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The Intermediate Care Facility for Development and Intellectual Disabilities (ICF/IID/DD) Facility program is identified in Kentucky Medicaid as Provider Type (11). In order to enroll and bill KentukyICF/IID/DD facilities to provide services to a Medicaid beneficiary, it must:

  • be enrolled in Medicare
  • be licensed in Kentucky
  • be enrolled as a Kentucky Medicaid provider
  • be enrolled with the Managed Care Organization (MCO) of any beneficiary it wishes to treat.

Covered Services

A beneficiary shall meet ICF/IID/DD criteria if they require physical or environmental management or rehabilitation and intellectual disabilities and meets the following criteria:

  • The beneficiary has significant developmental disabilities or significantly subaverage intellectual functioning and requires a planned program of active treatment to attain or maintain the individual's optimal level of functioning, but does not necessarily require nursing facility or nursing facility with waiver services;
  • The beneficiary requires a protected environment while overcoming the effects of developmental disabilities and subaverage intellectual functioning while learning fundamental living skills; learning to live happily and safely within their own limitations obtaining educational experiences that will be useful in self-supporting activities, or increasing his awareness of his environment; or
  • The beneficiary has a psychiatric primary diagnosis or if the mental care needs are adequately handled in a supportive environment (i.e., ICF/IID/DD) and do not require psychiatric inpatient treatment.

Exclusions

The beneficiary shall be specifically excluded from coverage in the following situations:

  • If the beneficiary case is 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 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 for ICF/IID services solely due to advanced age, or length of stay in an institution, or history of the previous institutionalization if the beneficiary qualifies for ICF/IID services on the basis of all other factors.

Excluding a beneficiary with intellectual or developmental disability to qualify for ICF/IID services, the disability shall have manifested itself prior to the individual's 22nd birthday.

For information on completing the Level I Screening and Level II evaluation, visit the Department for Behavioral Health, Developmental and Intellectual Disabilities PASSR website. You may access forms, manuals, and regulations from this site.

ICF/IID/DD facilities must meet the coverage provisions and requirements set forth in 907 KAR 1:022907 KAR 1:023907 KAR 1:037, and 907 KAR 1:755 in order to provide covered services. All services must be performed within the scope of practice for any provider. Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow Kentucky Medicaid regulations and must the requirements of the MCO for which they participate.

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.

Reimbursement

ICF/IID/DD facilities are reimbursed per 907 KAR 1:025, 907 KAR 1:042, 907 KAR 1:065, and 907 KAR 1:780.

Duplication of Service

The department shall 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

Medicaid shall reimburse an ICF/IID/DD facility during a beneficiaries' absence for acute care hospitalization and therapeutic home visits provided certain criteria are met. Bed reservation days shall not be available for beneficiaries admitted to a psychiatric hospital.

Facilities shall allow beneficiaries Medicaid is paying to reserve a bed, return to that bed when they are ready for discharge from the hospital or when returning from therapeutic home visits, regardless of the day of the week (this includes holidays and weekends.) If the facility chooses not to reserve a bed for a resident for whom bed reservation days are available, the facility shall advise the beneficiary prior to their departure from the facility.

It shall be the responsibility of the ICF/IID/DD facility to assure that services and items ordered by a beneficiaries physician are provided while the beneficiary is out of the facility (other than for hospitalization) and Medicaid will be billed to reserve the bed.) The ICF/IID/DD facility shall not be responsible if the beneficiary was on bed reservation days for hospitalization as the hospital would be providing required services and items. If the ICF/IID/DD facility cannot provide the required ancillaries directly, the facility shall make arrangements with 10 qualified sources (i.e., pharmacy, physical therapist, speech therapist, etc.) for the resident to obtain the required services and items. Pharmacies shall bill Medicaid directly therapists, etc. shall bill the facility. As always, if the beneficiary receives an ancillary service or item that Medicare Part B can cover, the nursing facility shall ensure that the carrier is billed prior to seeking reimbursement from Medicaid.

Criteria for approved bed reservation shall be:

  • 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 shall not be considered to be 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 shall only be available up to the day's Medicare eligibility is determined, provided the bed reservation day maximums are not exceeded.
  • Due to a demand for beds at the facility, there is a likelihood that the bed would be occupied by some other residents were it not reserved.
  • The hospitalization shall be in an acute care hospital or a Kentucky hospital certified to participate in the acute care hospital program. The hospitalization shall be approved by Carewise.
  • If hospitalization is approved, and the bed occupied by the resident is also a Medicaid certified acute care bed, the resident shall have been transferred to a specialty unit of a hospital.

Medicaid reimbursement for bed reservation days shall be limited as follows:

  • A maximum of 14 days per calendar year due to an acute care hospital stay.
  • A maximum of 10 days per the calendar year for leaves of absence other than hospitalization.
  • Reimbursement shall be 75% of a facility’s rate if the facility has an occupancy percentage of 95 % or higher.
  • Reimbursement shall be 50% of a facility’s rate if the facility has an occupancy percentage lower than 95%.
    Maximums are applied per beneficiary per the calendar year. Accumulated bed reserve days shall follow a beneficiary if the other facility rather than starting over at zero to a new relocation.

Prior Authorizations

For Fee for Service beneficiaries who require prior authorization for additional services that are deemed medically necessary, contact CareWise. For MCO beneficiaries who require prior authorization for additional services that are medically necessary, contact the beneficiaries MCO for more information.

Claims Submission

Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid fee for service (FFS) claims. Each MCO processes its own claims.

Coding: Kentucky Medicaid utilizes 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 Correct 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. (eff: 10/1/15) Kentucky Medicaid requires the use of UB-04 billing forms. Providers must bill using the Revenue Codes listed in the back of the billing manual.

Claim Appeals: Appeal requests made on denied FFS claims must be submitted to DXC. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO in question, if appealing an MCO claim.

Timely Filing: Claims must be received within 12 months from the date of service (DOS) or 6 months from the Medicare pay date whichever is longer, or within 12 months from the last Kentucky Medicaid denial. Please refer to the MCO in question, 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 - DXC - (800) 807-1232
Provider Questions - (855) 824-5615
Behavioral Health DBHDID Facilities  - (502) 564 - 4527
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth.net assistance - DXC - (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071
Pharmacy Prior Authorization - (800) 477-3071
Physician Administered Drug (PAD) List - Pharmacy Branch - (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 

Contact Information

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