Acute Care Hospitals

Acute care hospitals provide both inpatient and outpatient services, including emergency room services.

Inpatient services include: room and board (private and semi-private rooms); laboratory; radiology; pathology; cardiology; medical/surgical anesthesia; respiratory therapy; physical therapy; speech therapy; renal dialysis; and organ procurement.

Outpatient services include: emergency room services; drug therapy (administered while the patient is being treated in the emergency room or outpatient area); laboratory; radiology; pathology; medical/surgical anesthesia; respiratory therapy; physical therapy; speech therapy; and renal dialysis.

These services and related requirements are outlined in the following Kentucky Administrative Regulations:

907 KAR 1:012 and 907 KAR 1:013 for inpatient hospitals

907 KAR 1:014 and 907 KAR 1:015 for outpatient hospitals

1. Do outpatient services require review approval or prior authorization?
Some outpatient services do require prior approval through the Department for Medicaid (DMS) designated Peer Review Organization (PRO). Emergency admissions do not require pre-admission approval. Providers have two working days from the date of the emergency to obtain the approval from the PRO.  For more information on services which require a prior authorization in the outpatient setting, refer to the provider resource page.

2. Is reproductive sterilization payable by Medicaid when a patient was admitted as self-pay and then acquired retroactive Medicaid eligibility?
The sterilization consent form (MAP 250) is to be signed by the member and the person obtaining the consent at least 30 days prior to the sterilization. In the case of premature delivery or emergency abdominal surgery, the consent form is to be signed by the member and the person obtaining consent within 72 hours of the surgery.

3. What codes are covered by Medicaid?
There is a list of covered revenue codes for inpatient and outpatient billing in the appendix of the Hospital Services Manual.

4. How does a hospital participate in the Disproportionate Share Hospital (DSH) program?
Prior to billing a patient and/or submitting the cost of the hospital services to Medicaid as uncompensated, a hospital is to use the indigent care eligibility form (DSH-001) to assess a patient's financial situation to determine if the patient meets the DSH guidelines. The patient must be a Kentucky resident. Resources, financial and other, belonging to the patient and the patient's family are taken into consideration during the determination. The patient cannot have any other medical insurance coverage including private insurance, any type of government-funded coverage, KCHIP, or be eligible for Medicaid. Questions regarding the DSH program may be directed to DMS at (502) 564-6511.

5. How does a hospital qualify as a critical access hospital?
An acute care facility may qualify as a critical access hospital if the acute care facility is non-profit, public or for profit. The Office of Inspector General, Division of Licensure and Regulation must certify that the acute facility as a critical access hospital. The facility should be located in a rural county more than 35 miles from another acute care facility, 15 miles if in a mountainous area. The emergency room should have 24-hour availability. The acute care facility may have no more than 15 beds licensed as acute care and may have 10 beds licensed as swing beds. An average length of stay may not exceed 96 hours. According to 906 KAR 1:110, the acute care facility also needs to meet one of the following criteria:

• Be located in a county where the percentage of the population with income less than 200 percent of poverty is greater than the state average, based on data published by the UK Center for Rural Health.
• Be located in a county that has an unemployment rate higher than the state average unemployment rate, based on data published by the Cabinet for Health and Family Services (CHFS).
• Be located in a county with a greater number of people age 64 or older than the state average, based on data published by the UK Center for Rural Health.
• Treat on average more Medicare patients on a percentage basis than the state average percentage of Medicare patients, as determined by data published by CHFS.
• Treat on average more Medicaid patients as a percentage of total patients treated than the state average percentage of Medicaid patients, based on data published by CHFS.