Medicaid Materials by Reference - Cabinet for Health and Family Services

907 KAR Chapter 1

907 KAR 1:008 - Ambulatory surgical centers material incorporated by reference

The Ambulatory Surgical Centers Manual, October 2002

907 KAR 1:018- Reimbursement for drugs material incorporated by reference

MAC Price Inquiries and Research Request Form, June 2010

907 KAR 1:019 - Outpatient pharmacy program material incorporated by reference

Drug Prior Authorization Request Form, June 2011
Brand Name Drug Request Form, June 2011
Mental Health Drug Authorization Request Form for atypical antipsychotic agents, November2011
Subaxone and Subutex Prior Authorization Request Form, January 2014
Synagic Prior Authorization Request Form, September 2012
Zyvox (Linezolid) Drug Authorization Request Form, June 2011

907 KAR 1:022 - Nursing facility services and intermediate care facility for individuals with an intellectual disability or a developmental disability services material incorporated by reference

Medicaid Nursing Facility Services Manual, April 2006

907 KAR 1:023- Review and approval of selected therapies as ancillary services in nursing facilities material incorporated by reference

Technical Criteria for Reviewing Ancillary Services for Adults, November 2003
Technical Criteria for Review Ancillary Services for Pediatrics, November 2003
MAP-703 - Request for Reconsideration of Ancillary Therapy Billing, April 2000

907 KAR 1:025- Payments for ICF/IDD and cost-based facilities material incorporated by reference

Cost-Based Facility Reimbursement Cost Report, April 2000
Cost-Based Facility Reimbursement Cost Report Instructions, April 2000

907 KAR 1:026- Dental services material incorporated by reference

MAP-9 - Prior Authorization for Health Services, July 2010
MAP-9A - Kentucky Medicaid Program Orthodontic Services Agreement, December 1995
MAP-306 - Temporomandibular Joint (TMJ) Assessment Form, December 1995
MAP-396 - Kentucky Medicaid Program Orthodontic Evaluation Form, March 2001
MAP-559 - Six (6) Month Orthodontic Progress Report, December 1995
MAP-700 - Kentucky Medicaid Program Orthodontic Final Case Submission, December 1995

907 KAR 1:030- Home Health agency services material incorporated by reference

MAP-248 - Certification for Disposable Medical Supplies, March 2009
Home Health Services Manual, May 2014
Technical Criteria for Reviewing Ancillary Services for Adults, November 2003
Technical Criteria for Review Ancillary Services for Pediatrics, November 2003
Home Health Schedule of Supplies, May 2014

907 KAR 1:031 - Payments for Home Health services material incorporated by reference

Annual Medicaid Home Health/HCB Cost Report, May 1991
Annual Medicaid Home Health/HCB Cost Report Instructions, May 1991
Government Auditing Standards, 1994
Kentucky Medicaid Medical Supply Cost Settlement Worksheet, June 2003
Kentucky Medicaid Medical Supply Cost Settlement Worksheet Instructions, June 2003

907 KAR 1:039 - Hearing program reimbursement provisions and requirements

DMS Hearing Fee Schedule, December 2013

907 KAR 1:044- Community Mental Health Center services material incorporated by reference

Community Mental Health Center Services Manual, 7/March 2015

907 KAR 1:055 - Payment for Primary Care Center and Federally Qualified Health Center services material incorporated by reference

Universal Cost Report, May 2015
Universal Cost Report Instructions, May 2015
MAP-100501 - Prospective Payment System Rate Adjustment, November 2008
MAP-100501 - Form Instructions, February 2013

907 KAR 1:065 - Payments for price-based Nursing Facility services material incorporated by reference

Medicare Provider Reimbursement Manual - Part 2 (Pub. 15-11) Chapter 1. Cost Reporting - General (15-2-102) 102 and 104. Cost Reporting Period, April 2000
Supplemental Medicaid Schedules, November 2003
Instructions for Completing the Medicaid Supplemental Schedules, November 2003
Schedule J Request for Reimbursement, November 2003

907 KAR 1:145 - Supports for Community Living services material incorporated by reference

Supports for Community Living Manual, October 2007

907 KAR 1:155 - Payments for Supports for Community Living services material incorporated by reference

MAP-95 - Request for Equipment Form, May 2010
North Carolina Support Needs Assessment Profile (NC-SNAP), 2000
NC-SNAP Instructor's Manual, 1999

