907 KAR 3:160. Specialized children’s services clinics.

 

      RELATES TO: KRS 205.560, 620.020(4)

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), EO 2004-726

      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) authorizes the cabinet, by administrative regulation, to comply with a 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 establishes the requirements for providers and reimbursement by the Medicaid program for services provided by a specialized children’s services clinic.

 

      Section 1. Definitions. (1) "Affiliation agreement" means a written agreement between a provider and a children’s advocacy center to perform a child sexual abuse medical examination.

      (2) "Child sexual abuse medical examination" means an examination to determine child sexual abuse that includes:

      (a) A medical history taken from the child and a nonimplicated parent, guardian or primary caretaker;

      (b) A physical examination with detailed attention to the anogenital area;

      (c) If clinically indicated, a colposcopic examination; and

      (d) A mental health screening, provided on the same day and at the same location as the physical examination, to determine the impact of the alleged abuse on the mental health status of the child and the need for mental health services.

      (3) "Children’s advocacy center" is defined in KRS 620.020(4).

      (4) "Department" means the Department for Medicaid Services or its designated agent.

      (5) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

      (6) "Mental health professional" means:

      (a) A psychologist as defined in KRS 319.010(8);

      (b) A licensed clinical social worker in accordance with KRS 335.100;

      (c) An advanced registered nurse practitioner as defined in KRS 314.011(7);

      (d) A licensed marriage and family therapist as defined in KRS 335.300(2);

      (e) A certified professional counselor as defined in KRS 335.500(2); or

      (f) A certified professional art therapist as defined in KRS 309.130(2).

      (7) "Specialized children’s services clinic" means a clinic enrolled with the Kentucky Medicaid Program that provides child sexual abuse medical examinations and that meets the requirements of Section 3 of this administrative regulation.

      (8) "Usual and customary charge" means the amount a provider bills to the general public.

 

      Section 2. Covered Services. (1) A child sexual abuse medical examination provided as a clinic service by a specialized children’s services clinic shall be covered if medically necessary and provided to a recipient who is under the age of eighteen (18) years.

      (2) A child sexual abuse medical examination shall be performed by:

      (a) A licensed physician who:

      1. Completes the medical history and physical examination;

      2. Is employed by, under contract with, or has an affiliation agreement with a specialized children’s services clinic;

      3. Has received specialized training in the medical examination of sexually-abused children;

      4. Has received specialized training in the use of a colposcope and has access to a colposcope in the specialized children’s services clinic; and

      5. Shall make reports resulting from child sexual abuse medical examinations available for peer review and maintain confidentiality in accordance with Section 6 of this administrative regulation; and

      (b) A mental health professional who:

      1. Performs a mental health screening to determine the mental health status of the child and the need for further mental health services;

      2. Is directly supervised by the physician who performs the medical examination;

      3. Is employed by, under contract with, or has an affiliation agreement with a specialized children’s services clinic; and

      4. Has received specialized training in the mental health screening and assessment of sexually-abused children.

 

      Section 3. Provider Requirements. (1) A provider shall be enrolled with the department as a specialized children’s services clinic.

      (2) A specialized children’s services clinic shall be a children’s advocacy center whose providers are employed by, under contract with, or have a signed affiliation agreement with the clinic.

 

      Section 4. Billing for Services. (1) A child sexual abuse medical examination shall be billed by a specialized children’s services clinic as a comprehensive clinic service which shall include:

      (a) The services of the physician;

      (b) Mental health screening services provided by a mental health professional;

      (c) Services and supplies furnished as an incidental part of the physician’s professional services in the course of diagnosis and treatment; and

      (d) Medical services provided by other clinic employees under the direct supervision of the physician.

      (2) Services provided by a physician or mental health professional employed by, under contract with, or having a signed affiliation agreement with a specialized children’s services clinic shall be billed under the clinic’s provider number using a single reimbursement code designated by the department.

 

      Section 5. Reimbursement. (1) The department shall establish a statewide reimbursement rate based on a review of cost data and a consideration of rates paid to providers for similar services.

      (2) The initial rate of reimbursement for a child sexual abuse medical examination shall be the lesser of:

      (a) An all-inclusive statewide rate of $538 per examination; or

      (b) The provider’s usual and customary charge for the service.

      (3) The department shall determine the statewide rate using updated cost data submitted on an annual cost report from the center.

 

      Section 6. Medical Records and Confidentiality. (1) Except to the department, duly authorized representatives of federal or state agencies, multidisciplinary team members acting pursuant to KRS 620.050 or a physician participating in a peer review of a specific child sexual abuse case, a specialized children’s services clinic shall not disclose any information concerning an eligible recipient without:

      (a) Written consent of:

      1. The recipient; or

      2. If the recipient is a minor, the recipient’s parent, legal guardian, or attorney; or

      (b) A subpoena from a court of appropriate jurisdiction.

      (2) A specialized children’s services clinic shall:

      (a) Maintain a recipient’s medical records in accordance with 907 KAR 1:672;

      (b) Maintain up-to-date recipient medical records at the site where the medical services are provided;

      (c) Ensure that a recipient’s medical record shall be readily retrievable, complete, organized, and legible and shall reflect sound medical recordkeeping practices; and

      (d) Safeguard medical records against loss, destruction, and unauthorized use.

 

      Section 7. Appeal Rights. (1) An appeal of a negative action taken by the department regarding a Medicaid recipient shall be in accordance with 907 KAR 1:563.

      (2) An appeal of a negative action taken by the department regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

      (3) An appeal of a negative action taken by the department regarding a Medicaid provider shall be in accordance with 907 KAR 1:671. (28 Ky.R. 207; Am. 634; eff. 9-10-2001.)