907 KAR 17:015. Managed care organization requirements and policies relating to providers.

 

      RELATES TO: 194A.025(3), 42 U.S.C. 1396n(c), 42 C.F.R. 438

      STATUTORY AUTHORITY: KRS 194A.010(1), 194A.025(3), 194A.030(2), 194A.050(1), 205.520(3), 205.560, 42 U.S.C. 1396n(b), 42 C.F.R. Part 438

      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(3) authorizes the cabinet, by administrative regulation, to comply with a requirement that may be imposed or opportunity presented by federal law to qualify for federal Medicaid funds. 42 U.S.C. 1396n(b) and 42 C.F.R. Part 438 establish requirements relating to managed care. This administrative regulation establishes the managed care organization requirements and policies relating to providers.

 

      Section 1. Provider Network. (1) An MCO shall:

      (a) Enroll providers of sufficient types, numbers, and specialties in its network to satisfy the:

      1. Access and capacity requirements established in Section 2 of this administrative regulation; and

      2. Quality requirements established in 907 KAR 17:025, Section 5;

      (b) Attempt to enroll the following providers in its network:

      1. A teaching hospital;

      2. A rural health clinic;

      3. The Kentucky Commission for Children with Special Health Care Needs;

      4. A local health department; and

      5. A community mental health center;

      (c) Demonstrate to the department the extent to which it has enrolled providers in its network who have traditionally provided services to Medicaid recipients;

      (d) Have at least one (1) FQHC in a region where the MCO operates in accordance with 907 KAR 17:020, if there is an FQHC that is licensed to provide services in the region; and

      (e) Exclude, terminate, or suspend from its network a provider or subcontractor who engages in an activity that results in suspension, termination, or exclusion from a Medicare or Medicaid program.

      (2) The length of an exclusion, termination, or suspension referenced in subsection (1)(e) of this section shall equal the length of the exclusion, termination, or suspension imposed by a Medicare or Medicaid program.

      (3) If an MCO is unable to enroll a provider specified in subsection (1)(b) or (c) of this section, the MCO shall submit to the department for approval, documentation which supports the MCO’s conclusion that adequate services and service sites as required in Section 2 of this administrative regulation shall be provided without enrolling the specified provider.

      (4) If an MCO or the department determines that the MCO’s provider network is inadequate to comply with the access standards established in Section 2 of this administrative regulation for ninety-five (95) percent of the MCO’s enrollees, the MCO shall:

      (a) Notify the department; and

      (b) Submit a corrective action plan to the department.

      (5) A corrective action plan referenced in subsection (4)(b) of this section shall:

      (a) Describe the deficiency in detail; and

      (b) Identify a specific action to be taken by the MCO to correct the deficiency, including a time frame.

 

      Section 2. Provider Access Requirements. (1) The access standards requirements established in 42 C.F.R. 438.206 through 438.210 shall apply to an MCO.

      (2) An MCO shall make available and accessible to an enrollee:

      (a) Facilities, service locations, and personnel sufficient to provide covered services consistent with the requirements specified in this section;

      (b) Emergency medical services twenty-four (24) hours a day, seven (7) days a week; and

      (c) Urgent care services within 48 hours of request.

      (3)(a) An MCO’s primary care provider delivery site shall be within:

      1. Thirty (30) miles or thirty (30) minutes from an enrollee’s residence in an urban area; or

      2. Forty-five (45) miles or forty-five (45) minutes from an enrollee’s residence in a non-urban area.

      (b) An MCO’s primary care provider shall not have an enrollee to primary care provider ratio greater than 1,500:1.

      (c) An appointment wait time at an MCO’s primary care delivery site shall not exceed:

      1. Thirty (30) days from the date of an enrollee’s request for a routine or preventive service; or

      2. Forty-eight (48) hours from an enrollee’s request for urgent care.

      (4)(a) An appointment wait time for a specialist, except for a specialist providing a behavioral health service as provided in paragraph (b) of this subsection, shall not exceed:

      1. Thirty (30) days from the referral for routine care; or

      2. Forty-eight (48) hours from the referral for urgent care.

      (b)1. A behavioral health service requiring crisis stabilization shall be provided within twenty-four (24) hours of the referral.

      2. Behavioral health urgent care shall be provided within forty-eight (48) hours of the referral.

      3. A behavioral health service appointment following a discharge from an acute psychiatric hospital shall occur within fourteen (14) days of discharge.

