Kentucky Medicaid identifies the nursing facility (NF) program as Provider Type (12). To enroll in and bill Kentucky Medicaid, NF service providers must be:
- Licensed in Kentucky. Hospitals must contact the Office of Inspector General Division of Health Care for a survey/license
- Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary served.
NF services included in per diem rate are room and board, dietary services, nutritional supplements, social services, activities, respiratory therapy and supplies, nursing services, the use of equipment and facilities, medical and surgical supplies, prosthetic devices, laundry services, drugs ordered by the physician and personal items routinely provided by the facility. Other services, if medically necessary and ordered by a physician include X-rays, physical therapy, speech therapy, occupational therapy, laboratory services, oxygen and related oxygen supplies and may be billed separately from the per diem rate.
Beneficiaries may be eligible for nursing facility services who:
- Reside in a facility participating in the Kentucky Medicaid program and placed in a Medicaid-certified bed;
- Require and meet the nursing facility level of care criteria defined in
907 KAR 1:022 giving consideration for the medical diagnosis, age-related dependencies, care needs, services and health personnel required to meet these needs and the feasibility of meeting the needs through alternative institutional or non-institutional services; and
- Meet the income and resource limitations required by the program.
For information on completing the Level I screening and Level II evaluation, visit the
Department for Behavioral Health, Developmental and Intellectual Disabilities PASSR website where you can access forms, guidance and regulations.
NF service 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 to provide covered services. 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?
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.
Nursing 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 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
Medicaid will reimburse a nursing facility during a beneficiary acute care hospitalization and therapeutic home visits provided certain criteria are met. Bed reservation days will not be available for beneficiaries admitted to a psychiatric hospital.
Facilities will 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 will advise the beneficiary prior to departure from the facility.
It is the responsibility of the nursing facility to assure that services and items ordered by a beneficiary's 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 nursing facility is not responsible if the beneficiary was on bed reservation days for hospitalization as the hospital would be providing required services and items. If the nursing facility cannot provide the required ancillaries directly, the facility will 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 will bill Medicaid directly. Therapists and other service providers will bill the facility. As always, if the beneficiary receives an ancillary service or item that Medicare Part B can cover, the nursing facility will ensure the carrier is billed prior to 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 that the bed would be occupied by other residents were it 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 also is 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 will be 75 percent of a facility’s rate if the facility has an occupancy rate of 95 percent or more.
- Reimbursement will be 50 percent of a facility’s rate if the facility has an occupancy rate of less than 95 percent.
Maximums are applied per beneficiary per the calendar year. Accumulated bed reserve days will follow a beneficiary rather than starting over at zero at a new relocation.
CareWise provides prior authorization for fee-for-service (FFS)beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell to process the Kentucky Medicaid FFS 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 UB-04 billing forms. Providers will need to bill Kentucky Medicaid using the correct revenue codes.
Appeal requests made on denied FFS claims must be submitted to Gainwell. 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 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.
Topical Contact Information for Providers
If you can't find the information you need or have additional questions, please direct your inquiries to:
FFS Billing Questions - Gainwell Technologies
- (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization -
- (800) 292-2392Provider Enrollment or Revalidation
- (877) 838-5085KyHealth.net
assistance - Gainwell
- (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
MCO Contact Information
Anthem - (800) 205-5870
Aetna Better Health of KY - (855) 300-5528
Humana - (800) 444-9137
Molina - (800) 578-0775
United Health Care Community Plan - (866) 633-4449
WellCare of Kentucky - (877) 389-9457