922 KAR 1:360 (Section 11) makes the distinction between the effective dates for payment changes that result from materials submitted “on time” versus “late” for the Utilization Review (UR).
In order to be considered “on time”, the materials required for the Utilization Review must be received by CRP on or within 30 days prior to the due date.
On-time URs
According to 922 KAR 1:360 (Section 11):
If the child-caring facility makes timely submission of the reports, and if the:
(a) Level of care remains unchanged, payments shall continue unchanged;
(b) Level of care is reduced, and the:
1. Child remains in the same placement, the lower level of care shall be effective on the 31st day following the utilization review due date; or
2. Child is placed in another child-caring facility or child-placing agency after the utilization review due date, the rate for the lower level shall be effective on the day the child is placed; or
(c) Level of care is increased, the rate for the higher level of care shall be effective the day after the utilization review due date.
Late URs
According to 922 KAR 1:360 (Section 11):
If the child-caring facility or child-placing agency fails to submit the reports as specified…in time for the reports to be received by the gatekeeper within thirty (30) days prior to the utilization review due date, the cabinet shall:
(a) Suspend payments until the necessary information has been submitted to the gatekeeper;
(b) If a child’s level is reduced after untimely reports are received by the gatekeeper, make an adjustment for overpayment retroactive to the first utilization review due date that was missed; or
(c) If a child’s level is increased as a result of delinquent reports, apply a higher rate beginning the day after the untimely reports are received by the gatekeeper.
Redeterminations
According to 922 KAR 1:360 (Section 11):
If the child-caring facility, child-placing agency, or cabinet staff disagrees with the level of care assigned by the gatekeeper, the child-caring facility, child-placing agency, or cabinet staff may request a redetermination of the assigned level…
If the request for a redetermination is received by the gatekeeper within thirty (30) days after the most recent utilization review or admission, and if the gatekeeper assigns a higher level with a CRP-4, Children’s Review Program Notice of Level of Care Redetermination, the increased payment shall be retroactive to the most recent of the following:
(a) The date of the most recent utilization review due date; or
(b) The date of admission.
(3) If the request for redetermination is received by the gatekeeper more than thirty (30) days after the most recent utilization review or admission, and if a:
(a) Higher level is assigned by the gatekeeper with a CRP-4, the increased payment shall be effective the day after the request is received by the gatekeeper; or
(b) Lower level is assigned by the gatekeeper with a CRP-4, the lower payment shall be effective thirty (30) days after the request is received by the gatekeeper.
