Radiology services are recognized in Kentucky Medicaid as Provider Type (86). In order to enroll and bill Kentucky Medicaid, Radiology service providers must be:
- Enrolled as a Medicare Provider (and certified by Medicare to provide the given service)
- Licensed in Kentucky or the state in which they participate. Radiology service providers must contact the Kentucky Board of Medical Imaging and Radiation Therapy
- Enrolled as a Kentucky Medicaid provider and, if applicable, enrolled with the Managed Care Organization (MCO) of any beneficiary it serves.
Covered Services
Radiology is a medical specialty that uses imaging to diagnose and treat diseases seen within the body. They include x-rays, ultrasounds, magnetic resonance imaging (MRI), computer-assisted tomography, and therapeutic imaging. Services covered by Kentucky Medicaid are those listed on the Kentucky Medicaid Physician Fee Schedule. These are limited to procedures provided by a facility licensed to provide radiological services.
Nuclear Medicine is covered through the Pharmacy Program.
Radiologists must meet the coverage provisions and requirements set forth in
907 KAR 1:028. Any 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 all relevant Kentucky Medicaid regulations. Providers must also follow the requirements of the MCO for which they participate. All services must be medically necessary.
CT Scan Diagnoses
The Department for Medicaid Services reviews the medical necessity of CT scans performed for Medicaid patients. Diagnoses unrelated to the medical conditions/reasons for CT scans are not allowed. Inaccurate diagnosis coding may result in the denial or recovery of services because the medical necessity of the scan cannot be determined. Medicaid funds can be used only for medically necessary 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
Kentucky Medicaid shall reimbursement radiologist to provide radiological services to a beneficiary for the providers usual and customary charge for services; and not to exceed 60% of the upper payments limit established for the procedure in the Medicaid physician fee schedule pursuant to
907 3:010.
A radiology service actually consists of two parts. The professional component (PT 64/65) which is covered by the physician regulations and physician fee schedule. The technical component (PT 86) is covered by the Lab and Radiological Services Coverage and Reimbursement regulation. The reimbursement rates for PT (86) are found on the Physician 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.
Prior Authorization
Radiology providers are not responsible for obtaining prior authorization. Any necessary prior authorization should be obtained by the prescribing provider. Gainwell provides prior authorizations for any For Fee for Service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Claims Submission
Kentucky Medicaid currently contracts with Gainwell to process 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 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 CMS 1500 billing forms. 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:
- FFS Billing Questions - Gainwell- (800) 807-1232
- General 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 -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