RELATES TO:
KRS 205.560,
42 C.F.R.
447.26
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 Medicaid program
policies, including managed care and non-managed care, regarding health
care-acquired conditions and provider preventable conditions.
Section 1. Definitions.
(1) "Department" means the Department for
Medicaid Services or its designee.
(2) "Health care-acquired condition" is
defined by 42 C.F.R.
447.26.
(3) "In writing" means on paper or by
electronic means.
(4) "Inpatient
hospital" means an acute care hospital, critical access hospital, long-term
acute care hospital, psychiatric hospital, rehabilitation hospital, psychiatric
distinct part unit in an acute care hospital, or rehabilitation distinct part
unit in an acute care hospital.
(5)
"Managed care organization" means an entity for which the Department for
Medicaid Services has contracted to serve as a managed care organization as
defined in 42 C.F.R.
438.2.
(6) "Provider" is defined by
KRS 205.8451(7).
(7) "Recipient" is defined by
KRS 205.8451(9).
Section 2. Health Care-Acquired
Conditions.
(1) The department or a managed
care organization shall not reimburse for medical assistance in any inpatient
hospital setting for a health care-acquired condition.
(2) In accordance with
42 C.F.R.
447.26(d), if a health
care-acquired condition occurs, an inpatient hospital shall report the health
care-acquired condition to the department by:
(a) Identifying the health care-acquired
condition on a claim or document attached to or associated with the services or
course of treatment provided to the recipient that was not a health
care-acquired condition; or
(b) If
not submitting a claim for services or a course of treatment provided to the
recipient, reporting the health care-acquired condition in writing to the
department within twelve (12) months of the occurrence of the health
care-acquired condition.
Section 3. Other Provider Preventable
Conditions.
(1) The department or a managed
care organization shall not reimburse for a:
(a) Wrong surgical or other invasive
procedure performed on a recipient;
(b) Surgical or other invasive procedure
performed on the wrong body part; or
(c) Surgical or other invasive procedure
performed on the wrong person.
(2) In accordance with
42 C.F.R.
447.26, a provider who performs a procedure
listed in subsection (1) of this section shall report it to the department:
(a) By indicating the procedure on a claim or
document attached to or associated with a claim for services, other than the
services related to the procedure, provided to the recipient; or
(b) In writing within twelve (12) months of
the procedure if the provider does not submit a claim for payment to the
department for services provided to the recipient.
(3) Subsection (1) and (2) of this section
shall not apply to a nursing facility or an intermediate care facility for
individuals with an intellectual or developmental disability.
Section 4. Compliance with
42 C.F.R.
447.26. The department's or managed care
organization's reimbursement shall comply with
42 C.F.R.
447.26(c)(2) and
(3).
Section
5. Supersede. If any policy stated in another administrative
regulation within Title 907 of the Kentucky Administrative Regulations
contradicts a policy stated in this administrative regulation, the policy
stated in this administrative regulation shall supersede the policy stated
elsewhere within Title 907.
