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) “Certified alcohol and drug counselor” is defined by KRS 309.080(2).

      (3) “Certified social worker” means an individual who meets the requirements established in KRS 335.080.

      (4) "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.

      (5) "Department" means the Department for Medicaid Services or its designee.

      (6) "Emergency" means that a condition or situation requires an emergency service pursuant to 42 C.F.R. 447.53.

      (7) "Emergency medical condition" is defined by 42 U.S.C. 1395dd(e)(1).

      (8) "Enrollee" means a recipient who is enrolled with a managed care organization.

      (9) "Federal financial participation" is defined by 42 C.F.R. 400.203.

      (10) “Individualized education program” is defined by 34 C.F.R. 300.320.

      (11) "Licensed assistant behavior analyst” is defined by KRS 319C.010(7).

      (12) “Licensed behavior analyst” is defined by KRS 319C.010(6).

      (13) “Licensed clinical social worker" means an individual who meets the licensed clinical social worker requirements established in KRS 335.100.

      (14) “Licensed marriage and family therapist” is defined by KRS 335.300(2).

      (15) “Licensed professional art therapist” is defined by KRS 309.130(2).

      (16) “Licensed professional art therapist associate” is defined by KRS 309.130(3).

      (17) “Licensed professional clinical counselor” is defined by KRS 335.500(3).

      (18) “Licensed professional counselor associate” is defined by KRS 335.500(4).

      (19) “Licensed psychological associate” means an individual who:

      (a)1. Currently possesses a licensed psychological associate license in accordance with KRS 319.010(6); and

      2. Meets the licensed psychological associate requirements established in 201 KAR Chapter 26; or

      (b) Is a certified psychologist.

      (20) “Licensed psychological practitioner” means an individual who:

      (a) Meets the requirements established in KRS 319.053; or

      (b) Is a certified psychologist with autonomous functioning.

      (21) “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.

      (22) "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.

      (23) "Medical necessity" or "medically necessary" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

      (24) "Nonemergency" means that a condition or situation does not require an emergency service pursuant to 42 C.F.R. 447.53.

      (25) "Provider" is defined by KRS 205.8451(7).

      (26) "Recipient" is defined by KRS 205.8451(9).

      (27) "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. 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) The prior authorization requirements established in subsection (1) of this section shall not apply to:

      (a) An emergency service;

      (b) A radiology procedure if the recipient has a cancer or transplant diagnosis code; or

      (c) A service provided to a recipient in an observation bed.

      (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;

      (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. 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:

      (a) Intensive outpatient program services;

      (b) Partial hospitalization;

      (c) Individual outpatient therapy; or

      (d) Group outpatient therapy.

      (2)(a) Intensive outpatient program services shall be provided by a team:

      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 licensed psychological associate working under the supervision of a licensed psychologist;

      10. A licensed professional counselor associate working under the supervision of a licensed professional clinical counselor;

      11. A certified social worker working under the supervision of a licensed clinical social worker;

      12. A marriage and family therapy associate working under the supervision of a licensed marriage and family therapist;

      13. A physician assistant working under the supervision of a physician;

      14. A licensed professional art therapist;

      15. A licensed professional art therapist associate working under the supervision of a licensed professional art therapist; or

      16. A certified alcohol and drug counselor.

      (b) Intensive outpatient program services shall:

      1. Be an alternative to or transition from inpatient hospitalization or partial hospitalization for a mental health or substance use disorder;

      2. 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;

      3. Be provided at least three (3) hours per day at least three (3) days per week; and

      4. Include:

      a. Individual outpatient therapy, group outpatient therapy, or family outpatient therapy unless contraindicated;

      b. Crisis intervention; or

      c. Psycho-education.

      (c) During psycho-education the recipient or recipient’s family member shall be:

      1. 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

      2. Taught how to cope with the recipient’s diagnosis or condition in a successful manner.

      (d) An intensive outpatient program services treatment plan shall:

      1. Be individualized; and

      2. Focus on stabilization and transition to a lesser level of care.

      (e) To provide intensive outpatient program services, an outpatient hospital shall have:

      1. Access to a board-certified or board-eligible psychiatrist for consultation;

      2. Access to a psychiatrist, other physician, or advanced practiced registered nurse for medication prescribing and monitoring;

      3. Adequate staffing to ensure a minimum recipient-to-staff ratio of ten (10) recipients to one (1) staff person;

      4. The capacity to provide services utilizing a recognized intervention protocol based on nationally accepted treatment principles;

      5. 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;

      6. The capacity to provide the full range of intensive outpatient program services as stated in this paragraph;

      7. Demonstrated experience in serving individuals with behavioral health disorders;

      8. The administrative capacity to ensure quality of services;

      9. A financial management system that provides documentation of services and costs; and

      10. The capacity to document and maintain individual case records.

      (3)(a) Partial hospitalization shall be 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 licensed psychological associate working under the supervision of a licensed psychologist;

      10. A licensed professional counselor associate working under the supervision of a licensed professional clinical counselor;

      11. A certified social worker working under the supervision of a licensed clinical social worker;

      12. A marriage and family therapy associate working under the supervision of a licensed marriage and family therapist;

      13. A physician assistant working under the supervision of a physician;

      14. A licensed professional art therapist;

      15. A licensed professional art therapist associate working under the supervision of a licensed professional art therapist; or

      16. A certified alcohol and drug counselor.

      (b) 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.

