907 KAR 3:005 - Coverage of physicians' services
RELATES TO: KRS 205.510, 205.520, 205.560, 205.622, 205.8451, 311.840-311.862, 314.011, 369.101-369.120, 42 C.F.R. 400.203, 413.75(b), 415.174, 415.184, 431.17, 438.2, 440.40(b), 440.50, 441.20, 441.200-441.208, 441.250-441.259, 447.26, 455.410, Part 493, 45 C.F.R. Parts 160, 164, 42 U.S.C. 1320 - 1320d-8, 1396a(a)(19), (30), 1396r-8(a)
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 Medicaid Program coverage provisions and requirements relating to physicians' services.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
"APRN" is defined by
KRS
314.011(7).
(2) "Behavioral health practitioner under
supervision" means an individual who is:
(a)
1. A licensed psychological
associate;
2. A licensed
professional counselor associate;
3. A certified social worker;
4. A marriage and family therapy
associate;
5. A licensed
professional art therapist associate;
6. A licensed assistant behavior
analyst;
7. A licensed clinical
alcohol and drug counselor associate;
8. A certified psychologist; or
9. A certified alcohol and drug counselor;
and
(b) Employed by or
under contract with the same billing provider as the billing
supervisor.
(3) "Common
practice" means an arrangement through which a physician assistant administers
health care services under the supervision of a physician via a supervisory
relationship that has been approved by the Kentucky Board of Medical
Licensure.
(4) "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.
(5)
"Department" means the Department for Medicaid Services or its
designee.
(6) "Designated
controlled substance provider" means the provider designated as a lock-in
recipient's controlled substance prescriber:
(a) Pursuant to
907 KAR
1:677, if the recipient is not an enrollee;
or
(b) As established by the
managed care organization in which the lock-in recipient is enrolled, if the
lock-in recipient is an enrollee.
(7) "Designated primary care provider" means
the provider designated as a lock-in recipient's primary care provider:
(a) Pursuant to
907 KAR
1:677, if the recipient is not an enrollee;
or
(b) As established by the
managed care organization in which the lock-in recipient is enrolled, if the
lock-in recipient is an enrollee.
(8) "Direct physician contact" means that the
billing physician is physically present with and evaluates, examines, treats,
or diagnoses the recipient.
(9)
"Early and periodic screening and diagnosis and treatment" or "EPSDT" is
defined by
42
C.F.R. 440.40(b).
(10) "Emergency care" means:
(a) Covered inpatient or outpatient services
furnished by a qualified provider that are needed to evaluate or stabilize an
emergency medical condition that is found to exist using the prudent layperson
standard; or
(b) Emergency
ambulance transport.
(11)
"Enrollee" means a recipient who is enrolled with a managed care
organization.
(12) "Federal
financial participation" is defined by
42 C.F.R.
400.203.
(13) "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.
(14) "Graduate medical education program" or
"GME program" means:
(a) A residency program
approved by:
1. The Accreditation Council for
Graduate Medical Education of the American Medical Association;
2. The Committee on Hospitals of the Bureau
of Professional Education of the American Osteopathic Association;
3. The Commission on Dental Accreditation of
the American Dental Association; or
4. The Council on Podiatric Medicine
Education of the American Podiatric Medical Association; or
(b) An approved medical residency
program as defined by
42
C.F.R.
413.75(b).
(15) "Incidental" means that a medical
procedure:
(a) Is performed at the same time
as a primary procedure; and
(b)
1. Requires little additional resources;
or
2. Is clinically integral to the
performance of the primary procedure.
(16) "Integral" means that a medical
procedure represents a component of a more complex procedure performed at the
same time.
(17) "Lock-in recipient"
means:
(a) A recipient enrolled in the
lock-in program in accordance with
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 6.
(18) "Locum tenens APRN" means an APRN:
(a) Who temporarily assumes responsibility
for the professional practice of a physician participating in the Kentucky
Medicaid Program; and
(b) Whose
services are billed under the APRN's provider number.
(19) "Locum tenens physician" means a
substitute physician:
(a) Who temporarily
assumes responsibility for the professional practice of a physician
participating in the Kentucky Medicaid Program; and
(b) Whose services are paid under the
participating physician's provider number.
