907 KAR 10:014.
Outpatient hospital service coverage provisions and requirements.
RELATES TO: KRS 205.520, 42 C.F.R. 447.53
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3), 205.560, 205.6310, 205.8453
NECESSITY, FUNCTION, AND CONFORMITY: The
Cabinet for Health and Family Services, Department for Medicaid Services, has
responsibility to administer the Medicaid Program. KRS 205.520 empowers 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 Medicaid Program
service and coverage policies for outpatient hospital services.
Section 1. Definitions. (1) "Advanced
practice registered nurse" is defined by KRS 314.011(7).
(2) "Approved behavioral health services
provider" means:
(a) A physician;
(b) A psychiatrist;
(c) An advanced practice registered
nurse;
(d) A physician assistant;
(e) A licensed psychologist;
(f) A licensed psychological
practitioner;
(g) A certified psychologist with autonomous
functioning;
(h) A licensed clinical social worker;
(i) A licensed professional clinical
counselor;
(j) A licensed marriage and family therapist;
(k) A licensed psychological associate;
(l) A certified psychologist;
(m) A marriage and family therapy associate;
(n) A certified social worker;
(o) A licensed professional counselor associate;
(p) A licensed professional art
therapist;
(q) A licensed professional art therapist
associate;
(r) A licensed clinical alcohol and drug
counselor in accordance with Section 14 of this administrative regulation;
(s) A licensed clinical alcohol and drug
counselor associate in accordance with Section 14 of this administrative
regulation; or
(t) A certified alcohol and drug
counselor.
(3) "Behavioral health practitioner
under supervision" means an individual who is:
(a)1. A licensed professional counselor
associate;
2. A certified social worker;
3. A marriage and family therapy associate;
4. A licensed professional art therapist
associate;
5. A licensed assistant behavior analyst;
6. A physician assistant;
7. A certified alcohol and drug
counselor; or
8. A licensed clinical alcohol and drug
counselor associate in accordance with Section 14 of this administrative
regulation; and
(b) Employed by or under contract with
the same billing provider as the billing supervisor.
(4) "Billing
provider" means the
individual who, group of individual providers that, or organization that:
(a) Is authorized to bill the department
or a managed care organization for a service; and
(b) Is eligible to be reimbursed by the department
or a managed care organization for a service.
(5) "Billing
supervisor" means an individual who is:
(a)1. A physician;
2. A psychiatrist;
3. An advanced practice registered nurse;
4. A licensed psychologist;
5. A licensed clinical social worker;
6. A licensed professional clinical counselor;
7. A licensed psychological practitioner;
8. A certified psychologist with autonomous
functioning;
9. A licensed marriage and family therapist;
10. A licensed professional art
therapist; or
11. A licensed behavior analyst; and
(b) Employed by or under contract with
the same billing provider as the behavioral health practitioner under
supervision who renders services under the supervision of the billing supervisor.
(6) "Certified alcohol and drug counselor" is defined by KRS 309.080(2).
(7) "Certified
psychologist" means an
individual who is a certified psychologist pursuant to KRS 319.056.
(8) "Certified
psychologist with autonomous functioning" means an individual who is a
certified psychologist with autonomous functioning pursuant to KRS 319.056.
(9) "Certified
social worker" means an individual who meets the requirements established
in KRS 335.080.
(10) "Community
support associate" means a paraprofessional who meets the application,
training, and supervision requirements of 908 KAR 2:250.
(11) "Current procedural terminology
code" or "CPT code" means a code used for reporting procedures
and services performed by medical practitioners and published
annually by the American Medical Association in
Current Procedural Terminology.
(12) "Department" means the
Department for Medicaid Services or its designee.
(13) "Electronic
signature" is defined by KRS 369.102(8).
(14) "Emergency" means that a
condition or situation requires an emergency service pursuant to 42 C.F.R.
447.53.
(15) "Emergency medical
condition" is defined by 42 U.S.C. 1395dd(e)(1).
(16) "Enrollee" means a recipient
who is enrolled with a managed care organization.
(17)
"Face-to-face" means occurring:
(a) In person; or
(b) If authorized
by 907 KAR 3:170, via a real-time, electronic communication that involves two
(2) way interactive video and audio communication.
(18) "Federal financial participation" is defined by 42 C.F.R. 400.203.
