Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:102 - Advanced practice registered nurse services

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.520,
				205.622,
				205.8451,
				314.011,
				369.101
				- 369.120,
				42 C.F.R.
				400.203,
				431.17,
				438.2,
				455.410,
				45 C.F.R. Parts 160, 164,
				42
				U.S.C. 1320d -
				1320d-8,
				1396r-8
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 any requirement that may
				be imposed, or opportunity presented, by federal law to qualify for federal
				Medicaid funds. This administrative regulation establishes the provisions
				relating to advanced practice registered nurse services covered by the Medicaid
				Program.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
			 "APRN" is defined by
			 KRS
			 314.011(7).
(2) "Common practice" means an arrangement
			 through which a physician and an APRN jointly administer health care
			 services.
(3) "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.
(4)
			 "Department" means the Department for Medicaid Services or its designated
			 agent.
(5) "Enrollee" means a
			 recipient who is enrolled with a managed care organization.
(6) "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.
(7)
			 "Federal financial participation" is defined by
			 42 C.F.R.
			 400.203.
(8) "Global period" means the period of time
			 in which related preoperative, intraoperative, and postoperative services and
			 follow-up care for a surgical procedure are customarily provided.
(9) "Incidental" means that a medical
			 procedure is:
(a) Performed at the same time
			 as a primary procedure; and
(b)
			 Clinically integral to the performance of the primary procedure.
(10) "Integral" means that a
			 medical procedure represents a component of a more complex procedure performed
			 at the same time.
(11) "Locum
			 tenens APRN" means an APRN:
(a) Who
			 temporarily assumes responsibility for the professional practice of an APRN
			 participating in the Kentucky Medicaid Program; and
(b) Whose services are billed under the
			 Medicaid participating APRN's provider number.
(12) "Locum tenens physician" means a
			 substitute physician:
(a) Who temporarily
			 assumes responsibility for the professional practice of an APRN participating
			 in the Kentucky Medicaid Program; and
(b) Whose services are billed under the
			 Medicaid participating APRN's provider number.
(13) "Managed care organization" means an
			 entity for which the Department for Medicaid Services has contracted to serve
			 as a managed care organization as defined by
			 42
			 C.F.R. 438.2.
(14) "Medically necessary" or "medical
			 necessity" means that a covered benefit is determined to be needed in
			 accordance with
			 907
			 KAR 3:130.
(15) "Mutually exclusive" means that two (2)
			 procedures:
(a) Are not reasonably performed
			 in conjunction with one (1) another during the same patient encounter on the
			 same date of service;
(b) Represent
			 two (2) methods of performing the same procedure;
(c) Represent medically impossible or
			 improbable use of CPT codes; or
(d)
			 Are described in Current Procedural Terminology as inappropriate coding of
			 procedure combinations.
(16) "Physician administered drug" or "PAD"
			 means any rebateable covered outpatient drug that is:
(a) Provided or administered to a Medicaid
			 recipient;
(b) Billed by a provider
			 other than a pharmacy provider through the medical benefit, including a
			 provider that is a physician office or another outpatient clinical setting;
			 and
(c) An injectable or
			 non-injectable drug furnished incident to provider services that are billed
			 separately to Medicaid.
(17) "Provider" is defined by
			 KRS
			 205.8451(7).
(18) "Provider group" means a group of at
			 least two (2) individually licensed APRNs who:
(a) Are enrolled with the Medicaid Program
			 individually and as a group; and
(b) Share the same Medicaid group provider
			 number.
(19) "Rebateable"
			 means a drug for which the drug manufacturer has entered into and has in effect
			 a rebate agreement in accordance with
			 42 U.S.C.
			 1396r-8(a).
(20) "Recipient" is defined by
			 KRS
			 205.8451(9).
(21) "Timely filing" means receipt of a
			 Medicaid claim by the department within:
(a)
			 Twelve (12) months of the date the service was provided;
(b) Twelve (12) months of the date
			 retroactive eligibility was established; or
(c) Six (6) months of the Medicare
			 adjudication date if the service was billed to Medicare.