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205.6315 Requirements when private peer review organization is contracted with to conduct reviews of levels of care.

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Page 1 of 2 205.6315 Requirements when private peer review organization is contracted with to conduct reviews of levels of care. When the cabinet contracts with any private peer review organization to conduct <br>utilization reviews of the levels of care of the state's Medicaid program recipients, the <br>following shall apply: <br>(1) In determining the appropriate level of care of a Medicaid beneficiary who is a patient in a nursing facility setting, and prior to any change that reduces a Medicaid <br>beneficiary's eligibility for covered services, the contracted peer review organization <br>shall assure that: <br>(a) An in-person assessment of the Medicaid beneficiary is made; and <br>(b) A licensed physician has reviewed the written documentation of the peer review organization's evaluation and provided a written review of the <br>evaluation to be a part of the patient's record. (2) If the level of care is changed for a Medicaid beneficiary who is a resident or patient in a nursing facility setting or a Medicaid beneficiary who receives community-<br>based waiver services, and the change makes that beneficiary ineligible for the <br>Medicaid covered service, the peer review organization shall notify the <br>commissioner of Medicaid in the cabinet, and shall provide a written notification <br>sent by registered return receipt mail to the affected Medicaid beneficiary, nursing <br>facility, affected Medicaid beneficiary's attending physician, and the affected <br>beneficiary's responsible party. (3) If the level of care for a Medicaid beneficiary results in an adverse determination, the affected Medicaid beneficiary, or the responsible person or party, may appeal <br>through an application for reconsideration to be filed with the cabinet within ten <br>(10) days from the date of receipt of the registered return receipt written <br>notification. If the responsible party's registered return receipt mail is undeliverable, <br>the attending physician may initiate the appeal on behalf of the affected Medicaid <br>beneficiary. <br>(a) All benefits which the affected Medicaid recipient, and the nursing facility are eligible for shall be continued during that ten (10) day time frame; and (b) As long as the affected Medicaid recipient is engaged in an appeal of an adverse determination from a peer review organization, all benefits for which <br>the affected Medicaid recipient and nursing facility are eligible shall be <br>continued until an appropriate residential setting is secured, in any event, not <br>to exceed ninety (90) days from the date of the request for a hearing, or until a <br>final determination is made by a hearing officer. (4) (a) If the level of care is lowered for a Medicaid beneficiary who is a resident or patient in a nursing facility setting, an independent examination may be <br>conducted by the resident's attending physician. (b) If the resident's attending physician conducts an independent examination, the attending physician shall make a recommendation concerning the appropriate <br>level of care and forward, in writing, the results of the examination and the Page 2 of 2 recommendation to the peer review organization, the affected recipient, the <br>nursing facility, and the responsible party. (5) For the purposes of this section, &quot;responsible person or party&quot; shall mean an individual authorized by the resident of the facility to act for the resident as an <br>official delegate or agent. The responsible person may be a guardian, payee, family <br>member, or any other individual who has arranged for the care of the resident and <br>assumed this responsibility. The responsible party may or may not be related to the <br>resident. A responsible person or party is not a guardian unless so appointed by the <br>court. (6) The peer review organization shall: (a) Inform the patient and guardian, responsible party, or family member, upon initial qualification for Medicaid covered services, and with the written <br>notification of an adverse determination from a peer review organization: <br>1. Of the manner in which notification of any adverse decision will be <br>made; 2. Of the process for securing a timely review of any adverse decision; 3. That a request for reconsideration must be postmarked no later than ten <br>(10) days after receipt of the initial written notification of any adverse <br>decision; 4. Of the toll-free line that will be provided for questions regarding <br>reviews; and 5. Of the process for appealing an adverse reconsideration to the cabinet; (b) Provide a written peer review organization physician review of all adverse determinations; (c) Provide for an attending physician review of all adverse determinations as outlined in subsection (4) of this section; (d) Inform the commissioner of all information related to an appeal of an adverse action; and (e) Provide the information identified in paragraph (a) of this subsection, at the time of an adverse determination notification, to any affected nursing facility <br>in which a Medicaid beneficiary resides. Effective: July 15, 1998 <br>History: Created 1998 Ky. Acts ch. 205, sec. 1, effective July 15, 1998.