907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services

Link to law: http://www.lrc.ky.gov/kar/907/015/080.htm
Published: 2015

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      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.)