the payment to the department or managed care
organization 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 may be:
1. Interpreted to be fraud or abuse; and
2. Prosecuted in accordance with applicable
federal or state law.
(3)(a) When the department makes payment
for a covered service and the chemical dependency treatment center 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 chemical dependency treatment center.
(b)1. A chemical dependency treatment
center 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. Chemical dependency treatment center
makes the recipient aware in writing in advance of providing the service that
the:
(i) Recipient is liable for the payment;
and
(ii) Department is not covering the
service.
2. If a recipient makes payment for a service
in accordance with subparagraph 1 of this paragraph, the:
a. Chemical dependency treatment center
shall not bill the department for the service; and
b. Department shall not:
(i) Be liable for any part of the payment
associated with the service; and
(ii) Make any payment to the chemical
dependency treatment center regarding the service.
(4)(a) A chemical dependency treatment
center shall attest by the chemical dependency treatment center’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 chemical dependency treatment
center receives a request from the:
a. Department to provide a claim, related
information, related documentation, or record for auditing purposes, the chemical
dependency treatment center 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 chemical dependency
treatment center 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 chemical dependency treatment center 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 chemical dependency treatment center
may request a longer timeframe to provide information to the department or a managed
care organization if the chemical dependency treatment center 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 chemical dependency
treatment center shall result in the suspension or termination of the chemical
dependency treatment center from Medicaid Program participation in accordance
with 907 KAR 1:671.
Section 8. Third Party Liability. A chemical
dependency treatment center shall comply with KRS 205.622.
Section 9. 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 chemical dependency treatment
center 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 chemical
dependency treatment center'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 chemical dependency
treatment center's electronic signature policy;
2. The signed consent form; and
3. The original filed signature.
Section 10. Auditing Authority. The department
or managed care organization in which an enrollee is enrolled shall have the authority
to audit any:
(1) Claim;
(2) Health record; or
(3) Documentation associated with any
claim or health record.
Section 11. Federal Approval and Federal
Financial Participation. (1) The department’s reimbursement of services pursuant to this
administrative regulation shall be contingent upon:
(a) Receipt of federal financial
participation for the coverage; and
(b) Centers for Medicare and Medicaid
Services’ approval for the coverage.
(2) The reimbursement 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 12. Appeals. (1) An appeal of an
adverse action by the department regarding a service and a recipient who is not
enrolled with a managed care organization shall be in accordance with 907 KAR
1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with 907 KAR 17:010. (41 Ky.R. 2507; 42 Ky.R. 436; 756; eff.
10-2-2015.)