Rural Health Clinics (RHC) are Kentucky Medicaid Provider Type (35). To bill Kentucky Medicaid, RHC service providers must be:
- enrolled in Medicare
- enrolled as a Kentucky Medicaid provider
- enrolled with the managed care organization of any beneficiary it serves
RHCs were established to address the shortage of physicians serving patients in rural areas. The establishment of RHCs increases the use of non-physician providers such as nurse practitioners, physician assistants and certified nurse-midwives in rural areas. RHCs are federally designated through the Centers for Medicare and Medicaid Services (CMS).
RHC facilities must meet the coverage provisions and requirements of 907 KAR 1:082. Services must be performed within the scope of practice for any provider. Listing of services in an administrative regulation is not a guarantee of payment. Providers must follow all relevant state Medicaid regulations. All services must be medically necessary.
Non covered Services
The following services are not be covered as RHC: services provided in a hospital as defined in
42 U.S.C. 1395x(e); institutional services such as housekeeping, babysitting or similar homemaker services; services not provided in accordance with legal/regulatory restrictions.
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.
RHC services are reimbursed per 907 KAR 1:055.
Duplication of Service
The department does 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.
CareWise provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process FFS claims. Each MCO processes its own claims.
Kentucky Medicaid uses the National Correct Coding Initiative edits and the McKesson Claim Check System to verify mutually exclusive or incidental codes. Kentucky Medicaid also uses Correct 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.
Appeal requests made on denied FFS claims must be submitted to Gainwell Technologies and 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 the longer of either 12 months from the date of service or six months from the Medicare pay date or within 12 months from 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 Technologies - (800) 807-1232
General Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
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
Anthem - (800) 205-5870
Aetna Better Health of Kentucky - (855) 300-5528
Humana - (855) 852-7005
Passport Health Plan by Molina - (800) 578-0775
United Healthcare Community Plan - (866) 633-4449
WellCare of Kentucky- (877) 389-9457