907 KAR 1:102 - Advanced practice registered nurse services
RELATES TO: KRS 205.520, 205.622, 205.8451, 314.011, 369.101 - 369.120, 42 C.F.R. 400.203, 431.17, 438.2, 455.410, 45 C.F.R. Parts 160, 164, 42 U.S.C. 1320d- 1320d-8, 1396r-8
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 provisions relating to advanced practice registered nurse services covered by the Medicaid Program.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
"APRN" is defined by KRS
314.011(7).
(2) "Common practice" means an arrangement
through which a physician and an APRN jointly administer health care
services.
(3) "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.
(4)
"Department" means the Department for Medicaid Services or its designated
agent.
(5) "Enrollee" means a
recipient who is enrolled with a managed care organization.
(6) "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.
(7)
"Federal financial participation" is defined by
42 C.F.R.
400.203.
(8) "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.
(9) "Incidental" means that a medical
procedure is:
(a) Performed at the same time
as a primary procedure; and
(b)
Clinically integral to the performance of the primary procedure.
(10) "Integral" means that a
medical procedure represents a component of a more complex procedure performed
at the same time.
(11) "Locum
tenens APRN" means an APRN:
(a) Who
temporarily assumes responsibility for the professional practice of an APRN
participating in the Kentucky Medicaid Program; and
(b) Whose services are billed under the
Medicaid participating APRN's provider number.
(12) "Locum tenens physician" means a
substitute physician:
(a) Who temporarily
assumes responsibility for the professional practice of an APRN participating
in the Kentucky Medicaid Program; and
(b) Whose services are billed under the
Medicaid participating APRN's provider number.
(13) "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.
(14) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
(15) "Mutually exclusive" means that two (2)
procedures:
(a) Are not reasonably performed
in conjunction with one (1) another 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.
(16) "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.
(17) "Provider" is defined by
KRS
205.8451(7).
(18) "Provider group" means a group of at
least two (2) individually licensed APRNs who:
(a) Are enrolled with the Medicaid Program
individually and as a group; and
(b) Share the same Medicaid group provider
number.
(19)
"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).
(20) "Recipient" is defined by
KRS
205.8451(9).
(21) "Timely filing" means receipt of a
Medicaid claim by the department within:
(a)
Twelve (12) months of the date the service was provided;
(b) Twelve (12) months of the date
retroactive eligibility was established; or
(c) Six (6) months of the Medicare
adjudication date if the service was billed to Medicare.
Section 2. Conditions of
Participation.
(1) To participate in the
Medicaid program as a provider, an APRN or provider group shall comply with:
(2) A provider:
(a) Shall bill the:
1. Department rather than the recipient for a
covered service; or
2. Managed care
organization in which the recipient is enrolled if the recipient is an
enrollee;
(b) May bill
the recipient for a service not covered by Medicaid if the provider informed
the recipient of non-coverage prior to providing the service; and
(c)
1.
Shall not bill the recipient for a service that is denied by the department on
the basis of:
a. The service being incidental,
integral, or mutually exclusive to a covered service or within the global
period for a covered service;
b.
Incorrect billing procedures including incorrect bundling of
services;
c. Failure to obtain
prior authorization for the service; or
d. Failure to meet timely filing
requirements; and
2.
Shall not bill the enrollee for a service that is denied by the managed care
organization in which the recipient is enrolled if the recipient is an enrollee
on the basis of:
a. The service being
incidental, integral, or mutually exclusive to a covered service or within the
global period for a covered service;
b. Incorrect billing procedures including
incorrect bundling of services;
c.
Failure to obtain prior authorization for the service if prior authorization is
required by the managed care organization; or
d. Failure to meet timely filing
requirements.
(3)
(a) If
a provider receives any duplicate payment or overpayment from the department or
managed care organization, regardless of reason, the provider 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 or managed care organization 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) 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 record for the longer
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)
or (b) of this subsection, pursuant to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
(6) If a provider fails to maintain a health
record pursuant to subsection (4) or (5) of this section, the department shall:
(a) Not reimburse for any claim associated
with the health record; or
(b)
Recoup from the provider any payment made associated with the health
record.
(7) A provider
shall comply with 45 C.F.R. Part 164.
(8)
(a) A
service provided by an APRN to a recipient shall be substantiated by a health
record signed by the APRN that corresponds to the date and service reported on
the claim submitted for payment to the:
1.
Department if the claim is for a service to a recipient who is not an enrollee;
or
2. Managed care organization in
which the recipient is enrolled if the recipient is an enrollee.
