907 KAR 1:044 - [Repealed]
RELATES TO: KRS 194A.060, 205.520(3), 205.8451(9), 422.317, 434.840-434.860, 42 C.F.R. 415.208, 431.52, 431 Subpart F
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family 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 Medicaid Program coverage provisions and requirements regarding community mental health center (CMHC) behavioral health services provided to Medicaid recipients.
Section 1. Definitions.
(1) "Community mental health center" or
"CMHC" means a facility which meets the community mental health center
requirements established in
902
KAR 20:091.
(2) "Department" means the Department for
Medicaid Services or its designee.
(3) "Enrollee" means a recipient who is
enrolled with a managed care organization.
(4) "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.
(5) "Federal financial
participation" is defined in
42 C.F.R.
400.203.
(6) "Medically necessary" means that a
covered benefit is determined to be needed in accordance with
907
KAR 3:130.
(7) "Mental health associate" means an
individual who meets the mental health associate requirements established in
the Community Mental Health Center Behavioral Health Services Manual.
(8) "Professional equivalent" means an
individual who meets the professional equivalent requirements established in
the Community Mental Health Center Behavioral Health Services Manual.
(9) "Provider" is defined by
KRS
205.8451(7).
(10) "Qualified mental health professional"
means an individual who meets the requirements established in KRS
202A.0011(12).
(11) "Recipient" is
defined by KRS
205.8451(9).
Section 2. Requirements for a
Psychiatric Nurse. A registered nurse employed by a participating community
mental health center shall be considered a psychiatric or mental health nurse
if the individual:
(1) Possesses a Master of
Science in nursing with a specialty in psychiatric or mental health
nursing;
(2)
(a) Is a graduate of a four (4) year nursing
educational program with a Bachelor of Science in nursing; and
(b) Possesses at least one (1) year of
experience in a mental health setting;
(3)
(a) Is
a graduate of a three (3) year nursing educational program; and
(b) Possesses at least two (2) years of
experience in a mental health setting; or
(4)
(a) Is
a graduate of a two (2) year nursing educational program with an associate
degree in nursing; and
(b)
Possesses at least three (3) years of experience in a mental health
setting.
Section
3. Community Mental Health Center Behavioral Health Services
Manual. The conditions for participation, services covered, and limitations for
the community mental health center behavioral health services component of the
Medicaid Program shall be as specified in:
(1) This administrative regulation;
and
(2) The Community Mental Health
Center Behavioral Health Services Manual.
Section 4. Covered Services.
(1) Behavioral health services covered
pursuant to this administrative regulation and pursuant to the Community Mental
Health Center Behavioral Health Services Manual shall be rehabilitative mental
health and substance use disorder services including:
(a) Individual outpatient therapy;
(b) Group outpatient therapy;
(c) Family outpatient therapy;
(d) Collateral outpatient therapy;
(e) Therapeutic rehabilitation
services;
(f) Psychological
testing;
(g) Screening;
(h) An assessment;
(i) Crisis intervention;
(j) Service planning;
(k) A screening, brief intervention, and
referral to treatment;
(l) Mobile
crisis services;
(m) Assertive
community treatment;
(n) Intensive
outpatient program services;
(o)
Residential crisis stabilization services;
(p) Partial hospitalization;
(q) Residential services for substance use
disorders;
(r) Day
treatment;
(s) Comprehensive
community support services;
(t)
Peer support services; or
(u)
Parent or family peer support services.
(2)
(a) To
be covered under this administrative regulation, a service listed in subsection
(1) of this section shall be:
1. Provided by a
community mental health center that is:
a.
Currently enrolled in the Medicaid Program in accordance with
907
KAR 1:672; and
b. Except as established in paragraph (b) of
this subsection, currently participating in the Medicaid Program in accordance
with
907
KAR 1:671;
2. Provided in accordance with:
a. This administrative regulation;
and
b. The Community Mental Health
Center Behavioral Health Services Manual; and
3. Medically necessary.
(b) In accordance with
907
KAR 17:015, Section 3(3), a provider of a service to
an enrollee shall not be required to be currently participating in the
fee-for-service Medicaid Program.
Section 5. Electronic Documents and
Signatures.
(1) The creation, transmission,
storage, or other use of electronic signatures and documents shall comply with
requirements established in
KRS
369.101 to
369.120 and all applicable state
and federal laws and regulations.
(2) A CMHC choosing to utilize electronic
signatures shall:
(a) Develop and implement a
written security policy which shall:
1. Be
complied with by each of the center's employees, officers, agents, and
contractors; and
2. Stipulate which
individuals have access to which electronic signatures and password
authorization;
(b)
Ensure that electronic signatures are created, transmitted, and stored
securely;
(c) Develop a consent
form that shall:
1. Be completed and executed
by each individual utilizing an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(d) Provide the department, immediately upon
request, with:
1. A copy of the provider's
electronic signature policy;
2. The
signed consent form; and
3. The
original filed signature.
