PURPOSE: This rule establishes the responsibilities of service providers and outlines the framework of who is eligible to provide care; this includes hospitals and clinics, as well as individual providers of care.

1. (1) Provider &ECifiCStiO”S.

2. (A) Eligible children may be approved for hospitalization by contractual agreement in treatment centers.

   1. 1. Treatment centers shall have a w&atric unit which meets the requireme& of 19 CSR 30.20.021(4)(F)l.-7.
   2. 2. Treatment CS”tW8 shall have open heart surgical facilities and facilities for cardiac catheterization.
   3. 3. Treatment CS”tSI8 shall have the capacity for dealing appropriately with neurosurgica1 condition8 requiring emergency SStiCSS.
   4. 4. Treatment Ce”tW8 shall have the capacity for dealing appropriately with all pediatric SUrgiCd procedures.
   5. 5. Treatment Center8 shall have the capacity to be designated as pediatric trauma CS”tW8.
   6. 6. Treatment Center8 shall have the capacity to provide pediatric sp&dty outpatient rlinicn.
   7. 7. Treatment centers shall be approved by

the Joint Commission on the Accreditation of Hospitals (JCAH) or the American Ostecpathic A.W&tiO” (AOA).

1. (B) Special condition centers @CC!) include pediatric rehabilitation units, burn units, orthopedic units, dental units, plastic surgery units and otolaryngologic units and other pediatric facilities which do not have the full capacity of a treatment center, but have the capacity to provide limited or specialized services for Criuoled Children’s Service (CC& . . eligible clients.

   1. 1. SCCs shall belimitedin number. based

on geographic and demographic consideratiO”8 Of a”y give” part Of MiiSOUri.

1. 2. Eligible children may be approved for

hospitahzation or outpatient care by contractUd agreement for those SpSdiC condition8 for which the SCCs provide services.

1. 3. Emergency hospital admissions

shall be handled as required by 19 CSR 40-1.020(2)(D). In the event that the SCC is not able to provide adequate hospitalization, the patient shall be stabilized and subsequently transferred to a treatment center which is more fully equipped to deal with the emergency.

1. 4. SCCS shall be approved by JCAH or

AOA.

Roy D. Blunt SsrrearY Of strte

1. (C) CCS-approved phySi&+nS shcdl be certified by or eligible for certif?cation by a specialty or SubSpeCialty practice board recognized by and affiliated with the Anwican Medical Association (AMA) or the AOA. f3iiOp~XtOI8 shall be certified by or eligible for certiiication by a specialty or SUbSpeCialty practice board recognized by and affiliated with the Council of Chimpractic Education, the An~erican Chiropractic A.WCi&iO” or the Int.emational Chiiopractic AS80CiZ~ti0”. Phy sicians or chiropractors who are board-eligible shall have two (2) years from the time they are approved to obtain board certification before being discontinued from the CCS list of approved physicians or chiropractors. For certain conditions, the physician or chimpractor is expectad to act as an integral part of a” interdisciplinary team of physicians or chiropractors and other health prOf&O”& to deal with the medical aspects of the condition. These condition8 include spina bifida, cleft lip and palate, severe and extensive bums, spinal cord mjuries and head trauma with loss of w”scio”s”ess for more than twenty-four (24) hours. &“iCW shall be provided or supervised by a CCS-approved physician or chiropractor who is a specialist in the condition for which the child is CCS- approved.

2. (D) Therapists include speech therapists, physical therapists and occupational theranista =-----

   1. 1. Therapy must be approved in advance

by CCS. When therapy is recommended by the attending physician or interdisciplinary team, CCS authorization is necessary for therapy services not covered by another agency.

1. 2. Therapy services are provided by a

CCS-approved therapist.

1. 3. Therapy peISO”“e1 shall be licensed by

their respective boards in Missouri.

1. (E) General dental services are not approved by CCS, except us specified in 19 CSR 401,020(2)(C). Specialized dental services are approved for cleft lip and palate and gengevectomy for patients receiving dilantin therapy. CCS-approved specialty dentists must be boardcertified or board-eligible and licensed to practice in their specialty areas under section 332.171, RSMo (1986). Dentists who are board-eligibleshall have two(Z) years from the time they are approved to obtain board certification before being discontinued from the CCS list of approved dentists.

