Dental services are recognized by Kentucky Medicaid as Provider Type (60) individual or (61) group. In order to enroll as a Dentist with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
Dental service provider coverage for adults is limited but includes oral exams, emergency visits, X-rays, extractions, dentures, implants, and fillings. Dental coverage for children includes oral exams, emergency visits, x-rays, extractions, dentures, implants, and fillings.
Dentists must meet the coverage provisions and requirements of 907 KAR 1:126 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.
Limitations: Service limitations are covered in 907 KAR 1:126.
Verify eligibility
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.
Reimbursement
Reimbursement
for Dentist services is listed on the Kentucky Medicaid Dental fee
schedule which can be found on the Fee and Rate Schedule Home Page.
Reimbursement for Dentist is defined in regulation 907 KAR 1:626.
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
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 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.
Prior authorization requirements are covered by
907 KAR 1:026.
*Dentures require prior authorization
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 Dental providers to bill on a CMS 1500 billing 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.
Provider Inquiry Resources
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
Managed Care Organizations
*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.