Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
205.520,
42 C.F.R.
440.230, 441 Subpart B,
42
U.S.C. 1396d(r)
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. This administrative regulation
establishes the basis for the determination of the medical necessity and
clinical appropriateness of benefits and services for which payment shall be
made by the Medicaid Program on behalf of both the categorically and the
medically needy.
Section 1.
Definitions.
(1) "Clinically appropriate"
means appropriate pursuant to the nationally-recognized clinical criteria known
as Interqual developed by McKesson Health Solutions:
(a) For which the department has contracted;
and
(b) Which is available for
purchase from McKesson Health Solutions by:
2. Calling 1-800-522-6780; or
3. Submitting a written request to McKesson
Health Solutions, 275 Grove Street Suite 1 -210, Newton, MA
02466-2273.
(2)
"Covered benefit" or "covered service" means a health care service or item for
which the department shall reimburse in accordance with state and federal
regulations.
(3) "Department" means
the Department for Medicaid Services or its designee.
(4) "Prudent layperson standard" means the
standard for determining the existence of an emergency medical condition
whereby a prudent layperson who possesses an average knowledge of health and
medicine determines that a medical condition manifests itself by acute symptoms
of sufficient severity (including severe pain) such that the person could
reasonably expect the absence of immediate medical attention to result in
placing the health of the individual (or with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy, serious
impairment to bodily functions, or serious dysfunction of any bodily organ or
part.
Section 2. Medical
Necessity Determination.
(1) The
determination of whether a covered benefit or service is medically necessary
shall:
(a) Be based on an individualized
assessment of the recipient's medical needs; and
(b) Comply with the requirements established
in this paragraph. To be medically necessary or a medical necessity, a covered
benefit shall be:
1. Reasonable and required
to identify, diagnose, treat, correct, cure, palliate, or prevent a disease,
illness, injury, disability, or other medical condition, including
pregnancy;
2. Appropriate in terms
of the service, amount, scope, and duration based on generally-accepted
standards of good medical practice;
3. Provided for medical reasons rather than
primarily for the convenience of the individual, the individual's caregiver, or
the health care provider, or for cosmetic reasons;
4. Provided in the most appropriate location,
with regard to generally-accepted standards of good medical practice, where the
service may, for practical purposes, be safely and effectively
provided;
5. Needed, if used in
reference to an emergency medical service, to exist using the prudent layperson
standard;
6. Provided in accordance
with early and periodic screening, diagnosis, and treatment (EPSDT)
requirements established in
42
U.S.C. 1396d(r) and 42
C.F.R. Part 441 Subpart B for individuals under twenty-one (21) years of age;
and
7. Provided in accordance with
42 C.F.R.
440.230.
(2) The department shall have the final
authority to determine the medical necessity and clinical appropriateness of a
covered benefit or service and shall ensure the right of a recipient to appeal
a negative action in accordance with
907
KAR 1:563.
Section 3. Criteria to Establish Clinical
Appropriateness.
(1) The department shall
utilize criteria to determine if a given Medicaid service or benefit is
clinically appropriate.
(2) The
criteria referenced in subsection (1) of this section shall be the
nationally-recognized clinical criteria that meets the definition established
in Section 1(1) of this administrative regulation.
Section 4. Medical Director Role in Service
Denials.
(1) If a request for a service is
denied for failing to meet medical necessity or clinical appropriateness
criteria, the department's medical director shall have the authority to reverse
or approve the denial.
(2) The
letter of denial shall include the specific clinical reason that the service
was denied including any appropriate Interqual or other
criteria.
27 Ky.R. 1713;
eff. 2-1-2001; 33 Ky.R. 626; 1412; 1590; eff. 1-5-2007; TAm 1-13-2014; Crt eff.
12-6-2019.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.560,
42 U.S.C.
1396a, b,
d
