907 KAR 11:034. Early and periodic screening, diagnosis, and treatment services and early and periodic screening, diagnosis, and treatment special services.

 

      RELATES TO: KRS 205.520, 605.115, 42 C.F.R. 441.50-441.62, 42 U.S.C. 1396d

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services has responsibility to administer the Medicaid Program. KRS 205.520 authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed or opportunity presented by federal law for the provision of Medicaid to Kentucky's indigent citizenry. This administrative regulation establishes the provisions relating to the early and periodic screening, diagnosis and treatment service and early and periodic screening, diagnosis and treatment special services for which payment shall be made by the Medicaid Program on behalf of both categorically needy and medically needy children under age twenty-one (21).

 

      Section 1. Definition. (1) "By report" means a service or item for which a maximum allowance has not been established because the item is rarely billed to the Kentucky Medicaid Program or because the service is unusual, variable, or new.

      (2) "Department" means the Department for Medicaid Services or its designated agency.

      (3) "EPSDT" means early and periodic screening, diagnosis, and treatment.

      (4) "Periodicity" means the frequency with which an individual may be screened or rescreened.

      (5) "Recipient" means a Medicaid eligible child under the age of twenty-one (21), including the month in which the child becomes twenty-one (21).

      (6) "Screening" means the review of the health and health-related conditions of a recipient by a health care professional to determine if further diagnosis or treatment is needed.

      (7) "Service" means health care, treatment, a procedure, supply, item, or equipment.

 

      Section 2. Screening Provider Participation Requirements. A health care provider meeting the requirements established in this section shall be eligible to participate in the Medicaid Program as a screening provider:

      (1) A physician shall be licensed in the state of Kentucky;

      (2) An early and periodic screening clinic or other organization qualified to provide a screening service, including a local health department, shall be under the direction of a licensed physician, pediatric advanced registered nurse practitioner, or registered professional nurse currently licensed by the state of Kentucky who shall be responsible for assuring that the requirements of participation are met and that the procedure established by the Medicaid Program are carried out;

      (3) A screening clinic conducted under the direction of a registered professional nurse or an advanced registered nurse practitioner shall have a licensed physician acting as medical consultant; and

      (4) A screening examination or test performed by licensed professional staff, or supportive staff under the direct supervision of the licensed professional, shall be in accordance with the professional practice standards for the profession.

 

      Section 3. Screening. An EPSDT screening service shall be directed toward the early detection of a disease or abnormality. The service shall be appropriate for the age and health history of the recipient and shall include, as applicable:

      (1) An initial, periodic, or additional health assessment of a recipient provided in accordance with Sections 2 and 5 of this administrative regulation which includes the following:

      (a) Health and development history;

      (b) Unclothed physical examination;

      (c) Development assessment and mental health screening;

      (d) Assessment and provision of immunizations as appropriate for age and health history;

      (e) Assessment of nutritional status;

      (f) Vision testing;

      (g) Hearing testing;

      (h) Laboratory procedures appropriate for age and population groups, including lead screening and testing as appropriate;

      (i) Director referral for a dental service for diagnosis and treatment for a child two (2) years of age and over; or

      (j) Anticipatory guidance and health education;

      (2) A health assessment examination, or evaluation of a recipient by a licensed or certified health care professional acting within his scope of practice, at intervals other than those specified in Section 5 of this administrative regulation indicated by medical necessity, to determine the existence of a defect, physical or mental illness, or condition; or

      (3) Any other recipient encounter with a licensed or certified health care professional that results in the determination of the existence of a suspected:

      (a) Defect;

      (b) Illness;

      (c) Medical condition; or

      (d) A change or complication in a medical condition.

 

      Section 4. Immunizations. Each screening provider participating in accordance with Section 2(1), (2), and (3) of this administrative regulation shall be required to make available, at the time of screening, immunizations appropriate for age and health history of the recipient being screened.

 

      Section 5. Periodicity Schedule. The periodicity schedule, which is established in the manual incorporated by reference in this administrative regulation, shall define the age appropriate services and time frames for screenings. The periodicity schedule shall be recommended by the Department for Public Health and approved by the Department for Medicaid Services. An additional medical or dental assessment shall be provided if medically indicated. The periodicity schedule is incorporated by reference in the "Early and Periodic Screening, Diagnosis, and Treatment Services Manual".

 

      Section 6. Diagnosis and Treatment. If referral for additional service is indicated, further diagnosis and medical treatment services shall be covered if the service or diagnosis:

      (1) Is otherwise covered by the Medicaid Program; or

      (2)(a) Is not otherwise covered by the Medicaid Program; and

      (b) Meets the requirements for EPSDT special services as provided for in Section 7 of this administrative regulation.

 

      Section 7. EPSDT Special Services. EPSDT special services shall include other health care, diagnostic services, preventive services, rehabilitative services, treatment, or other measures described in 42 U.S.C. 1396d(a), that are not otherwise covered under the Kentucky Medicaid Program and that are medically necessary, as defined in Section 9 of this administrative regulation, to correct or ameliorate a defect, physical or mental illness, or condition of a recipient.

