RELATES TO:
KRS
205.520,
205.8451
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective
July 9, 2004, reorganized the Cabinet for Health Services and placed the
Department for Medicaid Services and the Medicaid Program under the Cabinet for
Health and Family Services. The Cabinet for Health and Family Services,
Department for Medicaid Services, has responsibility to administer the Medicaid
Program.
KRS
205.520(3) empowers 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
sets forth the provisions relating to Medicaid provider claims processing
requirements.
Section 1. Definitions.
(1) "Cabinet" means the Cabinet for Health
and Family Services.
(2) "Claim"
means a request for payment that relates to each individual billing submitted
by a provider to the department which details services rendered to a recipient
on a specific date. The claim may be either a line item of service or all
services for one (1) recipient on a bill.
(3) "Department" means the Department for
Medicaid Services or its designee.
(4) "Home infusion therapy" means the
parental administration of a premanufactured or sterile compounded product for
intravenous, intramuscular, subcutaneous or intraspinal infusion to a patient
in a nonacute alternative site setting.
(5) "POS" means on-line real time point of
sale claims electronically transmitted to the department.
(6) "ProDUR" means prospective drug use
review in accordance with
201 KAR
2:210.
(7)
"Provider" means as defined in 907 KAR
1:002, Section 1.
(8) "Provider type fifty-four (54)" means an
enrolled pharmacy provider who dispenses drugs to outpatient, long-term care
residents, and personal care home residents who are Medicaid recipients. A
number shall be assigned by the department to these providers and the first two
(2) digits shall be fifty-four (54).
(9) "Recipient" means as defined by
KRS
205.8451(9).
(11) "Unacceptable practice" means as defined
in
907
KAR 1:671, Section 1.
Section 2. Claims Processing.
(1) Claim submittal process for all Medicaid
providers.
(a) Providers, except for type
fifty-four (54), shall submit a claim by an electronic billing process or by
paper form approved by the department.
(b) Claims shall be submitted for payment
within twelve (12) months of the date the service was rendered to an eligible
Medicaid recipient for covered services or supplies.
(c) A provider shall submit additional
clarifying documentation for claims processing if required by the
department.
(d) By submitting a
claim a provider shall be:
1. Liable for the
accuracy of all claims submitted by the provider, its representatives employees
or any individual or entity working on the provider's behalf; and
2. Responsible for reviewing the statement of
payment or remittance statement to assure that paid claims shown are true and
correct, and for informing the department of any discrepancy.
(e) If a provider submits a claim
electronically, the provider's acceptance of payment shall be considered to be
the provider's certification that a paid claim is true and correct;
and
(f) Any submittal of a false
claim, statement, or document shall be considered an unacceptable practice and
subject to all the remedies available to the department.
(2) Provider type fifty-four (54) claims
shall meet POS submittal requirements for services provided on or after
December 1, 1996.
(a) A provider who files in
excess of 100 claims in a twelve (12) month period shall transmit by POS and be
subject to ProDUR.
(b) Providers
that receive a POS exemption shall be subject to ProDUR as specified in
201 KAR
2:210. POS exemptions shall be as follows:
1. Providers who are unable to submit POS
claims for a period of two (2) or more hours, for drugs in an emergency
situation which are essential to avoid life-threatening situations.
2. If a claim requires paper documentation as
requested by the department, this claim shall not be subject to POS.
3. A provider type fifty-four (54) who files
a maximum of 100 claims or less in a twelve (12) month period to the department
may request an exemption from the department for the POS requirement.
4. A provider type fifty-four (54) who
dispenses drugs to be used in the provision of home infusion therapy shall
request an exemption from the department for the POS requirement.
5. Retroactive recipient eligibility or
retroactive nursing facility resident status.
Section 3. Claim payment.
(1) Payment shall be made by the department,
if:
(a) The information required to pay the
claim is complete;
(b) The claim is
not under review for medical necessity;
(c) The provider has submitted all reports
and information relevant to the claim required by the department; and
(d) The department is not withholding the
provider's payments in accordance with
907
KAR 1:671.
(2) The department may audit a claim paid to
determine if any unacceptable practices have occurred that may result in a
sanction.