      4. A behavioral health service appointment not included in subparagraph 1, 2, or 3 of this paragraph shall occur within sixty (60) days of the referral.

      (5) An MCO shall have:

      (a) Specialists available for the subpopulations designated in 907 KAR 17:010, Section 17; and

      (b) Sufficient pediatric specialists to meet the needs of enrollees who are less than twenty-one (21) years of age.

      (6) An emergency service shall be provided at a health care facility most suitable for the type of injury, illness, or condition, whether or not the facility is in the MCO network.

      (7)(a) A hospital located in Region 1, Region 2, Region 4, Region 5, Region 6, Region 7, or Region 8 shall be within:

      1. Thirty (30) miles or thirty (30) minutes from an enrollee’s residence in an urban area; or

      2. Sixty (60) minutes of an enrollee’s residence in a non-urban area.

      (b) A hospital located in Region 3 shall be within:

      1. Thirty (30) miles or thirty (30) minutes of an enrollee’s residence in an urban area; or

      2. Sixty (60) miles or sixty (60) minutes of an enrollee’s residence in a non-urban area.

      (8) A behavioral or physical rehabilitation service in:

      (a) Region 1, Region 2, Region 4, Region 5, Region 6, Region 7, or Region 8 shall be within sixty (60) minutes of an enrollee’s residence; or

      (b) Region 3 shall be within sixty (60) miles or sixty (60) minutes of an enrollee’s residence.

      (9)(a) A dental service in:

      1. Region 1, Region 2, Region 4, Region 5, Region 6, Region 7, or Region 8 shall be within sixty (60) minutes of an enrollee’s residence; or

      2. Region 3 shall be within sixty (60) miles or sixty (60) minutes of an enrollee’s residence.

      (b) A dental appointment wait time shall not exceed:

      1. Three (3) weeks for a regular appointment; or

      2. Forty-eight (48) hours for urgent care.

      (10)(a) A general vision, laboratory, or radiological service in:

      1. Region 1, Region 2, Region 4, Region 5, Region 6, Region 7, or Region 8 shall be within sixty (60) minutes of an enrollee’s residence; or

      2. Region 3 shall be within sixty (60) miles or sixty (60) minutes of an enrollee’s residence.

      (b) A general vision, laboratory, or radiological appointment wait time shall not exceed:

      1. Three (3) weeks for a regular appointment; or

      2. Forty-eight (48) hours for urgent care.

      (11)(a) A pharmacy service in:

      1. Region 1, Region 2, Region 4, Region 5, Region 6, Region 7, or Region 8 shall be within sixty (60) minutes of an enrollee’s residence; or

      2. Region 3 shall be within sixty (60) miles or sixty (60) minutes of an enrollee’s residence.

      (b) A pharmacy delivery site, except for a mail-order pharmacy, shall not be further than fifty (50) miles from an enrollee’s residence.

      (c) Transport time or distance threshold shall not apply to a mail-order pharmacy except that it shall:

      1. Be physically located within the United States of America; and

      2. Provide delivery to the enrollee’s residence.

      (12)(a) Prior authorization shall not be required for a physical emergency service or a behavioral health emergency service.

      (b) In order to be covered, an emergency service shall be:

      1. Medically necessary;

      2. Authorized after being provided if the service was not prior authorized; and

      3. Covered in accordance with 907 KAR 17:020.

 

      Section 3. MCO Provider Enrollment. (1) A provider enrolled with an MCO shall:

      (a) Be credentialed by the MCO in accordance with the standards established in Section 4 of this administrative regulation; and

      (b) Be eligible to enroll with the Kentucky Medicaid Program in accordance with 907 KAR 1:672.

      (2) An MCO shall:

      (a) Not enroll a provider in its network if:

      1. The provider has an active sanction imposed by the Centers for Medicare and Medicaid Services or a state Medicaid agency;

      2. A required provider license or a certification is not current;

      3. Based on information or records available to the MCO:

      a. The provider owes money to the Kentucky Medicaid program; or

      b. The Kentucky Office of the Attorney General has an active fraud investigation of the provider; or

      4. The provider is not credentialed;

      (b) Have and maintain documentation regarding a provider’s qualifications; and

      (c) Make the documentation referenced in paragraph (b) of this subsection available for review by the department.

      (3)(a) A provider shall not be required to participate in Kentucky Medicaid fee-for-service to enroll with an MCO.

