Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 10 - Hospital Service Coverage and Reimbursement › Section 907 KAR 10:014 - Outpatient hospital service coverage provisions and requirements

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.520,
				42 C.F.R.
				447.53
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.
(31) "Licensed psychological practitioner"
			 means an individual who meets the requirements established in
			 KRS
			 319.053.
(32) "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.
(33) "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.
(34) "Marriage and family therapy associate"
			 is defined by
			 KRS
			 335.300(3).
(35) "Medical necessity" or "medically
			 necessary" means that a covered benefit is determined to be needed in
			 accordance with
			 907
			 KAR 3:130.
(36) "Nonemergency" means that a condition or
			 situation does not require an emergency service pursuant to
			 42 C.F.R.
			 447.53.
(37) "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.
(38) "Person-centered service plan" means a
			 plan of services for a recipient that meets the requirements established in
			 42 C.F.R.
			 441.540.
(39) "Physician" is defined by
			 KRS
			 205.510(11).
(40) "Physician assistant" is defined by
			 KRS
			 311.840(3).
(41) "Provider" is defined by
			 KRS
			 205.8451(7).
(42) "Provider abuse" is defined by
			 KRS
			 205.8451(8).
(43) "Recipient" is defined by
			 KRS
			 205.8451(9).
(44) "Recipient abuse" is defined by
			 KRS
			 205.8451(10).
(45) "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.
(46) "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.
(47) "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.