(19) "Individualized education program"
is defined by 34 C.F.R. 300.320.
(20) "Licensed assistant behavior analyst"
is defined by KRS 319C.010(7).
(21) "Licensed behavior analyst" is defined by KRS
319C.010(6).
(22) "Licensed
clinical alcohol and drug counselor" is defined by KRS 309.080(4).
(23) "Licensed
clinical alcohol and drug counselor associate" is defined by KRS
309.080(5).
(24) "Licensed clinical social worker" means an
individual who meets the licensed clinical social worker requirements established
in KRS 335.100.
(25) "Licensed marriage and family therapist" is defined
by KRS 335.300(2).
(26) "Licensed professional art therapist" is
defined by KRS 309.130(2).
(27) "Licensed professional art therapist associate"
is defined by KRS 309.130(3).
(28) "Licensed professional clinical counselor" is
defined by KRS 335.500(3).
(29) "Licensed professional counselor associate"
is defined by KRS 335.500(4).
(30) "Licensed psychological associate" means an
individual who:
(a) Currently
possesses a licensed psychological associate license in accordance with KRS
319.010(6); and
(b) Meets the
licensed psychological associate requirements established in 201 KAR Chapter 26.
(27) "Licensed psychological practitioner" means
an individual who meets the requirements established in KRS 319.053.
(28) "Licensed psychologist" means an individual
who:
(a) Currently
possesses a licensed psychologist license in accordance with KRS 319.010(6);
and
(b) Meets the
licensed psychologist requirements established in 201 KAR Chapter 26.
(29) "Lock-in recipient" means:
(a) A recipient enrolled in the
department's lock-in program pursuant to 907 KAR 1:677; or
(b) An enrollee enrolled in a managed
care organization’s lock-in program pursuant to 907 KAR 17:020, Section 8.
(30) "Marriage
and family therapy associate" is defined by KRS 335.300(3).
(31) "Medical necessity" or
"medically necessary" means that a covered benefit is determined to be
needed in accordance with 907 KAR 3:130.
(32) "Nonemergency" means that
a condition or situation does not require an emergency service pursuant to 42
C.F.R. 447.53.
(33) "Peer
support specialist" means an individual who meets the peer support specialist
qualifications established in:
(a) 908 KAR 2:220;
(b) 908 KAR 2:230;
or
(c) 908 KAR 2:240.
(34)
"Person-centered service plan" means a plan of services for a
recipient that meets the requirements established in 42 C.F.R. 441.540.
(35)
"Physician" is defined by KRS 205.510(11).
(36)
"Physician assistant" is defined by KRS 311.840(3).
(37) "Provider" is defined by
KRS 205.8451(7).
(38) "Provider
abuse" is defined by KRS 205.8451(8).
(39) "Recipient" is defined by
KRS 205.8451(9).
(40) "Recipient abuse"
is defined by KRS 205.8451(10).
(41) "Recipient’s
representative" means:
(a) For a recipient who
is authorized by Kentucky law to provide written consent, an individual acting
on behalf of, and with written consent from, the recipient; or
(b) A legal guardian.
(42) "Section
504 plan" means a plan developed under the auspices of Section 504 of the
Rehabilitation Act of 1973, as amended, 29 U.S.C. 794 (Section 504), to ensure
that a child who has a disability identified under the law and is attending an
elementary or secondary educational institution receives accommodations to
ensure the child’s academic success and access to the learning environment.
(43) "Unlisted procedure or
service" means a procedure or service:
(a) For which there is not a specific CPT
code; and
(b) Which is billed using a CPT code designated
for reporting unlisted procedures or services.
Section 2. Coverage Criteria. (1)(a) To
be covered by the department, the following shall be prior authorized and meet
the requirements established in paragraph (b) of this subsection:
1. Magnetic resonance imaging;
2. Magnetic resonance angiogram;
3. Magnetic resonance spectroscopy;
4. Positron emission tomography;
5. Cineradiography or videoradiography;
6. Xeroradiography;
7. Ultrasound subsequent to second obstetric
ultrasound;
8. Myocardial imaging;
9. Cardiac blood pool imaging;
10. Radiopharmaceutical procedures;
11. Gastric restrictive surgery or
gastric bypass surgery;
12. A procedure that is commonly
performed for cosmetic purposes;
13. A surgical procedure that requires
completion of a federal consent form; or
14. An unlisted procedure or service.
(b) To be covered by the department, an
outpatient hospital service, including a service identified in paragraph (a) of
this subsection, shall:
1. Be medically necessary;
2. Except for a behavioral health service
established in Section 5 of this administrative regulation, be clinically
appropriate pursuant to the criteria established in 907 KAR 3:130; and
3. If provided to a lock-in recipient or
enrollee, meet the requirements established in paragraph (c) of this
subsection.
