PCC Payment Dates

Purpose

922 KAR 1:360 (Section 11), makes the distinction between the effective date for payment changes that result from "on time" vs "late" materials for the Utilization Review (UR). From the providers' point of view, it is financially advantageous to have the UR materials be received by CRP on the due date or within 30 days before the due date.

Late URs

• Materials that are not submitted on time may result in the Cabinet suspending payments until the materials are received.
• Lowered LOCs that are from late materials will result in the Cabinet making an adjustment for overpayment retroactive to the first UR due date that was missed.
• Raised LOCs that are from late materials will result in the Cabinet applying the higher per diem rate beginning the day after the untimely reports are received by CRP.

On-time URs

• Lowered LOCs that are from on-time materials will have the new rate be effective:
  • If the child remains in the same program, on the 31st day after the UR due date, or:
  • If the child is placed in another child caring or child placing program within 30 days after the UR due date, on the day of admission to the new placement.
• Raised LOCs that are from on-time materials will have the new rate be effective the day after the UR due date.
• If the UR materials are on time and the child is moved from a PCC residential to a PCC therapeutic foster care program, the residential rate for the LOC that resulted from the UR will be in effect for 30 days after the change in placement. On the 31st day, the therapeutic foster care rate will apply.

Appeals

922 KAR 1:360 (Section 12) provides for an appeal of the LOC at any time by the PCC provider or DCBS worker. This is called a request for a "redetermination" of the LOC and may result in a new effective date for a new LOC rate:

• If the redetermination request is made within 30 days of the UR or a new admission and results in an increased LOC, the new rate is retroactive to the UR due date or to the date of admission, whichever is most recent.
• If the redetermination request is made more than 30 days after the UR or admission and results in an increased LOC, the new rate is effective the day after the materials were received by CRP.
• If the redetermination request is made more than 30 days after the UR or admission and results in a lowered LOC, the new rate is effective 30 days after the materials were received by CRP.