Psychiatric Residential Treatment Facilities (PRTF) Level I - PT (4)

Kentucky Medicaid identifies psychiatric residential treatment facility level I (PRTF I) as Provider Type (4). To enroll and bill Kentucky Medicaid, a PRTF I facility must be:

  • Licensed in Kentucky. PRTF I service providers must contact the Office of Inspector General Division of Health Care for a survey/license.
  • Enrolled as a Kentucky Medicaid provider and, if applicable, enrolled with the Managed Care Organization (MCO) of any beneficiary it serves.

Covered Services

PRTF I facilities are covered for beneficiaries ages 6 to 21 who require treatment on a continuous basis as a result of a severe mental or psychiatric illness. It is designed to serve children who need long-term, more intensive treatment and a more highly structured environment than they can receive in family and other community-based alternatives to hospitalization. Less restrictive and more homelike than hospitals, these facilities also serve children transitioning from hospitals who still are not ready for the demands of living at home or in a foster home.

PTRF I service providers must meet the coverage provisions and requirements of 907 KAR 9:005 and 907 KAR 9:015 to provide covered services. Any services performed must fall within the scope of practice for any provider. Listing of a service in the administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.

Exclusions and Limitations

 The following are not covered as PRTF services:

  • Chemical dependency treatment services if the need for the services is the beneficiary's primary diagnosis. However, chemical dependency treatment services are covered as incidental treatment if minimal chemical dependency treatment is necessary for successful treatment of the primary diagnosis
  • Outpatient services
  • Pharmacy services covered as pharmacy services in accordance with 907 KAR 23:010
  • Durable medical equipment covered as a durable medical equipment benefit in accordance with 907 KAR 1:479

A PRTF may not charge a beneficiary or responsible party representing a beneficiary any difference between private and semiprivate room charges.

Non-Covered Services

Services are not be covered if appropriate alternative services are available in the community. The following are not covered:

  • Admissions that are not medically necessary
  • Individuals with a major medical problem or minor symptoms
  • Individuals who might only require a psychiatric consultation rather than an admission to a psychiatric facility
  • Individuals who might need only adequate living accommodations, economic aid or social support services.

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 for PRTF I services is provided by 907 KAR 9:020.

Prior Authorizations

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​ to process Medicaid claims. Each MCO contracts with its own billing agent.


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.

Claim Appeals

Appeal requests made on denied claims must be submitted to Gainwell. The request must include the reason for the request along with a hard copy claim.

Timely Filing

Claims must be received within 12 months of the date of service or six months from the Medicare pay date whichever is longer, or within 12 months of the last Kentucky Medicaid denial.

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 - (800) 807-1232
  • General Provider Questions - (855) 824-5615
  • Office of Transportation Delivery at (888) 941-7433
  • Prior Authorization - Gainwell - (800) 292-2392, (800) 664-5725, (800) 807-8842
  • Provider Enrollment or Revalidation - (877) 838-5085
  • assistance -DXC - (800) 205-4696
  • 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

Contact Information