(b) If rendering services to a
recipient in a hospital, an APRN shall document in the health record of the
hospitalized recipient that the APRN performed one (1) or more of the
following:
1. A personal review of the
recipient's medical history;
2. A
physical examination;
3. A
confirmation or revision of the recipient's diagnosis;
4. A visit with the recipient; or
5. A discharge service for the
recipient.
Section 3. APRN Covered Services.
(1)
(a) An
APRN covered service shall be:
1. A medically
necessary service furnished by an APRN through face-to-face interaction between
the APRN and the recipient except as established in paragraph (c) of this
subsection; and
2. A service that
is:
a. Within the legal scope of practice of
the APRN as specified in:
(i)
201 KAR 20:057; and
(ii) 201 KAR 20:059; and
b. Eligible for reimbursement by Kentucky
Medicaid.
(b)
Any service covered pursuant to
907 KAR 3:005 shall be covered
under this administrative regulation if it meets the requirements established
in paragraph (a) of this subsection.
(c) Face-to-face interaction between the APRN
and recipient shall not be required for:
1. A
radiology service;
2. An imaging
service;
3. A pathology
service;
4. An ultrasound
study;
5. An echographic
study;
6. An
electrocardiogram;
7. An
electromyogram;
8. An
electroencephalogram;
9. A vascular
study;
10. A telephone analysis of
an emergency medical system or a cardiac pacemaker if provided under APRN
direction;
11. A sleep disorder
service;
12. A laboratory service;
or
13. Any other service that is
customarily performed without face-to-face interaction between the APRN and the
recipient.
(2) The prescribing of drugs by an APRN shall
be in accordance with
907 KAR 23:010.
(3) A covered delivery service provided in a:
(a) Hospital shall include:
1. Admission to the hospital;
2. Admission history;
3. Physical examination;
4. Anesthesia;
5. Management of uncomplicated
labor;
6. Vaginal delivery;
and
7. Postpartum care;
or
(b) Freestanding
birth center shall include:
1. Delivery
services in accordance with
907 KAR 1:180, Section 3(3);
and
2. Postnatal visits in
accordance with
907 KAR 1:180, Section
3(4).
(4) An
EPSDT screening service shall be covered if provided in compliance with the
periodicity schedule established in
907 KAR 11:034.
(5) Behavioral health services established in
907 KAR 15:010 that are provided
by an APRN or provider group that is the billing provider for the services
shall be:
(a) Provided in accordance with
907 KAR 15:010; and
(b) Covered in accordance with
907 KAR 15:010.
(6) A drug listed on the Physician
Administered Drug List shall be covered in accordance with
907 KAR 23:010.
Section 4. Service Limitations and
Exclusions.
(1)
(a) A limitation on a service provided by a
physician in accordance with
907 KAR 3:005 shall apply to
services covered under this administrative regulation.
(b) A service that is not covered pursuant to
907 KAR 3:005 shall not be
covered under this administrative regulation.
(2) The same service performed by an APRN and
a physician on the same day within a common practice shall be considered as one
(1) covered service.
(3)
(a) Except as established in paragraph (b) of
this subsection, coverage of a psychiatric service provided by an APRN shall be
limited to four (4) psychiatric services per APRN, per recipient, per twelve
(12) months.
(b) A service
designated as a psychiatry service CPT code that is provided by an APRN with a
specialty in psychiatry shall not be subject to the limit established in
paragraph (a) of this subsection.
(4) The department shall not cover more than
one (1) of the following evaluation and management services per recipient per
provider per date of service:
(a) A
consultation service;
(b) A
critical care service;
(c) An
emergency department evaluation and management service;
(d) A home evaluation and management
service;
(e) A hospital inpatient
evaluation and management service;
(f) A nursing facility service;
(g) An office or other outpatient evaluation
and management service; or
(h) A
preventive medicine service.
(5) Except for any cost sharing obligation
pursuant to
907 KAR 1:604, a:
(a) Recipient shall not be liable for payment
of any part of a Medicaid-covered service provided to the recipient;
and
(b) Provider shall not bill or
charge a recipient for any part of a Medicaid-covered service provided to the
recipient.
(6)
(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.
The prior authorization requirements established in
907 KAR 3:005 shall apply to
services provided under this administrative regulation.
Section 6. Locum Tenens. The department shall
cover services provided by a locum tenens APRN or locum tenens physician under
this administrative regulation:
(1) If the
service meets the requirements established in this administrative regulation;
and
Section 7. 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 under
907 KAR 8:030, the department
shall not reimburse for the same service provided to the same recipient on the
same day by another provider enrolled with the Medicaid Program.
Section 8. Third Party Liability.
A provider shall comply with
KRS
205.622.
Section 9. 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 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. 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 12. Appeal Rights. An appeal of a
department decision regarding:
(1) A 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)
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