Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) are Kentucky Medicaid as Provider Type (11). To bill Kentucky Medicaid, ICF/IID facilities must be:
- Licensed in Kentucky. NFs must contact the Office of Inspector General Division of Health Care for a survey/license.
- Enrolled as an active Kentucky Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary for whom it provides services.
ICF/IID services may be covered for individuals who:
- Have an intellectual disability as defined by the current Diagnostic and Statistical Manual of Mental Diseases with an onset of the condition prior to age 18 or have a related condition as defined by 42 CFR 435.1010 with an onset of the condition prior to age 21.
- Require physical or environmental management or habilitation, a planned program of active treatment, and a protected environment.
- Have substantial deficits in adaptive functioning that, without ongoing support, limit functioning in one or more activities of daily living (unrelated to age-appropriate dependencies with respect to a minor).
The beneficiary shall be specifically excluded from coverage if:
- They have a combination of care needs beyond the capability of the facility or placement in the facility is inappropriate due to potential danger to the health and welfare of the beneficiary, other residents, or staff of the facility; and
- If the beneficiary does not meet the preadmission screening and resident review (PASRR) criteria specified in 42 U.S.C. 1396r and 907 KAR 1:755 for entering or remaining in a facility.
A beneficiary who does not require a planned program of active treatment to attain or maintain the individual's optimal level of functioning shall not meet ICF/IID patient status. A beneficiary shall not be denied ICF/IID services solely due to advanced age, length of stay in an institution, or history of previous institutionalization if the beneficiary qualifies for ICF/IID services on the basis of all other factors.
ICF/IID providers must meet the coverage provisions and requirements of 907 KAR 1:022, 907 KAR 1:023, 907 KAR 1:037, and 907 KAR 1:755. Services must be performed within the scope of practice of any provider. Listing of services in an administrative regulation is not a guarantee of payment. Providers must follow all relevant Kentucky Medicaid regulations and the requirements of the MCO in which they participate, if applicable.
Verify eligibility by calling the automated voice response system at (800) 807-1301 or using the web-based KYHealth-Net System.
ICF/IID facilities are reimbursed per 907 KAR 1:025, 907 KAR 1:042, 907 KAR 1:065, and 907 KAR 1:780.
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 period.
Bed Reserve Days
If certain criteria are met, Medicaid reimburses an ICF/IID when a beneficiary is:
- Admitted to an acute care hospital; or
- Receiving therapeutic home visits.
Bed reservation days are not available for beneficiaries admitted to a psychiatric hospital.
When Medicaid is paying bed reservation days, the ICF/IID will allow the beneficiary to return any day of the week, including holidays or weekends. If the ICF/IID chooses not to reserve a bed for a beneficiary who is eligible for Medicaid bed reservation days, the ICF/IID must inform the beneficiary before departure from the facility.
The ICF/IID is responsible for assuring services and items ordered by a beneficiary's physician are provided when Medicaid is billed to reserve the bed, except when the beneficiary is hospitalized. During hospitalization, the hospital must provide any required services and items. If the nursing facility cannot provide the required ancillaries directly, the facility must make arrangements with 10 qualified sources (i.e., pharmacy, physical therapist, speech therapist, etc.) for the resident to receive the required services and items. Pharmacies bill Medicaid directly. Therapists and other service providers bill the facility. If the beneficiary receives an ancillary service or item that Medicare Part B covers, the ICF/IID must bill Medicare before seeking reimbursement from Medicaid.
Criteria for approved bed reservation
- The beneficiary is in Medicaid long-term care vendor payment status and has been a resident of the facility at least overnight. Persons for whom Medicaid is making Part A coinsurance payments are not in Medicaid payment status for purposes of this policy.
- The beneficiary is reasonably expected to return to the same facility with Medicaid as the primary payer. If returning to the same facility with Medicare as the primary payer, bed reservation days will be available only up to the period Medicare eligibility is determined, provided the bed reservation day maximums are not exceeded.
- If, due to a demand for beds at the facility, it is likely the bed would be occupied by other residents if it were not reserved.
- The hospitalization is in an acute care hospital or a Kentucky hospital certified to participate in the acute care hospital program. The hospitalization is approved by Carewise.
- If hospitalization is approved, and the bed occupied by the resident is also a Medicaid-certified acute care bed, the resident will have been transferred to a specialty unit of a hospital.
Limitations on Medicaid reimbursement for bed reservation days
- A maximum of 14 days per calendar year due to an acute care hospital stay.
- A maximum of 10 days per calendar year for leaves of absence other than hospitalization.
- Reimbursement is 75 percent of the facility rate if the facility has an occupancy rate of 95 percent or more.
- Reimbursement is 50 percent of the facility rate if the facility has an occupancy rate of less than 95 percent.
Maximums are applied per beneficiary per calendar year. Accumulated bed reserve days shall follow a beneficiary rather than starting over at zero to a new relocation.
CareWise provides prior authorization for fee-for-services (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid contracts with Gainwell Technologies to process Kentucky Medicaid FFS claims. Each MCO processes its own claims.
Kentucky Medicaid uses the National Correct Coding Initiative edits as well as the McKesson Claim Check System to verify incidental or mutually exclusive codes. Kentucky Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of UB-04 billing forms. Providers must bill Kentucky Medicaid using the CPT codes.
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.
Claims must be received the longer of either 12 months from the date of service or six months from the Medicare pay date or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim.
Provider Contact 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
Provider Questions - (855) 824-5615Behavioral Health DBHDID Facilities
- (502) 564 - 4527
Prior Authorization - CareWise
- (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085KyHealth.net
assistance - DGainwell Technologies
- (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071Pharmacy Prior Authorization
- (800) 477-3071
Physician Administered Drug (PAD) List - Pharmacy Branch - (502) 564-6890