      (b) If a provider is not a participant in Kentucky Medicaid fee-for-service, the provider shall obtain a Medicaid provider number from the department in accordance with 907 KAR 1:672.

 

      Section 4. Provider Credentialing and Recredentialing. (1) An MCO shall:

      (a) Have policies and procedures that comply with 907 KAR 1:672; KRS 205.560; and 42 C.F.R. 455 Subpart E, 455.400 to 455.470, regarding the credentialing and recredentialing of a provider;

      (b) Have a process for verifying a provider’s credentials and malpractice insurance that shall include:

      1. Written policies and procedures for credentialing and recredentialing of a provider;

      2. A governing body, or a group or individual to whom the governing body has formally delegated the credentialing function; and

      3. A review of the credentialing policies and procedures by the governing body or its delegate;

      (c) Have a credentialing committee that makes recommendations regarding credentialing;

      (d) If a provider requires a review by the credentialing committee, based on the MCO’s quality criteria, notify the department of the facts and outcomes of the review;

      (e) Have written policies and procedures for:

      1. Excluding, terminating, or suspending a provider; and

      2. Reporting a quality deficiency that results in an exclusion, suspension, or termination of a provider;

      (f) Document its monitoring of a provider;

      (g) Verify a provider’s qualifications through a primary source that includes:

      1. A current valid license or certificate to practice in the Commonwealth of Kentucky;

      2. A Drug Enforcement Administration certificate and number, if applicable;

      3. If a provider is not board certified, proof of graduation from a medical school and completion of a residency program;

      4. Proof of completion of an accredited nursing, dental, physician assistant, or vision program, if applicable;

      5. If a provider states on an application that the provider is board certified in a specialty, a professional board certification;

      6. A previous five (5) year work history;

      7. A professional liability claims history;

      8. If a provider requires access to a hospital to practice, proof that the provider has clinical privileges and is in good standing at the hospital designated by the provider as the primary admitting hospital;

      9. Malpractice insurance;

      10. Documentation, if applicable, of a:

      a. Revocation, suspension, or probation of a state license or Drug Enforcement Agency certificate and number;

      b. Curtailment or suspension of a medical staff privilege;

      c. Sanction or penalty imposed by the United States Department of Health and Human Services or a state Medicaid agency; or

      d. Censure by a state or county professional association; and

      11. The most recent provider information available from the National Practitioner Data Bank;

      (h) Obtain access to the National Practitioner Data Bank as part of its credentialing process;

      (i) Have:

      1. A process to recredential a provider at least once every three (3) years that shall be in accordance with subsection (3) of this section; and

      2. Procedures for monitoring a provider sanction, a complaint, or a quality issue between a recredentialing cycle;

      (j) Have or obtain National Committee for Quality Assurance (NCQA) accreditation for its Medicaid product line:

      1. By November 1, 2015, for an MCO that began participating November 1, 2011;

      2. By January 1, 2017, for an MCO that began participating January 1, 2013; or

      3. Within four (4) years of the date an MCO begins participation, for an MCO that did not begin participating by the effective date of this administrative regulation; and

      (k) Continuously maintain NCQA accreditation for its Medicaid product line after obtaining the accreditation.

      (2) If an MCO subcontracts a credentialing or recredentialing function, the MCO and the subcontractor shall have written policies and procedures for credentialing and recredentialing.

      (3) A provider shall complete a credentialing application, in accordance with 907 KAR 1:672, that includes a statement by the provider regarding:

      (a) The provider’s ability to perform essential functions of a position, with or without accommodation;

      (b) The provider’s lack of current illegal drug use;

      (c) The provider’s history of a:

      1. Loss of license or a felony conviction;

      2. Loss or limitation of a privilege; or

      3. Disciplinary action;

      (d) A sanction, suspension, or termination by the United States Department of Health and Human Services or a state Medicaid agency;

      (e) Clinical privileges and standing at a hospital designated as the primary admitting hospital of the provider;

      (f) Malpractice insurance maintained by the provider; and

      (g) The correctness and completeness of the application.

      (4) The department shall be responsible for credentialing and recredentialing a hospital-based provider.