(c) If the lock-in recipient is:
1. Not an enrollee, the outpatient
hospital service shall be:
a. Provided by the lock-in recipient’s
designated hospital pursuant to 907 KAR 1:677; or
b. A screening or emergency service that
meets the requirements of subsection (6)(a) of this section; or
2. An enrollee, the outpatient hospital
service shall be:
a. Provided by the enrollee’s designated
hospital as established by the managed care organization in which the enrollee
is enrolled; or
b. A screening or emergency service that
meets the requirements of subsection (6)(a) of this section.
(2)(a) The prior authorization
requirements established in subsection (1) of this section shall not apply to:
1. An emergency service;
2. A radiology procedure if the recipient
has a cancer or transplant diagnosis code; or
3. A service provided to a recipient in
an observation bed.
(b) A behavioral health service established
in Section 5 of this administrative regulation shall:
1. Be medically necessary; and
2. Not be subject to prior authorization.
(3) A referring physician, a physician
who wishes to provide a given service, an advanced practice registered nurse,
or a duly-licensed dentist may request prior authorization from the department.
(4) The following covered hospital outpatient
services shall be furnished by or under the supervision of a duly licensed
physician, or, if applicable, a duly-licensed dentist:
(a) A diagnostic service ordered by a physician;
(b) A therapeutic service;
(c) An emergency room service provided in
an emergency situation as determined by a physician; or
(d) A drug, biological, or injection
administered in the outpatient hospital setting.
(5) A covered hospital outpatient service
for maternity care may be provided by:
(a) An advanced practice registered nurse
who has been designated by the Kentucky Board of Nursing as a nurse midwife; or
(b) A registered nurse who holds a valid
and effective permit to practice nurse midwifery issued by the Cabinet for
Health and Family Services.
(6) The department shall cover:
(a) A screening of a lock-in recipient to
determine if the lock-in recipient has an emergency medical condition; or
(b) An emergency service to a lock-in recipient
if the department determines that the lock-in recipient had an emergency
medical condition when the service was provided.
Section 3. Hospital Outpatient Services
Not Covered by the Department. The following services shall not be considered a
covered hospital outpatient service:
(1) An item or service that does not meet
the requirements established in Section 2(1) of this administrative regulation;
(2) A service for which:
(a) An individual has no obligation to
pay; and
(b) No other person has a legal
obligation to pay;
(3) A medical supply or appliance, unless
it is incidental to the performance of a procedure or service in the hospital
outpatient department and included in the rate of payment established by the Medicaid
Program for hospital outpatient services;
(4) A drug, biological, or injection purchased
by or dispensed to a recipient;
(5) A routine physical examination; or
(6) A nonemergency service, other than a
screening in accordance with Section 2(6)(a) of this administrative regulation,
provided to a lock-in recipient:
(a) In an emergency department of a hospital;
or
(b) If provided by a hospital that is not
the lock-in recipient's designated hospital:
1. Pursuant to 907 KAR 1:677, if the
recipient is not an enrollee; or
2. As established by the managed care organization
in which the lock-in recipient is enrolled, if the lock-in recipient is an enrollee.
Section 4. Speech-language Pathology,
Physical Therapy, and Occupational Therapy Limits. (1) Speech-language pathology
services shall be limited to twenty (20) service visits per calendar year per
recipient.
(2) Physical therapy services shall be
limited to twenty (20) service visits per calendar year per recipient.
(3) Occupational therapy services shall
be limited to twenty (20) service visits per calendar year per recipient.
(4) A
service in excess of the limits established in subsection (1), (2), or (3) of
this section shall be approved if the service in excess of the limits is
determined to be medically necessary by the:
(a) Department, if
the recipient is not enrolled with a managed care organization; or
(b) Managed care
organization in which the enrollee is enrolled, if the recipient is an enrollee.
(5) Prior authorization by the department
shall be required for each service visit that exceeds the limit established in subsection
(1), (2), or (3) of this section for a recipient who is not enrolled with a
managed care organization.
