Renal Dialysis Center Services are recognized in Kentucky Medicaid as Provider Type 39. In order to enroll as a Renal Dialysis Center with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
Renal dialysis services
Renal sialysis services covered by Kentucky Medicaid are inpatient dialysis; outpatient dialysis; self-dialysis; home dialysis; physician services; laboratory services; hemodialysis; drugs; home supplies; and equipment. The service is provided by facility staff or individuals under contract with the facility per
42 CFR 405.2102.
Renal dialysis service providers must meet the coverage provisions of
907 KAR 1:400 to provide covered services. Medicare and private insurance must be billed prior to Kentucky Medicaid. Any services performed fall within the scope of practice for any provider. Listing of a service in the administrative regulation is not a guarantee of payment. Providers must follow the Kentucky Medicaid regulations. All services must be medically necessary.
Verifying 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 Renal Dialysis Services is listed on the Kentucky Medicaid Renal Dialysis Center Services fee schedule located on the Fee and Rate Schedule Home Page.
The Renal dialysis facility must be able to bill all third-party payers and furnish the full spectrum of diagnostic, therapeutic and rehabilitative services required for the care of ESRD patients (including inpatient dialysis furnished directly or indirectly under arrangement). Reimbursement for renal dialysis services is provided in the payment allowance limits for Medicare Part B drugs.
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 Renal Dialysis Service providers to bill on a CMS 1500 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
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.