907 KAR 11:034 - Early and periodic screening, diagnosis, and treatment services and early and periodic screening, diagnosis, and treatment special services
RELATES TO: KRS 205.520, 605.115, 42 C.F.R. 441.50-441.62, 42 U.S.C. 1396d
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 has responsibility to administer the Medicaid Program. KRS 205.520 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 Medicaid to Kentucky's indigent citizenry. This administrative regulation establishes the provisions relating to the early and periodic screening, diagnosis and treatment service and early and periodic screening, diagnosis and treatment special services for which payment shall be made by the Medicaid Program on behalf of both categorically needy and medically needy children under age twenty-one (21).
Section 1. Definition.
(1) "By report" means a service or item for
which a maximum allowance has not been established because the item is rarely
billed to the Kentucky Medicaid Program or because the service is unusual,
variable, or new.
(2) "Department"
means the Department for Medicaid Services or its designated agency.
(3) "EPSDT" means early and periodic
screening, diagnosis, and treatment.
(4) "Periodicity" means the frequency with
which an individual may be screened or rescreened.
(5) "Recipient" means a Medicaid eligible
child under the age of twenty-one (21), including the month in which the child
becomes twenty-one (21).
(6)
"Screening" means the review of the health and health-related conditions of a
recipient by a health care professional to determine if further diagnosis or
treatment is needed.
(7) "Service"
means health care, treatment, a procedure, supply, item, or
equipment.
Section 2.
Screening Provider Participation Requirements. A health care provider meeting
the requirements established in this section shall be eligible to participate
in the Medicaid Program as a screening provider:
(1) A physician shall be licensed in the
state of Kentucky;
(2) An early and
periodic screening clinic or other organization qualified to provide a
screening service, including a local health department, shall be under the
direction of a licensed physician, pediatric advanced registered nurse
practitioner, or registered professional nurse currently licensed by the state
of Kentucky who shall be responsible for assuring that the requirements of
participation are met and that the procedure established by the Medicaid
Program are carried out;
(3) A
screening clinic conducted under the direction of a registered professional
nurse or an advanced registered nurse practitioner shall have a licensed
physician acting as medical consultant; and
(4) A screening examination or test performed
by licensed professional staff, or supportive staff under the direct
supervision of the licensed professional, shall be in accordance with the
professional practice standards for the profession.
Section 3. Screening. An EPSDT screening
service shall be directed toward the early detection of a disease or
abnormality. The service shall be appropriate for the age and health history of
the recipient and shall include, as applicable:
(1) An initial, periodic, or additional
health assessment of a recipient provided in accordance with Sections 2 and 5
of this administrative regulation which includes the following:
(a) Health and development history;
(b) Unclothed physical examination;
(c) Development assessment and mental health
screening;
(d) Assessment and
provision of immunizations as appropriate for age and health history;
(e) Assessment of nutritional
status;
(f) Vision
testing;
(g) Hearing
testing;
(h) Laboratory procedures
appropriate for age and population groups, including lead screening and testing
as appropriate;
(i) Director
referral for a dental service for diagnosis and treatment for a child two (2)
years of age and over; or
(j)
Anticipatory guidance and health education;
(2) A health assessment examination, or
evaluation of a recipient by a licensed or certified health care professional
acting within his scope of practice, at intervals other than those specified in
Section 5 of this administrative regulation indicated by medical necessity, to
determine the existence of a defect, physical or mental illness, or condition;
or
(3) Any other recipient
encounter with a licensed or certified health care professional that results in
the determination of the existence of a suspected:
(a) Defect;
(b) Illness;
(c) Medical condition; or
(d) A change or complication in a medical
condition.
Section
4. Immunizations. Each screening provider participating in
accordance with Section 2(1), (2), and (3) of this administrative regulation
shall be required to make available, at the time of screening, immunizations
appropriate for age and health history of the recipient being
screened.
Section 5. Periodicity
Schedule. The periodicity schedule, which is established in the manual
incorporated by reference in this administrative regulation, shall define the
age appropriate services and time frames for screenings. The periodicity
schedule shall be recommended by the Department for Public Health and approved
by the Department for Medicaid Services. An additional medical or dental
assessment shall be provided if medically indicated. The periodicity schedule
is incorporated by reference in the "Early and Periodic Screening, Diagnosis,
and Treatment Services Manual".
Section
6. Diagnosis and Treatment. If referral for additional service is
indicated, further diagnosis and medical treatment services shall be covered if
the service or diagnosis:
(1) Is otherwise
covered by the Medicaid Program; or
(2)
(a) Is
not otherwise covered by the Medicaid Program; and
(b) Meets the requirements for EPSDT special
services as provided for in Section 7 of this administrative
regulation.
Section
7. EPSDT Special Services. EPSDT special services shall include
other health care, diagnostic services, preventive services, rehabilitative
services, treatment, or other measures described in
42
U.S.C. 1396d(a), that are
not otherwise covered under the Kentucky Medicaid Program and that are
medically necessary, as defined in Section 9 of this administrative regulation,
to correct or ameliorate a defect, physical or mental illness, or condition of
a recipient.