907 KAR 1:160 - Home and Community Based (HCB) Waiver program version 1 material incorporated by reference

MAP-24 - Memorandum to DCBS, August 2008
MAP-109 - Plan of Care/Prior Authorization for Waiver Services, July 2008
MAP-350 - Long Term Care Facilities and Home and Community Based Certification Form, June 2015
MAP-2000 - Initiation/Termination of Consumer Directed Option (CDO), June 2015
MAP-10 - Waiver Services, June 2015
Kentucky Consumer Directed Option Employee-Provider Contract, June 2015

907 KAR 1:170 - Reimbursement for Home and Community Based Waiver services material incorporated by reference

MAP-1021 - ADHC Payment Determination Form, August 2000
Adult Day Health Care Attending Physician Statement, August 2000
Health Department Home Health Annual Cost Report, November 2007
Health Department Home Health Annual Cost Report Instructions, November 2007

907 KAR 1:270 - Podiatry program services material incorporated by reference

Podiatry Program Manual, July 1997

907 KAR 1:340- Reimbursement for Hospice services material incorporated by reference

MAP-374 - Election of Medicaid Hospice Benefit Form, December 2011
MAP-384 - Hospice Drug Form, January 2012

907 KAR 1:400 - Renal Dialysis Center services material incorporated by reference

Renal Dialysis Center Services Manual, April 1991

907 KAR 1:434 - Family Planning services material incorporated by reference

Family Planning Services Manual, September 1988

907 KAR 1:436 - Hospice services manual material incorporated by reference

Hospice Services Manual, November 1989

907 KAR 1:450- Nurse Aide training criteria and registry material incorporated by reference

Medicaid Services Manual for Nurse Aide Training and Competency Evaluation Program, March 2005

907 KAR 1:479 - Durable Medical Equipment covered benefits and reimbursement material incorporated by reference

MAP-9 - Prior Authorization for Health Services, July 2010
MAP-1000 - Certificate of Medical Necessity, July 2010
MAP-1000B - Certificate of Medical Necessity, Metabolic Formulasand Foods, July 2010
Medicaid DME Program Fee Schedule, January 2010
MAP-1001 - Advance Member Notice, September 2006

907 KAR 1:560- Medicaid hearings and appeals regarding eligibility material incorporated by reference

Form PAFS-78, May 1996

907 KAR 1:595 - Model Waiver II services and payments material incorporated by reference

MAP-10 - Waiver Services, June 2015
MAP-115 - Application Intake, May 2015
MAP-116 - Service Plan-Participant Authorization, May 2015
MAP-350 - Long Term Care Facilities and Home and Community Based Certification Form, June 2015
MAP-351 - Medicaid Waiver Assessment, July 2015

907 KAR 1:626- Reimbursement of Dental services

Dental Fee Schedule, June 2015

907 KAR 1:631- Vision program reimbursement provisions and requirements

DMS Vision Program Fee Schedule, effective 1/January 2014

907 KAR 1:632 - Vision program coverage provisions and requirements

DMS Vision Program Fee Schedule, effective 1/January 2014

907 KAR 1:672 - Provider enrollment, disclosure, and documentation for Medicaid participation material incorporated by reference

KAPER-1 - Kentucky Application for Provider Evaluation and Reevaluation Form, March 2007
MAP-811 - Provider Application, July 2007
Dental Credentialing Form, July 2007

907 KAR 1:675 - Program integrity material incorporated by reference

MAP-800 - Notice of Fraud and/or Abuse Committed Against the Medicaid Program, August 1999

907 KAR 1:677 - Medicaid recipient lock-in program material incorporated by reference

Lock-In Member Referral Form, June 2010

907 KAR 1:755 - Pre-admission Screening and Resident Review Program (PASARR) manual material incorporated by reference

907 KAR 1:805 - Breat and Cervical Cancer eligibility for Medicaid material incorporated by reference

MAP-813B - BCCTP Eligibility Screening Form, 9/September 2002
MAP-813 - Breast and Cervical Cancer Treatment Progam Application, 1/1May 2003
MAP-813D - Breast and Cervical Cancer Treatment Program Request for Extension of Eligibility, 1/January 2003

