907 KAR 10:014. Outpatient hospital service coverage provisions and requirements

Link to law: http://www.lrc.ky.gov/kar/907/010/014.htm
Published: 2015

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      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.)