(20) "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.
(21) "Medicaid basis" means a scenario in
which:
(a) A provider provides a service to a
recipient as a Medicaid-participating provider in accordance with:
1.
907
KAR 1:671; and
2.
907
KAR 1:672;
(b) The Medicaid Program is the payer for the
service; and
(c) The recipient is
not liable for payment to the provider for the service other than any cost
sharing obligation owed by the recipient to the provider.
(22) "Medical necessity" or "medically
necessary" means that a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(23) "Medical resident" means:
(a) An individual who participates in an
approved graduate medical education (GME) program in medicine or osteopathy;
or
(b) A physician who is not in an
approved GME program, but who is authorized to practice only in a hospital,
including:
1. An individual with a:
a. Temporary license;
b. Resident training license; or
c. Restricted license; or
2. An unlicensed graduate of a foreign
medical school.
(24) "Mutually exclusive" means that two (2)
procedures:
(a) Are not reasonably performed
in conjunction with each other 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.
(25) "Non-Medicaid basis" means a scenario in
which:
(a) A provider provides a service to a
recipient;
(b) The Medicaid Program
is not the payer for the service; and
(c) The recipient is liable for payment to
the provider for the service.
(26) "Other licensed medical professional"
means a health care provider:
(a) Other than
a physician, physician assistant, advanced practice registered nurse, certified
registered nurse anesthetist, nurse midwife, or registered nurse; and
(b) Who has been approved to practice a
medical specialty by the appropriate licensure board.
(27) "Other provider preventable condition"
is defined by
42
C.F.R. 447.26(b).
(28) "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.
(29) "Physician assistant" is defined by
KRS
311.840(3).
(30) "Podiatrist" is defined by
KRS
205.510(12).
(31) "Provider group" means a group of at
least two (2) individually licensed physicians who:
(a) Are enrolled with the Medicaid Program
individually and as a group; and
(b) Share the same Medicaid group provider
number.
(32) "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).
(33) "Recipient" is defined by
KRS
205.8451(9).
(34) "Screening" means the evaluation of a
recipient by a physician to determine:
(a) If
a disease or medical condition is present; and
(b) If further evaluation, diagnostic
testing, or treatment is needed.
(35) "Supervising physician" is defined by
KRS
311.840(4).
(36) "Supervision" is defined by
KRS
311.840(6).
(37) "Timely filing" means receipt of a
Medicaid claim by the department:
(a) Within
twelve (12) months of the date the service was provided;
(b) Within twelve (12) months of the date
retroactive eligibility was established; or
(c) Within six (6) months of the Medicare
adjudication date if the service was billed to Medicare.
(38) "Unlisted procedure or service" means a
procedure or service:
(a) For which there is
not a specific CPT code; and
(b)
That is billed using a CPT code designated for reporting unlisted procedures or
services.
Section
2. Conditions of Participation.
(1)
(a) A
participating physician shall:
1. Be licensed
as a physician in the state in which the medical practice is located;
2. Comply with the:
3. Have the freedom to choose whether to
provide services to a recipient; and
4. Notify the recipient referenced in
paragraph (b) of this subsection of the provider's decision to accept or not
accept the recipient on a Medicaid basis prior to providing any service to the
recipient.
(b) A provider
may provide a service to a recipient on a non-Medicaid basis:
1. If the recipient agrees to receive the
service on a non-Medicaid basis before the service begins; and
2. The service is not a Medicaid-covered
service.
(c)
1. If a provider renders a Medicaid-covered
service to a recipient, regardless of if the service is billed through the
provider's Medicaid provider number or any other entity including a
non-Medicaid provider, the recipient shall not be billed for the
service.
2. The department shall
terminate from Medicaid Program participation a provider who participates in an
arrangement in which an entity bills a recipient for a Medicaid-covered service
rendered by the provider.
(2) If a provider agrees to provide services
to a recipient, the provider:
(a) Shall bill
the department rather than the recipient for a covered service;
(b) May bill the recipient for a service not
covered by Medicaid if the physician informed the recipient of noncoverage
prior to providing the service; and
(c) Shall not bill the recipient for a
service that is denied by the department on the basis of:
1. The service being incidental, integral, or
mutually exclusive to a covered service or within the global period for a
covered service;
2. Incorrect
billing procedures, including incorrect bundling of services;
3. Failure to obtain prior authorization for
the service; or
4. Failure to meet
timely filing requirements.