Section 6. No Duplication of Service.
(1) The department shall not reimburse for a
service provided to a recipient by more than one (1) provider, of any program
in which the service is covered, on the same day of service.
(2) For example, if a recipient is receiving
a behavioral health service from an independently enrolled behavioral health
service provider, the department shall not reimburse for the same service
provided to the same recipient by a community mental health center on the same
day of service.
Section
7. Records Maintenance, Protection, and Security.
(1) A provider shall maintain a current
health record for each recipient.
(2) A health record shall:
(a) Include:
1. An identification and intake record
including:
a. Name;
b. Social Security number;
c. Date of intake;
d. Home (legal) address;
e. Health insurance information;
f. Referral source and address of referral
source;
g. Primary care physician
and address;
h. The reason the
individual is seeking help including the presenting problem and
diagnosis;
i. Any physical health
diagnosis, if a physical health diagnosis exists for the individual, and
information, if available, regarding:
(i)
Where the individual is receiving treatment for the physical health diagnosis;
and
(ii) The physical health
provider; and
j. The
name of the informant and any other information deemed necessary by the
independent provider to comply with the requirements of:
(i) This administrative regulation;
(ii) The provider's licensure
board;
(iii) State law;
or
(iv) Federal law;
2. Documentation of
the:
a. Screening if the community mental
health center performed the screening;
b. Assessment; and
c. Disposition;
3. A complete history including mental status
and previous treatment;
4. An
identification sheet;
5. A consent
for treatment sheet that is accurately signed and dated; and
6. The individual's stated purpose for
seeking services;
(b)
Be:
1. Maintained in an organized central
file;
2. Furnished to the:
a. Cabinet for Health and Family Services
upon request; or
b. Managed care
organization in which the recipient is enrolled if the recipient is enrolled
with a managed care organization;
3. Made available for inspection and copying
by:
a. Cabinet for Health and Family Services'
personnel; or
b. Personnel of the
managed care organization in which the recipient is enrolled if
applicable;
4. Readily
accessible; and
5. Adequate for the
purpose of establishing the current treatment modality and progress of the
recipient; and
(c)
Document each service provided to the recipient including the date of the
service and the signature of the individual who provided the service.
(3) The individual who provided
the service shall date and sign the health record within forty-eight (48) hours
of the date that the individual provided the service.
(4)
(a)
Except as established in paragraph (b) or (c) of this subsection, a provider
shall maintain a health record regarding a recipient for at least six (6) years
from the date of the service or until any audit dispute or issue is resolved
beyond six (6) years.
(b) After a
recipient's death or discharge from services, a provider shall maintain the
recipient's health record for the longest of the following periods:
1. Six (6) years unless the recipient is a
minor; or
2. If the recipient is a
minor, three (3) years after the recipient reaches the age of majority under
state law.
(c) If the
Secretary of the United States Department of Health and Human Services requires
a longer document retention period than the period referenced in paragraph (a)
of this subsection, pursuant to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
(5) A provider shall comply with 45 C.F.R.
Part 164 .
(6) Documentation of a
screening shall include:
(a) Information
relative to the individual's stated request for services; and
(b) Other stated personal or health concerns
if other concerns are stated.
(7)
(a) A
provider's notes regarding a recipient shall:
1. Be made within forty-eight (48) hours of
each service visit; and
2. Describe
the:
a. Recipient's symptoms or behavior,
reaction to treatment, and attitude;
b. Therapist's intervention;
c. Changes in the plan of care if changes are
made; and
d. Need for continued
treatment if continued treatment is needed.
(b)
1. Any
edit to notes shall:
a. Clearly display the
changes; and
b. Be initialed and
dated.
2. Notes shall
not be erased or illegibly marked out.
(c) If services are provided by a
practitioner working under supervision, there shall be a monthly supervisory
note recorded by the supervising professional reflecting consultations with the
practitioner working under supervision concerning the:
1. Case; and
2. Supervising professional's evaluation of
the services being provided to the recipient.
(8) Immediately following a screening of a
recipient, the provider shall perform a disposition related to:
(a) A provisional diagnosis;
(b) A referral for further consultation and
disposition, if applicable; or
(c)
1. If applicable, termination of services and
referral to an outside source for further services; or
2. If applicable, termination of services
without a referral to further services.
(9) Any change to a recipient's plan of care
shall be documented, signed, and dated by the:
(a) Rendering practitioner; and
(b) Recipient or recipient's
representative.
