Acute Care Hospital is recognized in Kentucky Medicaid as Provider Type (01). In order to enroll as a Acute Care Hospital with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
Inpatient services which are medically necessary and clinically appropriate pursuant to the criteria individualized in
907 KAR 10:012 Section 3 states that an admission primarily indicated in the management of acute or chronic illness, injury or impairment, or for maternity care that could not be rendered on an outpatient basis are covered.
Outpatient services may include the following when medically necessary and clinically appropriate pursuant to
907 KAR 3:130: 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; rehabilitative services excluding occupational therapy include respiratory therapy; physical therapy; speech therapy.
Acute Care hospital service providers must meet the coverage provisions and requirements set forth in 907 KAR 10:012 and
907 KAR 10:014 in order to provide covered services. Any services performed must fall within the scope of practice for the provider. Listing of a service in an administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.
Non-Covered Services
- Services from providers who are not Kentucky Medicaid providers
- Services that are not medically necessary
- Cosmetic surgery
Verifying eligibility
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Reimbursement
Reimbursement for hospital services is regulated under 907 KAR 10:015.
A provider may request coverage for a CPT or HCPCS procedure code by submitting a request in writing to the department which includes necessity, CPT or HCPCS code, and expected reimbursement. Any codes considered experimental are not covered by Kentucky Medicaid.
Duplication of Service
Kentucky Medicaid will not reimburse for a service provided to a beneficiary by more than one provider of any program in which the same service is covered, during the same time.
Prior Authorization
Each MCO provides prior authorization for its beneficiaries.
Gainwell Technologies provides prior authorizations for fee-for-service (FFS) beneficiaries. For more information, visit Prior Authorizations.
Claims Submission
Each MCO processes its own claims.
Kentucky Medicaid contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. For more information, visit KYHealth-Net.
Coding
Kentucky Medicaid requires (Acute Care Hospital) providers to bill on a (CMS UB-04) claim form utilizing the following code types where applicable:
- Current Procedure Terminology (CPT) codes, regulated by the American Medical Association (AMA).
- Healthcare Common Procedure Coding System (HCPCS) codes, regulated by the Centers for Medicare and Medicaid Services (CMS).
- Current Dental Terminology (CDT) codes, regulated by the American Dental Association (ADA).
- International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes, maintained by the Centers for Disease Control & Prevention (CDC) and the National Center for Health Statistics (NCHS).
Kentucky Medicaid uses the Medicare National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits, the Medicaid Medically Unlikely Edits (MUEs), and the McKesson Claim Check System to verify codes mutually exclusive or incidental.
Claim Appeals
Appeal requests for denied FFS claims must be submitted to Gainwell Technologies. The request must include the Provider Inquiry Form, reason for the appeal, and a hard copy claim.
Please refer to the member's MCO if appealing an MCO claim.
Timely Filing
Claims must be received within twelve (12) months from the date the service was provided, twelve (12) months from the date retroactive eligibility was established, or six (6) months of the Medicare adjudication date if the service was billed to Medicare.
Diagnosis Related Group (DRG)
A Diagnosis Related Group (DRG) is used to group similar patient cases that are expected to utilize comparable levels of hospital resources. This system helps standardize hospital reimbursement and improve efficiency in healthcare delivery.
Answers to DRG
If a patient is only eligible for part of the stay, hospital providers may only bill for days when the patient was eligible. For proper calculation of the reimbursement, the actual admit and discharge date and all ICD-10 and procedure codes (including those from when the patient was ineligible) should be provided.
DRG payment is based upon principal diagnosis. There is no interim billing with DRGs.
The rules governing transfers and post-acute care transfers are the same as those used by Medicare.
Freestanding rehabs will be reimbursed under the per diem system. Rehab provided in an acute care facility will be reimbursed under the DRG system.
Professional component fees are not included in the DRG, physician providers will need to receive Medicaid provider numbers, and bill claims on the CMS 1500.
If it is determined that any changes made by Medicare are in the best interests of Medicaid, KMAP will follow any changes in the outliner calculation also made by Medicare.
Disproportionate Share Hospital Services (DSH)
Disproportionate
Share Hospital Program (DSH) is a program of hospital care for Kentucky's
indigent citizenry provided by Kentucky hospitals participating in the Kentucky
Medicaid Program. Prior to billing a patient and prior to submitting the cost
of the hospital service to Medicaid as uncompensated, a hospital uses the DSH Application -
indigent care eligibility form to assess a patient's financial situation to
determine if the patient meets the DSH guidelines.
For the patient to qualify for DSH services:
- 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.
Verify eligibility
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Provider Inquiry Information
If you can't find the information you need or have additional questions, please direct your inquiries to:
- Billing Questions- Gainwell Technologies, (800) 807-1232, ky_provider_inquiry@gainwelltechnologies.com
- Provider Questions- (855) 824-5615
- Prior Authorization- Gainwell Technologies, (800) 292-2392, (800) 644-5725, (800) 807-8842
- Provider Enrollment, Maintenance, and Revalidation- (877) 838-5085
- KYHealth.net assistance- Gainwell Technologies, (800) 205-4696, ky_edi_helpdesk@gainwelltechnolgies.com
- Pharmacy Questions- (502) 564-6890, dmsweb@ky.gov
- Pharmacy Clinical Support Questions- (800) 477-3071
- Pharmacy Prior Authorization- (844) 336-2676
- Physician Administered Drug (PAD) list- (502) 564-6890
- Hospital Cost Reports- Barb McCarter (502) 564-9271 or Eva Fincel (502) 564-9117
Provider MCO Information
*Anthem - (800) 205-5870
Aetna Better Health of KY - (855) 300-5528
Humana - (855) 852-7005
Passport Health Plan- (800) 578-0775
WellCare of KY - (877) 389-9457
*Effective Jan. 1, 2025, Anthem is no longer an active Medicaid Managed Care Organization, or MCO, in Kentucky. However, they are responsible for the payment of claims, appeals, or disputes for dates of service up to and including Dec. 31, 2024.