 

      Section 5. Provider Services. (1) An MCO shall have a provider services function responsible for:

      (a) Enrolling, credentialing, recredentialing, and evaluating a provider;

      (b) Assisting a provider with an inquiry regarding enrollee status, prior authorization, referral, claim submission, or payment;

      (c) Informing a provider of the provider’s rights and responsibilities;

      (d) Handling, recording, and tracking a provider grievance and appeal;

      (e) Developing, distributing, and maintaining a provider manual;

      (f) Provider orientation and training, including:

      1. Medicaid covered services;

      2. EPSDT coverage;

      3. Medicaid policies and procedures;

      4. MCO policies and procedures; and

      5. Fraud, waste, and abuse;

      (g) Assisting in coordinating care for a child or adult with a complex or chronic condition;

      (h) Assisting a provider with enrolling in the Vaccines for Children Program in accordance with 907 KAR 1:680; and

      (i) Providing technical support to a provider regarding the provision of a service.

      (2) An MCO’s provider services staff shall:

      (a) Be available at a minimum Monday through Friday from 8:00 a.m. to 6:00 p.m. Eastern Time; and

      (b) Operate a provider call center.

 

      Section 6. Provider Manual. (1) An MCO shall provide a provider manual to a provider within five (5) working days of enrollment with the MCO.

      (2) Prior to distributing a provider manual or update to a provider manual, an MCO shall procure the department’s approval of the provider manual or provider manual update.

      (3) The provider manual shall be available in hard copy and on the MCO’s Web site.

 

      Section 7. Provider Orientation and Education. An MCO shall:

      (1) Conduct an initial orientation for a provider within thirty (30) days of enrollment with the MCO to include:

      (a) Medicaid coverage policies and procedures;

      (b) Reporting fraud and abuse;

      (c) Medicaid eligibility groups;

      (d) The standards for preventive health services;

      (e) The special needs of enrollees;

      (f) Advance medical directives;

      (g) EPSDT services;

      (h) Claims submission;

      (i) Care management or disease management programs available to enrollees;

      (j) Cultural sensitivity;

      (k) The needs of enrollees with mental, developmental, or physical disabilities;

      (l) The reporting of communicable diseases;

      (m) The MCO’s QAPI program as referenced in 907 KAR 17:025, Section 5;

      (n) Medical records;

      (o) The external quality review organization; and

      (p) The rights and responsibilities of enrollees and providers; and

      (2) Ensure that a provider:

      (a) Is informed of an update on a federal, state, or contractual requirement;

      (b) Receives education on a finding from its QAPI program if deemed necessary by the MCO or department; and

      (c) Makes available to the department training attendance rosters that shall be dated and signed by the attendees.

 

      Section 8. Primary Care Provider Responsibilities. (1) A PCP shall:

      (a) Maintain:

      1. Continuity of an enrollee’s health care;

      2. A current medical record for an enrollee in accordance with Section 12 of this administrative regulation; and

      3. Formalized relationships with other PCPs to refer enrollees for after-hours care, during certain days, for certain services, or other reasons to extend their practice;

      (b) Refer an enrollee for specialty care or other medically necessary services:

      1. Within the MCO's network; or

      2. If the services are not available within the MCO's network, outside the MCO's network;

      (c) Discuss advance medical directives with an enrollee;

      (d) Provide primary and preventive care, including EPSDT services;

      (e) Refer an enrollee for a behavioral health service if clinically indicated; and

      (f) Have an after-hours phone arrangement that ensures that a PCP or a designated medical practitioner returns the call within thirty (30) minutes.

      (2) An MCO shall monitor a PCP to ensure compliance with the requirements established in this section.

 

      Section 9. Provider Discrimination. An MCO shall:

      (1) Comply with the anti-discrimination requirements established in:

      (a) 42 U.S.C. 1396u-2(b)(7);

      (b) 42 C.F.R. 438.12; and

      (c) KRS 304.17A-270; and

      (2) Provide written notice to a provider denied participation in the MCO’s network stating the reason for the denial.

 

      Section 10. Release for Ethical Reasons. An MCO shall:

      (1) Not require a provider to perform a treatment or procedure that is contrary to the provider’s conscience, religious beliefs, or ethical principles in accordance with 42 C.F.R. 438.102;

      (2) Not prohibit or restrict a provider from advising an enrollee about health status, medical care, or a treatment:

      (a) Whether or not coverage is provided by the MCO; and

      (b) If the provider is acting within the lawful scope of practice; and

      (3) Have a referral process in place if a provider declines to perform a service because of an ethical reason.