(10)
(a) Notes regarding services to a recipient
shall:
1. Be organized in chronological
order;
2. Be dated;
3. Be titled to indicate the service
rendered;
4. State a starting and
ending time for the service; and
5.
Be recorded and signed by the rendering provider and include the professional
title (for example, licensed clinical social worker) of the provider.
(b) Initials, typed signatures, or
stamped signatures shall not be accepted.
(c) Telephone contacts, family collateral
contacts not covered under this administrative regulation, or other
nonreimbursable contacts shall:
1. Be recorded
in the notes; and
2. Not be
reimbursable.
(11)
(a) A
termination summary shall:
1. Be required,
upon termination of services, for each recipient who received at least three
(3) service visits; and
2. Contain
a summary of the significant findings and events during the course of treatment
including the:
a. Final assessment regarding
the progress of the individual toward reaching goals and objectives established
in the individual's plan of care;
b. Final diagnosis of clinical impression;
and
3. Individual's
condition upon termination and disposition.
(b) A health record relating to an individual
who was terminated from receiving services shall be fully completed within ten
(10) days following termination.
(12) If an individual's case is reopened
within ninety (90) days of terminating services for the same or related issue,
a reference to the prior case history with a note regarding the interval period
shall be acceptable.
(13)
(a) Except as established in paragraph (b) of
this subsection, if a recipient is transferred or referred to a health care
facility or other provider for care or treatment, the transferring CMHC shall,
if the recipient gives the CMHC written consent to do so, within ten (10)
business days of the transfer or referral, transfer the recipient's health
records in a manner that complies with the health records' use and disclosure
requirements as established in or required by:
1.
a. The
Health Insurance Portability and Accountability Act;
(b) If a recipient is transferred
or referred to a residential crisis stabilization unit, a psychiatric hospital,
a psychiatric distinct part unit in an acute care hospital, or an acute care
hospital for care or treatment, the transferring CMHC shall, within forty-eight
(48) hours of the transfer or referral, transfer the recipient's health records
in a manner that complies with the health records' use and disclosure
requirements as established in or required by:
1.
a. The
Health Insurance Portability and Accountability Act;
(14)
(a) If a CMHC's Medicaid Program
participation status changes as a result of voluntarily terminating from the
Medicaid Program, involuntarily terminating from the Medicaid Program, a
licensure suspension, or death of a provider, the health records regarding
recipients to whom the CMHC has provided services shall:
1. Remain the property of the CMHC;
and
2. Be subject to the retention
requirements established in subsection (4) of this section.
(b) A CMHC shall have a written
plan addressing how to maintain health records in the event of a provider's
death.
Section
8. Medicaid Program Participation Compliance.
(1) A CMHC shall comply with:
(a)
907
KAR 1:671;
(b)
907
KAR 1:672; and
(c) All applicable state and federal
laws.
(2)
(a) If a CMHC receives any duplicate payment
or overpayment from the department or managed care organization, regardless of
reason, the CMHC shall return the payment to the department or managed care
organization that issued the duplicate payment or overpayment.
(b) Failure to return a payment to the
department in accordance with paragraph (a) of this subsection may be:
1. Interpreted to be fraud or abuse;
and
2. Prosecuted in accordance
with applicable federal or state law.
Section 9. Third Party Liability.
A provider shall comply with
KRS
205.622.
Section 10. Auditing Authority. The
department or the managed care organization in which an enrollee is enrolled
shall have the authority to audit any:
(1)
Claim;
(2) Health record;
or
(3) Documentation associated
with the claim or health record.
Section 11. Federal Approval and Federal
Financial Participation.
(1) The department's
coverage of services pursuant to this administrative regulation shall be
contingent upon:
(a) Receipt of federal
financial participation for the coverage; and
(b) Centers for Medicare and Medicaid
Services' approval for the coverage.
(2) The coverage of services provided by a
licensed clinical alcohol and drug counselor or licensed clinical alcohol and
drug counselor associate shall be contingent and effective upon approval by the
Centers for Medicare and Medicaid Services.
Section 12. Appeal Rights.
(1) An appeal of an adverse action by the
department regarding a recipient who is not enrolled with a managed care
organization shall be in accordance with
907
KAR 1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with
907
KAR 17:010.
Section 13. Incorporation by Reference.
(1) The "Community Mental Health Center
Behavioral Health Services Manual", May 2015, is incorporated by
reference.
(2) This material may be
inspected, copied, or obtained, subject to applicable copyright law, at the
Department for Medicaid Services, 275 East Main Street, 6th Floor West,
Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m. or online
at the department's Web site at
http://www.chfs.ky.gov/dms/incorporated.htm.
Notes
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 210.450, 42 U.S.C. 1396a -d
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