Section 5. Behavioral Health Services. (1)
The following behavioral health services shall be covered under this
administrative regulation in accordance with the following requirements:
(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 14 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 14 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 14 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 14 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 14 of this administrative regulation; or
14. A behavioral health practitioner
under supervision, except for a licensed assistant behavior analyst;
(h) Service planning 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; or
14. A behavioral health practitioner
under supervision except for:
a. A certified alcohol and drug
counselor; or
b. A licensed clinical alcohol and drug
counselor associate;
(i) 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 14 of this administrative regulation; or
14. A behavioral health practitioner
under supervision, except for a licensed assistant behavior analyst;
(j) Assertive community treatment
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 behavioral health practitioner
under supervision except for a:
a. Licensed assistant behavior analyst;
b. Certified alcohol and drug counselor;
or
c. Licensed clinical alcohol and drug counselor
associate;
14. A peer support specialist working under
the supervision of an approved behavioral health services provider except for
a:
a. Licensed clinical alcohol and drug counselor;
b. Licensed clinical alcohol and drug counselor
associate; or
c. Certified alcohol and drug counselor;
or
15. A community support associate;
(k) Comprehensive community support
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 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 behavioral health practitioner
under supervision except for a:
a. Licensed clinical alcohol and drug counselor
associate; or
b. Certified alcohol and drug counselor;
or
15. A community support associate;
(l) Therapeutic rehabilitation program 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 behavioral health practitioner
under supervision except for a:
a. Licensed assistant behavior analyst;
b. Licensed clinical alcohol and drug counselor
associate; or
c. Certified alcohol and drug counselor;
or
14. A peer support specialist working under
the supervision of an approved behavioral health services provider except for
a:
a. Licensed clinical alcohol and drug counselor;
b. Licensed clinical alcohol and drug counselor
associate; or
c. Certified alcohol and drug counselor; or
(m) Partial hospitalization provided by:
1. A licensed
psychologist;
2. A licensed
professional clinical counselor;
3. A licensed
clinical social worker;
4. A licensed
marriage and family therapist;
5. A physician;
6. A psychiatrist;
7. An advanced
practice registered nurse;
8. A licensed
psychological practitioner;
9. A certified
psychologist with autonomous functioning;
10. A licensed
clinical alcohol and drug counselor in accordance with Section 14 of this
administrative regulation;
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; or
13. A behavioral
health practitioner under supervision, except for a licensed assistant behavioral
analyst.
(2)(a) A screening shall:
1. Determine the likelihood that an
individual has a mental health disorder, substance use disorder, or
co-occurring disorders;
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
mental health disorder, substance use disorder, or co-occurring disorders;
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 at the outpatient hospital;
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 mental health and substance use disorder services and supports
to:
a. Reduce symptoms
or harm; or
b. 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 mental health
disorder, substance use disorder, or co-occurring mental health and substance
use disorders; 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, an outpatient hospital 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 and who is
experiencing or has experienced a mental health disorder, substance use disorder,
or co-occurring mental health and substance use disorders to a recipient by
sharing a similar mental health disorder, substance use disorder, or
co-occurring mental health and substance use disorders 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 mental health disorder, substance use disorder, or co-occurring mental
health and substance use disorders to a parent or family member of a child sharing a similar
mental health disorder, substance use disorder, or co-occurring mental
health and substance use disorders 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 mental health disorder, substance use disorder, or co-occurring mental
health and substance use disorders to a parent or family member of a child sharing a similar
mental health disorder, substance use disorder, or co-occurring mental
health and substance use disorders 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, an outpatient hospital 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 mental health disorder, substance use disorder, or
co-occurring disorders;
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, an outpatient hospital 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, mental health disorder, or co-occurring mental health and
substance use disorders;
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 well-being of the recipient;
and
(ii) Recipient’s recovery from a
substance use disorder, mental health disorder, or co-occurring mental health
and substance use disorders;
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, mental health disorder, or co-occurring mental health
and substance use disorders; 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, a 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
and filed in the recipient’s health record.
(m)1. Service planning shall:
a. Involve assisting a recipient in
creating an individualized plan for services needed for maximum reduction of
the effects of a mental health disorder;
b. Involve restoring a recipient's
functional level to the recipient's best possible functional level; and
c. Be performed using a person-centered
planning process.