(3)
(a) If a
provider receives any duplicate payment or overpayment from the department,
regardless of reason, the provider shall return the payment to the
department.
(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.
(4)
(a) A
provider shall maintain a current health record for each recipient.
(b)
1. A
health record shall document each service provided to the recipient including
the date of the service and the signature of the individual who provided the
service.
2. The individual who
provided the service shall date and sign the health record within seventy-two
(72) hours from the date that the individual provided the service.
(5)
(a) Except as established in paragraph (b) of
this subsection, a provider shall maintain a health record regarding a
recipient for at least five (5) years from the date of the service or until any
audit dispute or issue is resolved beyond five (5) years.
(b) 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.
(6) A provider shall comply with 45 C.F.R.
Part 164 .
Section 3.
Covered Services.
(1) To be covered by the
department, a service shall be:
(a) Medically
necessary;
(b) Clinically
appropriate pursuant to the criteria established in
907
KAR 3:130;
(c) Except as provided in subsection (2) of
this section, furnished to a recipient through direct physician contact;
and
(d) Eligible for reimbursement
as a physician service.
(2) Direct physician contact between the
billing physician and recipient shall not be required for:
(a) A service provided by a:
1. Medical resident if provided under the
direction of a program participating teaching physician in accordance with
42
C.F.R. 415.174 and
415.184;
2. Locum tenens physician who provides direct
physician contact;
3. Physician
assistant in accordance with Section 7 of this administrative regulation;
or
4. Locum tenens APRN who
provides direct APRN contact;
(b) A radiology service, imaging service, in
office lab, pathology service, ultrasound study, echographic study,
electrocardiogram, electromyogram, electroencephalogram, vascular study, or
other service that is usually and customarily performed without direct
physician contact;
(c) The
telephone analysis of emergency medical systems or a cardiac pacemaker if
provided under physician direction;
(d) A sleep disorder service; or
(e) A telehealth consultation provided in
accordance with
907
KAR 3:170.
(3) A service provided by another licensed
medical professional shall be covered if the other licensed medical
professional is:
(a) Employed by the
supervising physician; and
(b)
Licensed in the state of practice.
(4) A sleep disorder service shall be covered
if performed in:
(a) A hospital; or
(b) A sleep laboratory if the sleep
laboratory has documentation demonstrating that it complies with criteria
approved by the:
1. American Sleep Disorders
Association; or
2. American Academy
of Sleep Medicine.
Section 4. Service Limitations.
(1) A covered service provided to a lock-in
recipient shall be limited to a service provided by the lock-in recipient's
designated primary care provider or designated controlled substance provider
unless:
(a) The service represents emergency
care; or
(b) The lock-in recipient
has been referred to the provider by the lock-in recipient's designated primary
care provider.
(2) An
EPSDT screening service shall be covered in accordance with
907
KAR 11:034.
(3) A laboratory procedure performed in a
physician's office shall be limited to a procedure for which the physician has
been certified in accordance with 42 C.F.R. Part 493 .
(4) A drug listed on the Physician
Administered Drug List shall be covered in accordance with
907 KAR
23:010.
(5) A service allowed in accordance with 42
C.F.R. 441, Subpart E (441.200 to 441.208) or Subpart F (441.250 to 441.259 and
the Appendix to Subpart F), shall be covered within the scope and limitations
of 42 C.F.R. 441, Subpart E and Subpart F.
(6)
(a)
Except as provided in paragraph (b) of this subsection, coverage for a service
designated as a psychiatry service CPT code and provided by a physician shall
be limited to four (4) services, per physician, per recipient, per twelve (12)
months.
(b) Coverage for a service
designated as a psychiatry service CPT code that is provided by a board
certified or board eligible psychiatrist or by an advanced practice registered
nurse with a specialty in psychiatry shall not be subject to the limits
established in paragraph (a) of this subsection.