 

      Section 8. EPSDT Diagnostic and Treatment Provider and EPSDT Special Services Provider Participation Requirements. (1) An EPSDT diagnostic or treatment provider shall meet the requirements for participation in the Kentucky Medicaid Program as specified in Title 907 KAR for the particular diagnostic or treatment service rendered.

      (2) Except as otherwise specified in Title 907 KAR, a provider seeking to provide an EPSDT special service, as established in Section 7 of this administrative regulation, shall first contact the department in writing or by telephone to apply for enrollment to become an EPSDT special services provider. In order to be enrolled, the provider shall supply documentation or other evidence which establishes that all of the following conditions are met:

      (a) The provider shall:

      1. Be licensed, certified, or authorized state law to provide the service; and

      2. Not be suspended or otherwise disqualified.

      (b) If the provider is out of state, the provider shall meet comparable requirements in the state in which he does business.

 

      Section 9. Prior Authorization for EPSDT Diagnosis and Treatment Services and EPSDT Special Services. Except as otherwise provided for in this section or in 907 KAR Chapter 1 or 3, an EPSDT diagnosis or treatment service or an EPSDT special service which is not otherwise covered by the Kentucky Medicaid Program shall be covered subject to prior authorization if the requirements of subsections (1) and (2) of this section are met. The department shall review a request for a service to determine medical necessity without regard to whether the screen was performed by a Kentucky Medicaid provider or a non-Medicaid provider.

      (1) A request for prior authorization for an EPSDT service established in Section 6(1) or (2) of this administrative regulation shall state that the request is for an EPSDT service, and shall be accompanied by the following information:

      (a) The primary diagnosis and significant associated diagnoses;

      (b) Prognosis;

      (c) Date of onset of the illness or condition, and etiology if known;

      (d) Clinical significance or functional impairment caused by the illness or condition;

      (e) Specific types of services to be rendered by each discipline with physician's prescription if applicable;

      (f) Therapeutic goals to be achieved by each discipline and anticipated time for achievement of goals if applicable;

      (g) The extent to which health care services have been previously provided to address the defect, illness, or condition, and results demonstrated by prior care if applicable; and

      (h) Other documentation necessary to justify the medical necessity of the requested service.

(2) Except as otherwise provided for in 907 KAR Chapter 1 or 3, a request for approval of a service shall meet the standard of medical necessity for EPSDT if the following applicable criteria are met:

      (a) The service shall be to correct or ameliorate a defect, physical or mental illness, or condition;

      (b) The service to be provided shall be medical or remedial in nature;

      (c) The service shall be individualized and consistent with the recipient's medical needs;

      (d) The service shall not be requested primarily for the convenience of the beneficiary, family, physician or another provider of services;

      (e) The service shall not be unsafe or experimental;

      (f) If an alternative medically accepted mode of treatment exists, the service shall be the most cost-effective and appropriate service for the child;

      (g) A request for a diagnosis or treatment service in a community-based setting:

      1. May not be approved if the costs would exceed those of equivalent services at the appropriate institutional level of care; and

      2. Shall be individually assessed for appropriateness in keeping with the standards of medical necessity and the best interest of the child.

      (h) The service to be provided shall be:

      1. Generally recognized by the appropriate medical profession as an accepted modality of medical practice or treatment;

      2. Within the authorized scope of practice of the provider; and

      3. An appropriate mode of treatment for the medical condition of the recipient;

      (i) Scientific evidence, if available, shall be submitted consisting of:

      1. Well designed and well conducted investigations published in peer-review journals, demonstrating that the service is intended to produce measurable physiological outcomes;

      2. In the case of psychological or psychiatric services, measurable psychological outcomes, concerning the short and long-term effects of the proposed service on health outcomes;

      3. Opinions and evaluations published by national medical organizations, consensus panels and other technology evaluation bodies supporting provision of the benefit, shall also be considered if available;

      (j) The predicted beneficial outcome of the service shall outweigh potential harmful effects;

      (k) The services improve the overall health outcomes as much as, or more than, established alternatives.

      (3) If reimbursement is being sought on a "by report" basis, a description of the service, the proposed unit of service, and the requested dollar amount shall be included with the request for authorization.

      (4) A prior authorization request for an EPSDT service shall be reviewed for medical necessity without regard to the source of the referral to the service.

      (5) A school-based health service provided in accordance with 907 KAR 1:715 which is included in an authorized Individual Education Program (IEP) shall be considered to be medically necessary and shall not be subject to further Medicaid prior authorization requirements.

 

      Section 10. Appeal Rights. A recipient shall have the right of appeal as established in 907 KAR 1:563.

 

      Section 11. Incorporation by Reference. (1) "Early and Periodic Screening, Diagnosis, and Treatment Screening Services and Early and Periodic Screening, Diagnosis, and Treatment Special Services Manual", Department for Medicaid Services, May 1998 Edition, is incorporated by reference.

      (2) This material may be inspected, copied, or obtained at the Department for Medicaid Services, Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (Recodified from 904 KAR 1:034, 5-2-86; Am. 15 Ky.R. 2459; eff. 8-5-89; 23 Ky.R. 1796; 2747; eff. 12-18-96; 25 Ky.R. 930; 1380; eff. 12-16-98; Recodified from 907 KAR 1:034; eff. 5-3-2011.)