2. A service plan:
a. Shall be directed by the:
(i) Recipient; or
(ii) Recipient’s representative if the recipient
is under the age of eighteen (18) years or is unable to provide direction;
b. Shall include practitioners of the
recipient’s choosing; and
c. May include:
(i) A mental health advance directive
being filed with a local hospital;
(ii) A crisis plan; or
(iii) A relapse prevention strategy or
plan.
(n) 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
mental health disorder, substance use disorder, or co-occurring disorders
services if the recipient is determined to need additional services to address the
recipient’s substance use.
(o)1. Assertive community treatment
shall:
a. Be an
evidence-based psychiatric rehabilitation practice which provides a
comprehensive approach to service delivery for individuals with a severe mental
illness; and
b. Include:
(i) Assessment;
(ii) Treatment
planning;
(iii) Case management;
(iv) Psychiatric
services;
(v) Medication
prescribing and monitoring;
(vi) Individual
outpatient therapy;
(vii) Group
outpatient therapy;
(viii) Mobile
crisis services;
(ix) Mental health
consultation;
(x) Family support
and basic living skills; or
(xi) Peer support.
2.a. Mental health
consultation shall involve brief, collateral interactions with other treating
professionals who may have information for the purpose of treatment planning
and service delivery.
b. Family support
shall involve the assertive community treatment team’s working with the
recipient’s natural support systems to improve family relations in order to:
(i) Reduce
conflict; and
(ii) Increase the
recipient’s autonomy and independent functioning.
c. Basic living
skills shall be rehabilitative services focused on teaching activities of daily
living necessary to maintain independent functioning and community living.
3. To provide
assertive community treatment services, an outpatient hospital shall:
a. Employ at least
one (1) team of multidisciplinary professionals:
(i) Led by an
approved behavioral health services provider except for a licensed clinical
alcohol and drug counselor, a licensed clinical alcohol and drug counselor
associate, or a certified alcohol and drug counselor; and
(ii) Comprised of
at least four (4) full-time equivalents including a psychiatrist, a nurse, a
case manager, a peer support specialist, or an approved behavioral health
services provider except for a licensed clinical alcohol and drug counselor, a
licensed clinical alcohol and drug counselor associate, or a certified alcohol
and drug counselor;
b. Have adequate
staffing to ensure that no team’s caseload size exceeds ten (10) participants
per team member (for example, if the team includes five (5) individuals, the
caseload for the team shall not exceed fifty (50) recipients);
c. Have the
capacity to:
(i) Employ staff
authorized to provide assertive community treatment services in accordance with
this paragraph;
(ii) Coordinate the
provision of services among team members;
(iii) Provide the
full range of assertive community treatment services as stated in this
paragraph; and
(iv) Document and
maintain individual health records; and
d. Demonstrate
experience in serving individuals with persistent and severe mental illness who
have difficulty living independently in the community.
(p)1. Comprehensive
community support services shall:
a. Be activities necessary to allow an
individual to live with maximum independence in the community;
b. Be intended to ensure successful community
living through the utilization of skills training as identified in the
recipient’s plan of care; and
c. Consist of using a variety of
psychiatric rehabilitation techniques to:
(i) Improve daily living skills;
(ii) Improve self-monitoring of symptoms
and side effects;
(iii) Improve emotional regulation
skills;
(iv) Improve crisis coping skills; and
(v) Develop and enhance interpersonal
skills.
2. To provide comprehensive community
support services, an outpatient hospital shall:
a. Have the capacity to employ staff authorized
pursuant to 908 KAR 2:250 to provide comprehensive community support services
in accordance with subsection (1)(k) of this section and to coordinate the
provision of services among team members; and
b. Meet the requirements for comprehensive
community support services established in 908 KAR 2:250.
(q)1. Therapeutic rehabilitation program
services shall be:
a. A rehabilitative service for an:
(i) Adult with a severe mental illness;
or
(ii) Individual under the age of
twenty-one (21) years who has a severe emotional disability; and
b. Designed to maximize the reduction of
the effects of a mental health disorder and the restoration of the individual’s
functional level to the individual’s best possible functional level.
2. A recipient in a therapeutic
rehabilitation program shall establish the recipient’s own rehabilitation goals
within the person-centered service plan.