(7) Coverage for an evaluation and management
service shall be limited to one (1) per physician, per recipient, per date of
service.
(8) Coverage for a fetal
diagnostic ultrasound procedure shall be limited to two (2) per nine (9) month
period per recipient unless the diagnosis code justifies the medical necessity
of an additional procedure.
(9) An
anesthesia service shall be covered if:
(a)
Administered by:
1. An anesthesiologist who
remains in attendance throughout the procedure; or
2. An individual who:
a. Is licensed in Kentucky to practice
anesthesia;
b. Is licensed in
Kentucky within his or her scope of practice; and
c. Remains in attendance throughout the
procedure;
(b)
Medically necessary; and
(c) Not
provided as part of an all-inclusive CPT code.
(10) The following shall not be covered:
(a) An acupuncture service;
(b) An autopsy;
(c) A cast or splint application in excess of
the limits established in
907 KAR
3:010;
(d)
Except for therapeutic bandage lenses, contact lenses;
(e) A hysterectomy performed for the purpose
of sterilization;
(f) Lasik
surgery;
(g) Paternity
testing;
(h) A procedure performed
for cosmetic purposes only;
(i) A
procedure performed to promote or improve fertility;
(j) Radial keratotomy;
(k) A thermogram;
(l) An experimental service that is not in
accordance with current standards of medical practice;
(m) A service that does not meet the
requirements established in Section 3(1) of this administrative regulation;
or
(n) Medical assistance for
another provider preventable condition in accordance with
907
KAR 14:005.
(11)
(a) In
accordance with
42 C.F.R.
455.410, to prescribe medication, order a
service for a recipient, or refer a recipient for a service, a provider shall
be currently enrolled and participating in the Medicaid program.
(b) The department shall not reimburse for a:
1. Prescription prescribed by a provider that
is not currently:
a. Participating in the
Medicaid program pursuant to
907
KAR 1:671; and
b. Enrolled in the Medicaid program pursuant
to
907
KAR 1:672; or
2. Service:
a. Ordered by a provider that is not
currently:
(i) Participating in the Medicaid
program pursuant to
907
KAR 1:671; and
(ii) Enrolled in the Medicaid program
pursuant to
907
KAR 1:672; or
b. Referred by a provider that is not
currently:
(i) Participating in the Medicaid
program pursuant to
907
KAR 1:671; and
(ii) Enrolled in the Medicaid program
pursuant to
907
KAR
1:672.
Section 5. Prior Authorization
Requirements for Recipients Who are Not Enrolled with a Managed Care
Organization.
(1) Except as provided by
subsection (3) of this section, the following procedures for a recipient who is
not enrolled with a managed care organization shall require prior authorization
by the department:
(a) Magnetic resonance
imaging;
(b) Magnetic resonance
angiogram;
(c) Magnetic resonance
spectroscopy;
(d) Positron emission
tomography;
(e) Cineradiography or
videoradiography;
(f)
Xeroradiography;
(g) Ultrasound
subsequent to second obstetric ultrasound;
(h) Myocardial imaging;
(i) Cardiac blood pool imaging;
(j) Radiopharmaceutical procedures;
(k) Gastric restrictive surgery or gastric
bypass surgery;
(l) A procedure
that is commonly performed for cosmetic purposes;
(m) A surgical procedure that requires
completion of a federal consent form;
(n) An organ transplant in accordance with
907 KAR
1:350; or
(o) A covered unlisted procedure or
service.
(2)
(a) Prior authorization by the department
shall not be a guarantee of recipient eligibility.
(b) Eligibility verification shall be the
responsibility of the provider.
(3) The prior authorization requirements
established in subsection (1) of this section shall not apply to:
(a) An emergency service;
(b) A radiology procedure if the recipient
has a cancer or transplant diagnosis code; or
(c) A service provided to a recipient in an
observation bed.
(4) A
referring physician, a physician who wishes to provide a given service, a
podiatrist, a chiropractor, or an advanced practice registered nurse:
(a) May request prior authorization from the
department; and
(b) If requesting
prior authorization, shall request prior authorization by:
1. Mailing or faxing:
a. A written request to the department with
information sufficient to demonstrate that the service meets the requirements
established in Section 3(1) of this administrative regulation; and
b. If applicable, any required federal
consent forms; or
2.
