Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:672 - Provider enrollment, disclosure, and documentation for Medicaid participation

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.520,
				205.560,
				205.8451(2),(7),(8),(9),
				205.8477,
				304.17A-545(5),
				311.621-311.643,
				42 U.S.C.
				1396a(w),
				42
				C.F.R. 455.100-455.106,
				42
				C.F.R. 1003.101
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 for the provision of medical
				assistance to Kentucky's indigent citizenry.
				KRS
				205.560(12) requires the
				Medical Assistance Program to use the form and guidelines established pursuant
				to
				KRS
				304.17A-545(5) for assessing
				the credentials of those applying for participation in the Medical Assistance
				Program.
				KRS
				205.560(13) requires the
				department to develop a specific form and establish guidelines for assessing
				the credentials of dentists applying for participation in the Medical
				Assistance Program. This administrative regulation establishes provisions
				related to Medicaid provider enrollment, disclosure, documentation
				requirements, and guidelines for assessing the credentials of those applying
				for participation in the Medicaid Program.
Section
			 1. Definitions.
(1) "Applicant"
			 means a person or entity who applies for enrollment as a participating Medicaid
			 provider.
(2) "Cabinet" means the
			 Cabinet for Health and Family Services.
(3) "Claim" means a request for payment under
			 the Medicaid Program that:
(a) Relates to each
			 individual billing submitted by a provider to the department;
(b) Details services rendered to a recipient
			 on a specific date; and
(c) May be
			 a line item of service or all services for one (1) recipient on a
			 bill.
(4) "Credentialed
			 provider" means a provider that is required to complete the credentialing
			 process in accordance with
			 KRS
			 205.560(12) and (13) and
			 includes the following individuals who apply for enrollment in the Medicaid
			 Program:
(a) A dentist;
(b) A physician;
(c) An audiologist;
(d) A certified registered nurse
			 anesthetist;
(e) An
			 optometrist;
(f) An advance
			 registered nurse practitioner;
(g)
			 A podiatrist;
(h) A chiropractor;
			 or
(i) A physician
			 assistant.
(5)
			 "Department" means the Department for Medicaid Services or its designated
			 agent.
(6) "Disclosure" means the
			 provision of information required by
			 42
			 C.F.R. 455.100 through
			 455.106.
(7) "Evaluation" or "credentialing" means:
(a) A process for collecting and verifying
			 professional qualifications of a health care provider;
(b) An assessment of whether a health care
			 provider meets specified criteria relating to professional competence and
			 conduct; and
(c) A process to be
			 completed before a health care provider may participate in the Medicaid Program
			 on an initial or ongoing basis.
(8) "Exclusion" is defined by
			 42
			 C.F.R. 1003.101.
(9) "Furnish" means to provide medical care,
			 services, or supplies that are:
(a) Provided
			 directly by a provider;
(b)
			 Provided under the supervision of a provider; or
(c) Prescribed by a provider.
(10) "Managing employee" means a
			 general manager, business manager, administrator, director, or other individual
			 who exercises operational or managerial control over or conducts the day-to-day
			 operation of an institution, entity, organization, or agency.
(11) "Medically necessary" or "medical
			 necessity" means that a covered benefit is determined to be needed in
			 accordance with
			 907
			 KAR 3:130.
(12) "Noncredentialed provider" means a
			 provider that is not required to complete the credentialing process in
			 accordance with
			 KRS
			 205.560(12) and includes any
			 individual or entity not identified in subsection (4) of this
			 section.
(13) "Provider" is defined
			 by
			 KRS
			 205.8451(7).
(14) "Recipient" is defined by
			 KRS
			 205.8451(9).
(15) "Reevaluation" or "recredentialing"
			 means a process for identifying a change that may have occurred in a health
			 care provider since the last evaluation or credentialing that may affect the
			 health care provider's ability to perform services.
(16) "Services" means medical care, services,
			 or supplies provided to a Medicaid recipient.
(17) "Subcontractor" means an individual,
			 agency, entity, or organization to which a Medicaid provider or the
			 department's fiscal agent has:
(a) Contracted
			 or delegated some of its management functions or responsibilities of providing
			 medical care or services to its patients; or
(b) Entered into a contract, agreement,
			 purchase order, or lease, including lease of real property, to obtain space,
			 supplies, equipment, or nonmedical services associated with providing services
			 and supplies that are covered under the Medicaid Program.
(18) "Terminated" means a provider's
			 participation in the Medicaid Program has ended and a contractual relationship
			 no longer exists between the provider and the department for the provision of
			 Medicaid-covered services to eligible recipients by the provider or its
			 subcontractor.
(19) "Unacceptable
			 practice" means conduct by a provider which constitutes "fraud" or "provider
			 abuse", as defined in
			 KRS
			 205.8451(2) or (8), or
			 willful misrepresentation, and includes the practices specified in Section 5 of
			 this administrative regulation.