Ambulatory Surgical Center (ASC) Services - PT (36)

Kentucky Medicaid identifies ambulatory surgical centers (ASC) as Provider Type (36). To enroll in and bill Kentucky Medicaid, ASC service providers must be: 

  • Licensed in the state in which they operate. In Kentucky, hospitals must contact the Office of Inspector General, Division of Health Care for a survey/license.
  • Enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization of any beneficiary it serves.

ASC Requirements

In order to be covered as an ASC operated by a hospital, a facility must:

  1. Elect that status, unless determined otherwise;
  2. Be a separately identified entity, physically, administratively and financially independent from other operations of the hospital with costs treated as a non-reimbursable cost center on the hospital cost report; and
  3. Meet all requirements for health and safety and agree to the assignment, coverage, and reimbursement rules as they apply to freestanding ASCs.

To be eligible to enter into an agreement with Medicare, Medicaid, and other third-party payers, ASC facilities must be surveyed and certified as complying with all conditions for coverage as an ASC as directed in 42 CFR 416.40-416.49.

Covered Services

ASC covered surgical procedures are commonly performed on an inpatient basis in hospitals but may be safely performed in an ASC; are not commonly performed or may be safely performed in physicians offices; are limited to procedures requiring a dedicated operating room or suite and generally requiring a post-operative recovery room or short-term (not overnight) convalescent room.

ASCs must meet the coverage provisions and requirements set forth in 907 KAR 1:008 to provide covered services. ASCs provide outpatient surgical procedures that are medically necessary. Any services performed must fall within the scope of practice for the provider. Listing of service in an administrative regulation is not a guarantee of payment.  Providers must follow Kentucky Medicaid regulations. All services must be medically necessary. 

How do I verify eligibility? 

You may verify eligibility by contacting the automated voice response system at (800) 807-1301 or using the Web-based KYHealth-Net System.

Not Covered

Services or procedures not covered by Kentucky Medicaid include but are not limited to acupuncture services;  any services not performed in compliance with state and federal requirements (i.e. sterilization, hysterectomy and induced termination of pregnancy procedures); services determined as not medically necessary; artificial insemination or procedures for the treatment of infertility including procedures for the reversal of voluntary sterilization; biofeedback services; call back/stat and handling or processing fees; and dental procedures for routine dental care not considered high risk.


Maximum reimbursement for facility services furnished with a covered ASC surgical procedure will be the provider's billed charges or 100 percent of the surgical group rate, whichever is less.

Multiple Procedures

When more than one covered procedure is performed in a single operative session, reimbursement for facility services will be 100 percent of the surgical group rate for the primary procedure and 50 percent of the surgical group rate for the secondary procedure. 

Duplication of Service

The department 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 period.

Prior Authorizations

CareWise provides prior authorizations for any fee-for-service beneficiaries. Each MCO provides prior authorization for its beneficiaries.

Claims Submission

Kentucky Medicaid currently contracts with Gainwell Technologies to process the Kentucky Medicaid fee for service claims. Each MCO processes its own claims.


Kentucky Medicaid uses the National Correct Coding Initiative (NCCI) edits as well as the McKesson Claim Check System to verify codes that are mutually exclusive or incidental. Kentucky Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system (HCPCS) codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of CMS 1500 billing forms. Providers will need to bill Kentucky Medicaid using the correct CPT codes.

Claim Appeals

Appeal requests made on denied FFS claims must be submitted to Gainwell Technologies. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO if appealing an MCO claim.

Timely Filing

Claims must be received within 12 months of the date of service (DOS) or six months from the Medicare pay date whichever is longer, or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim. 

Provider Information

If you can't find the information you need or have additional questions, please direct your inquiries to:
Regarding licensure - Office of Inspector General (OIG), Division of Health Care - (502) 564-7963
FFS Billing Questions - Gainwell Technologies- (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Recertification - (877) 838-5085 assistance - Gainwell Technologies - (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071
Pharmacy Prior Authorization - (800) 477-3071
Physician Administered Drug List - Pharmacy Branch - (502) 564-6890

Provider MCO Information

Aetna Better Health of Kentucky - (855) 300-5528
Anthem Blue Cross Blue Shield - (855) 690-7784 
Humana Healthy Horizons in Kentucky- (800) 444-9137
Passport Health Plan by Molina - (844) 778-2700 
UnitedHealthcare Community Plan​ - (866) 633-4449
WellCare of Kentucky - (877) 389-9457

Report Fraud and Abuse

(800) 372-2970


42 CFR 416 ASC Services

Chapter 216B Licensure and Regulation of Health Facilities and Services
KRS 216B.105  License procedure -- Hearings -- Decisions of the cabinet to be in writing and of record. 
902 KAR Cabinet for Health and Family Services  - Public Health Title page
902 KAR 20:101 ASC Facility Specifications 902 KAR 20:106 ASC Operation and Services
907 KAR - Cabinet for Health and Family Services - DMS Title page
907 KAR 1:008 ASC services and reimbursement
907 KAR 3:130 Medical necessity and clinically appropriate determination basis

Provider Resources

Medicaid Provider Directory
Provider Letter Home
PT 36 - ASC Provider Summary

ASC Forms

Map-9 - Prior Authorization for Health Services and Instructions
MAP -235 - Certification Form For Induced Abortion or Induced Miscarriage
MAP-250 - Consent for Sterilization Form
MAP-251 - Hysterectomy Consent Form

Billing Instructions

Provider Billing Instruction Home

Fee and Rate Schedule

Fee and Rate Schedule Home 
2022 ASC Fee Schedule: PDF - Excel 
2021 ASC Fee Schedule
2020 ASC Fee Schedule
ASC Payment Group Information

Contact Information