907 KAR 1:835 - Michelle P. Waiver (MPW) services material incorporated by reference

MAP-10 - Waiver Services Physician's Recommendation, June 2015
MAP-115 - Application Intake, May 2015
MAP-116 - Service Plan-Participant Authorization, May 2015
MAP-350 - Long Term Care Facilities and Home and Community Based Program Certification Form, June 2015
MAP-351 - Conflict Free Case Management Exemption, May 2015
MAP-2000 - Initiation/Termination of Participant Directed Services (PDS), June 2015
Kentucky Participant Directed Services Employee Provider Contract, June 2015

907 KAR Chapter 3

907 KAR 3:020 - Targeted Case Management and Rehab through Title V Agency material incorporated by reference

The Policies and Procedures Manual for Title V Services, July 1996

907 KAR 3:090 - Acquired Brain Injury Services material incorporated by reference

MAP-109 - Prior Authorization for Waiver Services, July 2008
MAP-24C - SCL or ABI Admission Discharge Notification, July 2008
MAP-26 - Acquired Brain Injury (ABI) Waiver Services Program Application, July 2008
MAP-95 - Request for Equipment Form, May 2010
MAP-10 - Waiver Services, August 2010
Incident Report Form, July 2008
MAP-2000 - Initiation/Termination of Consumer Directed Option (CDO), July 2008
MAP-350 - Long Term Care Facilities and Home and Community Based Program Certification Form, June 2015
Rancho Los Amigo Level of Cognitive Function Scale, November 1974
MAP-351 - Medicaid Waiver Assessment, June 2015
Mayo-Portland Adaptability Inventory-4, March 2003
Person Centered Planning: Guiding Principles, March 2005
MAP-4100a - Acquired Brain Injury Waiver Program Provider Information and Services, September 2010
Kentucky Consumer Directed Option Employee Provider Contract, 5/April 2007

907 KAR 3:210 - Acquired Brain Injury Services Long Term Care Waiver and Reimbursement material incorporated by reference

MAP-10 - Waiver Services Physician's Recommendation, June 2015
MAP-115 - Application Intake, May 2015
MAP-116 - Service Plan-Participant Authorization, May 2015
MAP-350 - Long Term Care Facilities and Home and Community Based Program Certification Form, June 2015
MAP-351 - Medicaid Waiver Assessment, July 2015
MAP-531 - Conflict-Free Case Management Exemption, May 2015
MAP-2000 - Initiation/Termination of Participant-Directed Services (PDS), June 2015
MAP-4100a - Acquired Brain Injury Waiver Program Provider Information and Services, September 2009
Kentucky Participant Direct Services Employee Provider Contract, June 2015
Family Guide to the Ranco Levels of Cognitive Functioning, August 2006

907 KAR 3:215 - Tobacco Cessation Coverage and Reimbursement material incorporated by reference

Tobacco Cessation Referral Form, January 2011

907 KAR Chapter 5

907 KAR 5:005 - Health Insurance Premium Payment (HIPP) Program material incorporated by reference

Application for Health Insurance Premium Payment (HIPP) Form PA 41, September 2009

907 KAR Chapter 7

907 KAR 7:010 - Home and Community Based Waiver Services Version 2 material incorporated by reference

MAP-115 - Application Intake, Participant Authorization, May 2015
MAP-116 - Service Plan-Participant Authorization, May 2015
MAP-531 - Conflict-Free Case Management Exemption, May 2015
PDS Request Form for Immediate Family Member, Guardian or Legally Responsible Individual as a Paid Service Provider, 8/January 2015
MAP-2000 - Initiation/Termination of Consumer Directed Option (CDO), June 2015
Kentucky Consumer Directed Option Employee-Provider Contract, June 2015
MAP-350 - Long Term Care Facilities and Home and Community Based Program Certification Form, June 2015
Kentucky Home Assessment Tool (K-HAT), 7/January 2015

907 KAR 7:015 - Reimbursement for Home and Community Based Waiver Services Version 2 material incorporated by reference

Kentucky Home Assessment Tool (K-HAT), 7/January 2015
Health Department Home Health Annual Cost Report, November 2007
Health Department Home Health Annual Cost Report Instructions, November 2007

907 KAR Chapter 9

907 KAR 9:005 - Level I and II Psychiatric Residential Treatment Facility Services and Coverage Policies

907 KAR 9:010 - Reimbursement for Level I and II Psychiatric Residential Treatment Facility Services

Form CMS-2552-96, August 2010

907 KAR 9:020 - Reimbursement Provisions and Requirements Regarding Outpatient Behavioral Health Services Provided by Level I and II Psychiatric Residential Treatment Facilities.