Submitting a request via the department's web-based portal with information
sufficient to demonstrate that the service meets the requirements established
in Section 3(1) of this administrative regulation.
Section 6. Therapy
Service Limits.
(1) Speech-language pathology
services shall be limited to twenty (20) service visits per recipient per
calendar year, except as established in subsection (4) of this
section.
(2) Physical therapy
services shall be limited to twenty (20) service visits per recipient per
calendar year, except as established in subsection (4) of this
section.
(3) Occupational therapy
services shall be limited to twenty (20) service visits per recipient per
calendar year, except as established in subsection (4) of this
section.
(4) A service in excess of
the limits established in subsection (1), (2), or (3) of this section shall be:
(a) Prior authorized in accordance with
subsection (5) of this section if the recipient is not enrolled with a managed
care organization; and
(b) Approved
if the additional service is determined to be medically necessary by:
1. The department, if the recipient is not
enrolled with a managed care organization; or
2. The managed care organization in which the
enrollee is enrolled, if the recipient is an enrollee.
(5) Prior authorization by the
department shall be required for each service visit that exceeds the limit
established in subsection (1), (2), or (3) of this section for a recipient who
is not enrolled with a managed care organization.
Section 7. Physician Assistant Services.
(1) Except for a service limitation specified
in subsection (2) or (3) of this section, a service provided by a physician
assistant in common practice with a Medicaid-enrolled physician shall be
covered if:
(a) The service meets the
requirements established in Section 3(1) of this administrative
regulation;
(b) The service is
within the legal scope of certification of the physician assistant;
(c) The service is approved in the
contractual supervisory relationship between the physician assistant, their
supervising physician, and the Kentucky Board of Medical Licensure;
and
(d) The physician assistant
complies with:
1.
KRS
311.840 to
311.862;
and
2. If applicable, Section
2(1)(b) of this administrative regulation.
(2) A same service performed by a physician
and either a physician assistant or an APRN on the same day within a common
practice shall be considered as one (1) covered service.
(3) The following physician assistant
services shall not be covered:
(a) A physician
noncovered service specified in Section 4(10) of this administrative
regulation;
(b) An anesthesia
service;
(c) An obstetrical
delivery service; or
(d) A service
provided in assistance of surgery.
Section 8. Behavioral Health Services Covered
Pursuant to
907
KAR 15:010. The requirements and provisions
established in
907
KAR 15:010 for a service covered pursuant to this
administrative regulation and
907
KAR 15:010 shall apply if the service is provided by:
(1) A physician who is the billing
provider;
(2) A provider group that
is the billing provider; or
(3) A
behavioral health practitioner under supervision who works for a:
(a) Physician who is the billing provider;
or
(b) Provider group that is the
billing provider.
Section
9. Duplication of Service Prohibited.
(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 during the same time period.
(2) For example, if a recipient is receiving
a speech-language pathology service from a speech-language pathologist enrolled
with the Medicaid Program, the department shall not reimburse for the same
service provided to the same recipient during the same time period via the
physicians' services program.
Section
10. Third Party Liability. A provider shall comply with
KRS
205.622.
Section 11. Use of Electronic Signatures.
(1) The creation, transmission, storage, and
other use of electronic signatures and documents shall comply with the
requirements established in
KRS
369.101 to
369.120.
(2) A provider that chooses to use electronic
signatures shall:
(a) Develop and implement a
written security policy that shall:
1. Be
adhered to by each of the provider's employees, officers, agents, or
contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using 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
(c) 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 12. Auditing Authority. The
department shall have the authority to audit any claim, medical record, or
documentation associated with the claim or medical record.
Section 13. Federal Approval and Federal
Financial Participation. The department's coverage of services pursuant to this
administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
Section 14. Appeal Rights. An appeal of a
department decision regarding:
(1) A Medicaid
recipient who is not enrolled with a managed care organization based upon an
application of this administrative regulation shall be in accordance with
907
KAR 1:563; or
(2) An enrollee based upon an application of
this administrative regulation shall be in accordance with
907
KAR 17:010.
Notes
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.560(1)
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