Section 8. EPSDT
Diagnostic and Treatment Provider and EPSDT Special Services Provider
Participation Requirements.
(1) An EPSDT
diagnostic or treatment provider shall meet the requirements for participation
in the Kentucky Medicaid Program as specified in Title 907 KAR for the
particular diagnostic or treatment service rendered.
(2) Except as otherwise specified in Title
907 KAR, a provider seeking to provide an EPSDT special service, as established
in Section 7 of this administrative regulation, shall first contact the
department in writing or by telephone to apply for enrollment to become an
EPSDT special services provider. In order to be enrolled, the provider shall
supply documentation or other evidence which establishes that all of the
following conditions are met:
(a) The provider
shall:
1. Be licensed, certified, or
authorized state law to provide the service; and
2. Not be suspended or otherwise
disqualified.
(b) If the
provider is out of state, the provider shall meet comparable requirements in
the state in which he does business.
Section 9. Prior Authorization for EPSDT
Diagnosis and Treatment Services and EPSDT Special Services. Except as
otherwise provided for in this section or in 907 KAR Chapter 1 or 3, an EPSDT
diagnosis or treatment service or an EPSDT special service which is not
otherwise covered by the Kentucky Medicaid Program shall be covered subject to
prior authorization if the requirements of subsections (1) and (2) of this
section are met. The department shall review a request for a service to
determine medical necessity without regard to whether the screen was performed
by a Kentucky Medicaid provider or a non-Medicaid provider.
(1) A request for prior authorization for an
EPSDT service established in Section 6(1) or (2) of this administrative
regulation shall state that the request is for an EPSDT service, and shall be
accompanied by the following information:
(a)
The primary diagnosis and significant associated diagnoses;
(b) Prognosis;
(c) Date of onset of the illness or
condition, and etiology if known;
(d) Clinical significance or functional
impairment caused by the illness or condition;
(e) Specific types of services to be rendered
by each discipline with physician's prescription if applicable;
(f) Therapeutic goals to be achieved by each
discipline and anticipated time for achievement of goals if
applicable;
(g) The extent to which
health care services have been previously provided to address the defect,
illness, or condition, and results demonstrated by prior care if applicable;
and
(h) Other documentation
necessary to justify the medical necessity of the requested service.
(2) Except as otherwise provided
for in 907 KAR Chapter 1 or 3, a request for approval of a service shall meet
the standard of medical necessity for EPSDT if the following applicable
criteria are met:
(a) The service shall be to
correct or ameliorate a defect, physical or mental illness, or
condition;
(b) The service to be
provided shall be medical or remedial in nature;
(c) The service shall be individualized and
consistent with the recipient's medical needs;
(d) The service shall not be requested
primarily for the convenience of the beneficiary, family, physician or another
provider of services;
(e) The
service shall not be unsafe or experimental;
(f) If an alternative medically accepted mode
of treatment exists, the service shall be the most cost-effective and
appropriate service for the child;
(g) A request for a diagnosis or treatment
service in a community-based setting:
1. May
not be approved if the costs would exceed those of equivalent services at the
appropriate institutional level of care; and
2. Shall be individually assessed for
appropriateness in keeping with the standards of medical necessity and the best
interest of the child.
(h) The service to be provided shall be:
1. Generally recognized by the appropriate
medical profession as an accepted modality of medical practice or
treatment;
2. Within the authorized
scope of practice of the provider; and
3. An appropriate mode of treatment for the
medical condition of the recipient;
(i) Scientific evidence, if available, shall
be submitted consisting of:
1. Well designed
and well conducted investigations published in peer-review journals,
demonstrating that the service is intended to produce measurable physiological
outcomes;
2. In the case of
psychological or psychiatric services, measurable psychological outcomes,
concerning the short and long-term effects of the proposed service on health
outcomes;
3. Opinions and
evaluations published by national medical organizations, consensus panels and
other technology evaluation bodies supporting provision of the benefit, shall
also be considered if available;
(j) The predicted beneficial outcome of the
service shall outweigh potential harmful effects;
(k) The services improve the overall health
outcomes as much as, or more than, established
alternatives.
(3) If
reimbursement is being sought on a "by report" basis, a description of the
service, the proposed unit of service, and the requested dollar amount shall be
included with the request for authorization.
(4) A prior authorization request for an
EPSDT service shall be reviewed for medical necessity without regard to the
source of the referral to the service.
(5) A school-based health service provided in
accordance with
907 KAR
1:715 which is included in an authorized Individual
Education Program (IEP) shall be considered to be medically necessary and shall
not be subject to further Medicaid prior authorization requirements.
Section 10. Appeal Rights. A
recipient shall have the right of appeal as established in
907
KAR 1:563.
Section
11. Incorporation by Reference.
(1) "Early and Periodic Screening, Diagnosis,
and Treatment Screening Services and Early and Periodic Screening, Diagnosis,
and Treatment Special Services Manual", Department for Medicaid Services, May
1998 Edition, is incorporated by reference.
(2) This material may be inspected, copied,
or obtained at the Department for Medicaid Services, Cabinet for Health and
Family Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday
through Friday, 8 a.m. to 4:30 p.m.
Notes
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), EO 2004-726
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