2. (F) Appliances, prostheses and equipment that are approved by CCS are provided by contractual agreement with direct service vendors; approved repair8 and replacements are also provided by co”tmctual agreement with direct service vendors. Appliances, prostheses and equipment authorized by CCS include artificial limbs, artificial stock eyes,

   CODE OF STATE REGUtATlONS 19 CSR 40-l ,

   m

braces, catheterization SUpplieS, communication devices, dental appliances within arthondontic and prosthodontic limitations, ear molds, hearing aids, ostomy supplies and feeding tubes, respirator equipment, shoes for specific diagnostic criteria, tracheostomy tubes and supplies, wheelchairs, walkers, ambulatory aids and universal Cuff8 and splints.

1. (G) Outpatient x-ray and laboratory SW vices are authorized if they are directly related to the medical condition the client has been enrolled under. They may be requested by the patient’s attending physician, chiropractor, dentist or interdisciplinary team. Whenever possible, they should be included in the client’s individual care plan (ICP).
2. (H) All outpatient drugs, supplies and equipment C&i”g more than three hundred dollars ($300) m”8t be pre-authorized by CCS. Medication, nutritional formulas and SUpplieS necessary for the tK?atme?“t Of a disease or condition may be provided.
3. (I) Payment for medical services shall be limited to those services available in Missouri, except when a client develops specialized needs which cannot be treated in bk%3Uti and must be refened Out-Of-State.

1. (2) Any person or facility wishing to provide health care for CCS shall complete a provider application. CCS shzdl notify providers of application approval and make contractual agreements with facilities approved to provide health care.

   1. (A) Approved providers shall agree to accept as payments in full, the amounts established by CCS.

      1. 1. If a provider receives payment from a

source other than CCS which is equal to or exceeds the amount of the program fee schedule for the authorized services rendered, the provider may not seek any additional amount from either the client or the program.

1. 2. Approved providers shall submit bills

on forms prescribed by CCS and within the billing time limits negotiated between CCS and its providers. Unless the provider receives a waiver of the time limit from the program administrator or designee, failure to comply with time limits may result in denial of the claim.

1. (B) Approved providers shall submit to the case manager legible and complete medical or chiropractic reports for each service or set of related services authorized by CCS. Failure to submit medical reports may result in tamination of provider agreement.

   1. 1. Medical reports submitted to CCS are

the property of CCS. CCS shall not I’&“Se the reports except under the f&wing CirC”“lSt”“- CW 19CSR40-l-HEALTH

1. A. Reports shall be given to other

providers when necessary to assure continuity of treatment or provision of services to the client, if the client consents to the release; and

1. B. Reports shall be used by CCS as

necessary to collect for services paid for by CCS from liable third parties.

1. 2. For a client to receive and continue

receiving services, the client’s CCS-approved physician or chiropractor shall initiate a proposal for services to be incorporated into the ICP.

1. (C) CCS shall reimburse for diagnostic evaluations or treatment services only if B prior written authorization has been provided.

   1. 1. Emergency authorization of reimburse

ment for treatment service(s) shall be provided by CCS in situations which are determined by the CCS program administrator or designee to have the potential for irrevocable damage, injury or long-term consequences if treatment is not provided immediately. In these instances, CCS shall be notified by the attending physician or hospital within seventy-two (72) hours after admission to a CCS-approved ho&al. Elieibilitv for further authorization shail be d&mined according to criteria in 19 CSR 40-1.020(2)(D).

1. 2. Purchase of services related to psycho.

social disturbances are excluded, except when attributable to a medical condition for which the client is enrolled. Requests for these services are subject to review by the program administrator or designee.

1. 3. Purchase of services related to educa-

tional activities or educational disabilities are excluded.

1. 4. Out-of-state providers are subject to the

same fee schedule, time limitations, standards and requirements as in-state providers.

Auth: sections 192.005.2., 201.060, 201.100 and 201.120, RSMo (1986). This rule was previously filed as 13 CSR 50. 160.070. Emergency rule filed Dec. 12, 1984, effectiue Dec. 22, 1984, expired April 20, 1985. Original rule filed Dec. 12, 1984, effect& April 11, 1985. Amended: Filed June 2, 1987, effective Aug. 13, 1937. Amended: Filed Jan. 18, 1989, effectiue April 27,1989.