Kentucky Medicaid identifies Preventative Services as Provider Type (20). To enroll and bill Kentucky Medicaid, Preventative Services providers must be:
Covered Services
The following medically-necessary preventive, screening, diagnostic, rehabilitative, and remedial services provided by the Department for Public Health directly or indirectly through its subcontractors shall be covered:
- A chronic disease service
- A communicable disease service
- An early and periodic screening, diagnosis and treatment (EPSDT) service
- A family planning service
- A maternity service
- A pediatric service
Preventative Service providers must meet the coverage provisions and requirements set forth in 907 KAR 1:360 to provide covered services. All services must be performed within the scope of practice for any provider. Providers must follow Kentucky Medicaid regulations and the requirements of the MCO in which they participate.
Service Limitations
A laboratory procedure shall be limited to a procedure for which the provider has been certified in accordance with 42 C.F.R. Part 493. A service allowed in accordance with 42 C.F.R. 441, Subpart E or Subpart F shall be covered within the scope and limitations of these federal regulations. Coverage for a fetal diagnostic ultrasound procedure shall be limited to two per nine-month period per beneficiary unless the diagnosis code justifies the medical necessity of an additional procedure.
Verifying eligibility
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Reimbursement
Reimbursement for Preventative Services in pursuant to 907 KAR 1:360 and the Preventative Fee Schedule.
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.
Claims Submission
Kentucky Medicaid currently contracts with Gainwell 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) KY Medicaid requires the use of CMS 1500 billing forms. (eff: 02/12) Providers will need to bill Kentucky Medicaid using the correct CPT codes.
Claim Appeals: 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 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 - Gainwell - (800) 807-1232
- Provider Questions - (855) 824-5615
- Prior Authorization - Gainwell - (800) 292-2392, (800) 664-5725, (800) 807-8842
- Provider Enrollment or Revalidation - (877) 838-5085
- KyHealth.net assistance - Gainwell - (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