Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
205.520
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has a 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 occupational therapy services
provided by an independent occupational therapist or occupational therapy
assistant working under the direct supervision of an independent occupational
therapist.
Section 1. Provider
Participation.
(1)
(a) To be eligible to provide and be
reimbursed for an occupational therapy service as an independent provider, a
provider shall be:
1. Currently enrolled in
the Kentucky Medicaid Program in accordance with
907
KAR 1:672;
2. Except as established in paragraph (b) of
this subsection, currently participating in the Kentucky Medicaid Program in
accordance with
907
KAR 1:671; and
3. Except as provided in subsection (2) of
this section, an occupational therapist.
(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.
(2) Occupational therapy services provided in
accordance with Section 2 of this administrative regulation by an occupational
therapy assistant who works under the direct supervision of an occupational
therapist who meets the requirements in subsection (1) of this section shall be
reimbursable if the occupational therapist is the biller for the
services.
Section 2.
Coverage and Limit.
(1) The department shall
reimburse for an occupational therapy service if:
(a) The service:
1. Is provided:
a. By an:
(i) Occupational therapist who meets the
requirements in Section 1(1) of this administrative regulation; or
(ii) Occupational therapy assistant who works
under the direct supervision of an occupational therapist who meets the
requirements in Section 1(1) of this administrative regulation; and
b. To a
recipient;
2. Is ordered
for the recipient by a physician, physician assistant, or advanced practice
registered nurse for:
a. Maximum reduction of
a physical or intellectual disability; or
b. Restoration of a recipient to the
recipient's best possible functioning level;
3. Is prior authorized; and
4. Is medically necessary; and
(b) A specific amount of visits is
requested for the recipient by an occupational therapist, physician, physician
assistant, or an advanced practice registered nurse.
(2)
(a)
There shall be an annual limit of twenty (20) occupational therapy service
visits per recipient per calendar year except as established in paragraph (b)
of this subsection.
(b) The limit
established in paragraph (a) of this subsection may be exceeded if services in
excess of the limits are determined to be medically necessary by the:
1. Department, if the recipient is not
enrolled with a managed care organization; or
2. Managed care organization in which the
enrollee is enrolled, if the recipient is an enrollee.
(c) Prior authorization by the department
shall be required for each service visit that exceeds the limit established in
paragraph (a) of this subsection for a recipient who is not enrolled with a
managed care organization.
Section 3. No Duplication of Service.
(1) The department shall not reimburse for an
occupational therapy service provided to a recipient by more than one (1)
provider of any program in which occupational therapy services are covered
during the same time period.
(2)
For example, if a recipient is receiving an occupational therapy service from
an occupational therapist enrolled with the Medicaid Program, the department
shall not reimburse for the same occupational therapy service provided to the
same recipient during the same time period via the home health
program.
Section 4.
Records Maintenance, Protection, and Security.
(1) A provider shall maintain a current
health record for each recipient.
(2) 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.
(3) The individual who provided the service
shall date and sign the health record on the date that the individual provided
the service.
(4)
(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.
(5) A provider shall comply with 45 C.F.R.
Part 164 .
Section 5.
Medicaid Program Participation Compliance.
(1)
A provider 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 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.
Section 6. Third Party Liability.
A provider shall comply with
KRS
205.622.
Section 7. 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 8. Auditing Authority. The department
shall have the authority to audit any claim, medical record, or documentation
associated with any claim or medical record.
Section 9. 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 10. Appeal Rights.
(1) An appeal of an adverse action by the
department regarding a service and 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.
40 Ky.R. 2038;
2765; eff. 7-7-2014; Crt eff. 12-6-2019.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
42
C.F.R. 440.130,
42
U.S.C. 1396d(a)(13)(C)