Level I and Level II PRTF Non-Medicare Services Fee Schedule, January 2015

907 KAR Chapter 10

907 KAR 10:012 - Inpatient Hospital Service Coverage material incorporated by reference

CMS Manual System Pub. L. 100-03 Medicare National Coverage Determinations Transmittal 101, 6/December 2009

907 KAR 10:015 - Payments for Outpatient Hospital Services material incorporated by reference

Supplemental Worksheet E-3, Part VII, November 2011
Supplemental Medicaid Schedule KMAP-1, November 2011
Supplemental Medicaid Schedule KMAP-4, November 2011
Supplemental Worksheet KMAP-5, November 2011
Supplemental Medicaid Schedule KMAP-6, November 2011

907 KAR 10:815- Non-Diagnostic Related Group Inpatient Hospital Reimbursement material incorporated by reference

Supplemental Medicaid Schedule KMAP-1, January 2007
Supplemental Medicaid Schedule KMAP-4, January 2007

907 KAR 10:820 - Disproportionate Share Hospital Distributions material incorporated by reference

Disproportionate Share Hospital (DSH) Program Manual, January 2008
Application for Disproportionate Share Hospital (DSH) Program, March 2007

907 KAR 10:825 - Diagnosis-related group (DRG) Inpatient Hospital Reimbursement Manual material incorporated by reference

Supplemental Medicaid Schedule KMAP-1, January 2007
Supplemental Medicaid Schedule KMAP-4, January 2007
CMS Manual System Pub. L. 100-03 Medicare National Coverage Determinations Transmittal 101, 6/December 2009

907 KAR Chapter 11

907 KAR 11:034 - Early Periodic Screening and Diagnostic Testing (EPSDT) Screening Services and EPSDT Special Services material incorporated by reference

Early and Periodic Screening, Diagnosis, and Treatment Screening Services and Early and Periodic Screening, Diagnosis, and Treatment Special Services Manual, May 1998

907 KAR Chapter 12

907 KAR 12:010 - New Supports for Community Living Waiver Service and Coverage Policies Manual material incorporated by reference

MAP-115 - Application Intake, May 2015
MAP-116 - Service Plan-Participant Authorization, May 2015
MAP-350 - Long Term Care Facilities and Home and Community Based Program Certification Form, June 2015
MAP-531 - Conflict Free Case Management Exemption, May 2015
MAP-532 - PDS Request for Immediate Family Member, Guardian, or Legally Responsible Individual as Paid Service Provicer, December 2013

907 KAR 12:020 - Reimbursement for New Supports for Community Living Waiver Services

Kentucky Exceptional Supports Protocol, June 2015

907 KAR Chapter 13

907 KAR 13:015 - Private Duty Nursing Service or Supply Reimbursement Provisions and Requirements

Private Duty Nursing Supplies Fee Schedule, 7/July 2014

907 KAR Chapter 15

907 KAR 15:015 - Reimbursement Provisions and Requirements for Behavioral Health Services Provided by Independent Providers

Behavioral Health and Substance Abuse Services Outpatient (Non-Facility) Fee Schedule, June 2016

907 KAR Chapter 17

907 KAR 17:020 - Managed Care Organization Service and Service Coverage Requirements and Policies

MCO Service Areas, November 2012

907 KAR Chapter 20 - Medicaid Eligibility

907 KAR 20:010- Medicaid procedures for determining initial and continuing eligiblity other than procedures related to a modified adusted gross income eligiibility standard or related to former foster care individiduals

HCFS Program Issuance Transmittal Notice Region !V (May 7, 1997)

907 KAR Chapter 23 - Out Patient Pharmacy Program

907 KAR 23:010 - Medicaid Procedures for Determining Initial and Continuing Eligibility Material Incorporated by Reference

Kentucky Medicaid Substance Use Treatment Pharmacy Prior Authorization Form for Buprenorphine Products (rev Jan. 3, 2017)
Kentucky Medicaid Prharmacy Prior Authoriztion form )rev Jan. 3, 2017)

907 KAR 23:020 - Reimbursement for outpatient Drugs

Kentucky Medicai MAC Price Research Requst Form (2012)

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