      (c) Partial hospitalization may be provided to an adult or a child.

      (d) Admission criteria for partial hospitalization shall be based on an inability to adequately treat the recipient through community-based therapies or intensive outpatient services.

      (e) A partial hospitalization program shall consist of individual outpatient therapy, group outpatient therapy, family outpatient therapy, or medication management.

      (f)1. The department shall not reimburse for educational, vocational, or job training services provided as part of partial hospitalization.

      2. 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.

      3. The department shall not reimburse for services identified in a Medicaid-eligible child’s individualized education program.

      (g) Partial hospitalization shall typically be:

      1. Provided for at least four (4) hours per day; and

      2. Focused on one (1) primary presenting problem (i.e. substance use, sexual reactivity, or another problem).

      (h) An outpatient hospital’s partial hospitalization program shall:

      1. Include the following personnel for the purpose of providing medical care if necessary:

      a. An advanced practice registered nurse;

      b. A physician assistant or physician available on site; and

      c. A board-certified or board-eligible psychiatrist available for consultation; and

      2. Have the capacity to:

      a. Provide services utilizing a recognized intervention protocol based on nationally accepted treatment principles;

      b. Employ required practitioners and coordinate service provision among rendering practitioners; and

      c. Provide the full range of services included in the scope of partial hospitalization established in this subsection.

      (4)(a) Individual outpatient therapy shall be 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 licensed psychological associate working under the supervision of a licensed psychologist;

      10. A licensed professional counselor associate working under the supervision of a licensed professional clinical counselor;

      11. A certified social worker working under the supervision of a licensed clinical social worker;

      12. A marriage and family therapy associate working under the supervision of a licensed marriage and family therapist;

      13. A physician assistant working under the supervision of a physician;

      14. A licensed professional art therapist;

      15. A licensed professional art therapist associate working under the supervision of a licensed professional art therapist;

      16. A licensed behavior analyst; or

      17. A licensed assistant behavior analyst working under the supervision of a licensed behavior analyst.

      (b) Individual outpatient therapy shall:

      1. Be provided to promote the:

      a. Health and wellbeing of the individual; or

      b. Recovery from a substance related disorder;

      2. Consist of:

      a. A face-to-face, one-on-one encounter between the provider and recipient; and

      b. A behavioral health therapeutic intervention provided in accordance with the recipient’s identified treatment plan;

      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.

      (5)(a) Group outpatient therapy 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 licensed psychological associate working under the supervision of a licensed psychologist;

      10. A licensed professional counselor associate working under the supervision of a licensed professional clinical counselor;

      11. A certified social worker working under the supervision of a licensed clinical social worker;

      12. A marriage and family therapy associate working under the supervision of a licensed marriage and family therapist;

      13. A physician assistant working under the supervision of a physician;

      14. A licensed professional art therapist;

      15. A licensed professional art therapist associate working under the supervision of a licensed professional art therapist;

      16. A licensed behavior analyst; or

      17. A licensed assistant behavior analyst.

      (b)1. Group outpatient therapy shall:

      a. Be provided to promote the:

      (i) Health and wellbeing of the individual; or

      (ii) Recovery from a substance use disorder, mental health disorder, or co-occurring disorders;

      b. Consist of a face-to-face behavioral health therapeutic intervention provided in accordance with the recipient’s identified treatment plan;

      c. Be provided to a recipient in a group setting:

      (i) Of nonrelated individuals; and

      (ii) Not to exceed twelve (12) individuals in size;

      d. Center on goals including building and maintaining healthy relationships, personal goals setting, and the exercise of personal judgment;

      e. Not include physical exercise, a recreational activity, an educational activity, or a social activity; and

      f. Not exceed three (3) hours per day.

      2. The group shall have a:

      a. Deliberate focus; and

      b. Defined course of treatment.

      3. The subject of a group receiving group outpatient therapy shall be related to each recipient participating in the group.

      4. The provider shall keep individual notes regarding each recipient within the group and within each recipient’s health record.

 

      Section 6. 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 7. 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 on the date that the individual provided the service.

      (2)(a) Except as established in paragraph (b) of this subsection, a provider shall maintain a health record regarding a recipient for at least five (5) years from the date of the service or until any audit dispute or issue is resolved beyond five (5) years.

      (b) 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 provider shall comply with 45 C.F.R. Part 164.

 

      Section 8. 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, regardless of reason, the provider shall return the payment to the department.

      (b) Failure to return a payment to the department 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.

 

      Section 9. Third Party Liability. A provider shall comply with KRS 205.622.

 

      Section 10. 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 11. Auditing Authority. The department shall have the authority to audit any claim, medical record, or documentation associated with any claim or medical record.

 

      Section 12. Federal Approval and Federal Financial Participation. The department’s coverage of services pursuant to this administrative regulation shall be contingent upon:

      (1) Receipt of federal financial participation for the coverage; and

      (2) Centers for Medicare and Medicaid Services’ approval for the coverage.

 

      Section 13. 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 7-16-2013; 40 Ky.R. 2009; 2554; 2771; eff. 7-7-2014.)