3. A therapeutic rehabilitation program
shall:
a. Be delivered using a variety of
psychiatric rehabilitation techniques;
b. Focus on:
(i) Improving daily living skills;
(ii) Self-monitoring of symptoms and side
effects;
(iii) Emotional regulation skills;
(iv) Crisis coping skill; and
(v) Interpersonal skills; and
c. Be delivered individually or in a
group.
(r)1. Partial hospitalization shall be
a short-term (average of four (4) to six (6) weeks), less than twenty-four (24)-hour,
intensive treatment program for an individual who is experiencing significant
impairment to daily functioning due to a substance use disorder, a mental
health disorder, or co-occurring mental health and substance use disorders.
2. Partial hospitalization may be provided
to an adult or a child.
3. Admission criteria for partial
hospitalization shall be based on an inability to adequately treat the recipient
through community-based therapies or intensive outpatient services.
4. A partial hospitalization program shall
consist of individual outpatient therapy, group outpatient therapy, family outpatient
therapy, or medication management.
5.a. The department shall not reimburse
for educational, vocational, or job training services provided as part of
partial hospitalization.
b. An outpatient hospital’s partial
hospitalization program shall have an agreement with the local educational
authority to come into the program to provide all educational components and
instruction which are not Medicaid billable or reimbursable.
c. The department shall not reimburse for services
identified in a Medicaid-eligible
child’s individualized education program.
6. Partial hospitalization shall
typically be:
a. Provided for at least four (4) hours
per day; and
b. Focused on one (1) primary presenting
problem (i.e. substance use, sexual reactivity, or another problem).
7. An outpatient hospital’s partial
hospitalization program shall:
a. Include the following personnel for
the purpose of providing medical care if necessary:
(i) An advanced practice registered nurse;
(ii) A physician assistant or physician
available on site; and
(iii) A board-certified or board-eligible
psychiatrist available for consultation; and
b. Have the capacity to:
(i) Provide services utilizing a
recognized intervention protocol based on nationally accepted treatment
principles;
(ii) Employ required practitioners and
coordinate service provision among rendering practitioners; and
(iii) Provide the full range of services
included in the scope of partial hospitalization established in this
subsection.
(3) The extent and type of a screening
shall depend upon the nature of the problem of the individual seeking or being
referred for services.
(4) 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.
(5) The department shall not reimburse
for a service billed by or on behalf of an entity or individual who is not a
billing provider.
(6) A behavioral health service shall be:
(a) Stated in the recipient’s plan of
care; and
(b) Provided in accordance with the recipient’s
plan of care.
(7)(a) An outpatient hospital shall
establish a plan of care for each recipient receiving behavioral health
services from the outpatient hospital.
(b)1. For a recipient receiving intensive outpatient
program services, the recipient’s plan of care shall be:
a. Reviewed every thirty (30) days; and
b. Updated every sixty (60) days or
earlier if clinically indicated.
2. For a recipient receiving behavioral
health services other than intensive outpatient program services, the
recipient’s plan of care shall be reviewed and updated every six (6) months or
earlier if clinically indicated.
Section 6. Additional Behavioral Health Service
Limits and Non-covered Behavioral Health 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) For a recipient who is receiving
assertive community treatment, the following shall not be billed or reimbursed
for the same period of time in which the recipient receives assertive community
treatment:
(a) An assessment;
(b) Case management;
(c) Individual outpatient therapy;
(d) Group outpatient therapy;
(e) Peer support services; or
(f) Mobile crisis services.
(3) The department shall not reimburse
for both a screening and an SBIRT provided to a recipient on the same date of
service.
(4) 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) Psychiatric or psychological testing
for another agency, including a court or school, that does not result in the
individual receiving psychiatric intervention or behavioral health therapy from
the outpatient hospital;
(c) A consultation or educational service
provided to a recipient or to others;
(d) 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 Section 1(17) of
this administrative regulation;
(e) Travel time;
(f) A field trip;
(g) A recreational activity;
(h) A social activity; or
(i) A physical exercise activity group.
(5)(a) A consultation by one (1) provider
or professional with another shall not be covered under this administrative
regulation except as established in Section 5(2)(l)1 of this administrative regulation.
(b) A third party contract shall not be
covered under this administrative regulation.
(6) 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.
(7)(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;
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; or
4. A service planning activity in which
the corresponding current procedural terminology code establishes that the
recipient is not present.
