Kentucky Medicaid identifies physician service providers as Provider Type (64) individual or (65) group. To enroll and bill Kentucky Medicaid, physician service providers must be:
- Licensed in the state in which they operate. In Kentucky, physician service providers must be licensed with the
Kentucky Board of Medical Licensure
- Enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.
Covered Services
What are physician services?
Medically necessary services furnished by a physician through face-to-face interaction between the physician and the beneficiary.
Telehealth is billable for this provider type.
How do I verify beneficiaries' eligibility?
You may verify eligibility by:
- contacting the automated voice response system at (800) 807-1301
- using the Web-based KYHealth-Net System
Physician service providers must meet the coverage provisions and requirements of
907 KAR 3:005. 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.
Reimbursement
Reimbursement for physician services is provided in the Physician Fee Schedule. Reimbursement is based on the Kentucky Medicare rate and repricing methodology in
907 KAR 3:010 Section. Other services may be approved on a case-by-case basis and approved by the medical director. A provider may request coverage for a procedure code by submitting a request in writing to the department which includes necessity, CPT code and expected reimbursement. Any codes considered experimental are not covered by Kentucky Medicaid.
Multiple Procedures
Multiple procedures performed by the same physician on the same patient at the same session are reimbursed at the lower of the usual billed charge or at 100 percent of the Physician Fee Schedule for the major procedure and 50 percent for the lesser procedures. Anything considered incidental is 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 service is covered during the same time period.
Prior Authorizations
Prior authorized service codes are indicated on the Physician Fee Schedule and are governed by
907 KAR 3:005 Section 5. CareWise provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Claims Submission
Kentucky Medicaid currently contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. Each MCO processes its own claims.
Coding
Kentucky Medicaid uses the National Correct Coding Initiative 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 codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of CMS 1500 billing forms. Providers will need to bill Kentucky Medicaid using the correct CPT codes.
Claim Appeals
Appeal requests of 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.
Timely Filing
Claims must be received within 12 months of the date of service or 6 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.
Provider Contact Information
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 - CareWise (800)292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth.net assistance - Gainwell Technologies - (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
Molina - (800) 578-0775
WellCare of KY - (877) 389-9457