 

      Section 11. Provider Grievances and Appeals. (1) An MCO shall have written policies and procedures for the filing of a provider grievance or appeal.

      (2) A provider shall have the right to file:

      (a) A grievance with an MCO; or

      (b) An appeal with an MCO regarding:

      1. A provider payment issue; or

      2. A contractual issue.

      (3)(a) A provider grievance or appeal shall be resolved within thirty (30) calendar days.

      (b)1. If a grievance or appeal is not resolved within thirty (30) days, an MCO shall request a fourteen (14) day extension from the provider.

      2. The provider shall approve the extension request from the MCO.

      (c) If a provider requests an extension, the MCO shall approve the extension.

 

      Section 12. Medical Records. (1) An MCO shall:

      (a) Require a provider to maintain an enrollee medical record on paper or in an electronic format; and

      (b) Have a process to systematically review provider medical records to ensure compliance with the medical records standards established in this section.

      (2) An enrollee medical record shall:

      (a) Be legible, current, detailed, organized, and signed by the service provider;

      (b)1. Be kept for at least five (5) years from the date of service unless a federal statute or regulation requires a longer retention period; and

      2. If a federal statute or regulation requires a retention period longer than five (5) years, be kept for at least as long as the federally-required retention period;

      (c) Include the following minimal detail for an individual clinical encounter:

      1. The history and physical examination for the presenting complaint;

      2. A psychological or social factor affecting the patient’s physical or behavioral health;

      3. An unresolved problem, referral, or result from a diagnostic test; and

      4. The plan of treatment including:

      a. Medication history, medications prescribed, including the strength, amount, and directions for use and refills;

      b. Therapy or other prescribed regimen; and

      c. Follow-up plans, including consultation, referrals, and return appointment.

      (3) A medical chart organization and documentation shall, at a minimum, contain the following:

      (a) Enrollee identification information on each page;

      (b) Enrollee date of birth, age, gender, marital status, race or ethnicity, mailing address, home and work addresses, and telephone numbers (if applicable), employer (if applicable), school (if applicable), name and telephone number of an emergency contact, consent form, language spoken, and guardianship information (if applicable);

      (c) Date of data entry and of the encounter;

      (d) Provider’s name;

      (e) Any known allergies or adverse reactions of the enrollee;

      (f) Enrollee’s past medical history;

      (g) Identification of any current problem;

      (h) If a consultation, laboratory, or radiology report is filed in the medical record, the ordering provider’s initials or other documentation indicating review;

      (i) Documentation of immunizations;

      (j) Identification and history of nicotine, alcohol use, or substance abuse;

      (k) Documentation of notification of reportable diseases and conditions to the local health department serving the jurisdiction in which the enrollee resides or to the Department for Public Health pursuant to 902 KAR 2:020;

      (l) Follow-up visits provided secondary to reports of emergency room care;

      (m) Hospital discharge summaries;

      (n) Advance medical directives for adults; and

      (o) All written denials of service and the reason for each denial.

 

      Section 13. Provider Surveys. (1) An MCO shall:

      (a) Conduct an annual survey of provider satisfaction of the quality and accessibility to a service provided by an MCO;

      (b) Annually assess the need for conducting other surveys to support quality and performance improvement initiatives;

      (c) Submit to the department for approval the survey tool used to conduct the survey referenced in paragraph (a) of this subsection; and

      (d) Provide to the department:

      1. A copy of the results of the provider survey referenced in paragraph (a) of this subsection;

      2. A description of a methodology to be used to conduct surveys;

      3. The number and percentage of providers surveyed;

      4. Provider survey response rates;

      5. Provider survey findings; and

      6. Interventions conducted or planned by the MCO related to activities in this section.

      (2) The department shall:

      (a) Approve provider survey instruments prior to implementation; and

      (b) Approve or disapprove an MCO’s provider survey tool within fifteen (15) days of receipt of the survey tool.

 

      Section 14. Cost Reporting Information. The department shall provide to the MCO the calculation of Medicaid allowable costs as used in the Medicaid Program.

 

      Section 15. Centers for Medicare and Medicaid Services Approval and Federal Financial Participation. A policy established in this administrative regulation shall be null and void if the Centers for Medicare and Medicaid Services:

      (1) Denies or does not provide federal financial participation for the policy; or

      (2) Disapproves the policy. (39 Ky.R. 1831; Am. 2350; eff. 6-27-2013.)