(b) A behavioral health service that does
not meet the requirement in paragraph (a) of this subsection shall not be
covered.
Section 7. 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 service is covered during the
same time period.
(2) For example, if a recipient is
receiving speech-language pathology services from a speech-language pathologist
enrolled with the Medicaid Program, the department shall not reimburse for
speech-language pathology services provided to the same recipient during the
same time period via the outpatient hospital services program.
Section 8. General Records Maintenance,
Protection, and Security. (1)(a) A provider shall maintain a current health
record for each recipient.
(b)1. 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.
2. The individual who provided the
service shall date and sign the health record within forty-eight (48) hours of the
date that the individual provided the service.
(2)(a) Except as established in paragraph (b) or
(c) of this subsection, an outpatient hospital 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.
(3)(a) A provider 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, an outpatient
hospital 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 managed care organization.
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.
(4)(a) If an outpatient hospital’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 outpatient hospital shall:
1. Remain the property of the outpatient
hospital; and
2. Be subject to the retention
requirements established in this section.
(b) An outpatient hospital shall have a
written plan addressing how to maintain health records in the event of death of
an owner or deaths of owners.
Section 9. Additional Requirements
Regarding Behavioral Health Services Health Records. (1) The requirements
established in this section shall apply to a health record regarding a
behavioral health service.
(2) A health record regarding a recipient who
received a behavioral health service 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 outpatient hospital in order to
comply with the requirements of:
(i) This administrative regulation;
(ii) The outpatient hospital’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.
(3) 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.
(4)(a) An outpatient hospital’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.
(5) 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.
(6) 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.
(7)(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.
(8)(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.
(9) 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.
(10)(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 outpatient hospital 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, or an acute care
hospital for care or treatment, the transferring outpatient hospital 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.
Section 10. Medicaid Program
Participation Compliance. (1) A provider 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 provider receives any
duplicate payment or overpayment from the department or managed care
organization, regardless of reason, the provider 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 or a managed
care organization makes payment for a covered service and the outpatient
hospital 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 outpatient hospital.
(b)1. An outpatient hospital 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. Outpatient hospital 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. Outpatient hospital shall not bill the
department or managed care organization for the service; and
b. Department or managed care
organization shall not:
(i) Be liable for any part of the payment
associated with the service; and
(ii) Make any payment to the outpatient
hospital regarding the service.
(c) Except as established in paragraph
(b) of this subsection or except for a cost sharing obligation owed by a
recipient, a provider shall not bill a recipient for any part of a service provided
to the recipient.
(4)(a) An outpatient hospital shall
attest by the outpatient hospital’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 an outpatient hospital receives
a request from the:
a. Department to provide a claim, related
information, related documentation, or record for auditing purposes, the outpatient
hospital 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 outpatient hospital 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 an outpatient hospital 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. An outpatient hospital may request a
longer timeframe to provide information to the department or a managed care
organization if the outpatient hospital 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 an outpatient
hospital shall result in the suspension or termination of the outpatient
hospital from Medicaid Program participation.
Section 11. Third Party Liability. A provider
shall comply with KRS 205.622.
Section 12. 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 provider 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
provider'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 provider's electronic signature
policy;
2. The signed consent form; and
3. The original filed signature.
Section 13. Auditing Authority. The department or the managed care organization
in which an enrollee is enrolled shall have the authority to audit any:
(1) Claim;
(2) Health record;
or
(3) Documentation
associated with any claim or health record.
Section 14. Federal Approval and Federal
Financial Participation. (1) The department’s coverage 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 coverage of services provided by
a licensed clinical alcohol and drug counselor or licensed clinical alcohol and
drug counselor associate shall be contingent and effective upon approval by the
Centers for Medicare and Medicaid Services.
Section 15. Appeal Rights. (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. (Recodified from 904 KAR 1:014, 5-6-1986; Am.
17 Ky.R. 557; eff. 10-14-1990; 33 Ky.R. 578; 1550; eff. 1-5-2007; 37 Ky.R. 984;
eff. 11-05-2010; Recodified from 907 KAR 1:014, eff. 5-3-2011; TAm eff. 7-16-2013;
40 Ky.R. 2009; 2554; 2771; eff. 7-7-2014; 41 Ky.R. 2428; 42 Ky.R. 406; 741;
eff. 10-2-2015.)
