Rural Health Clinics are recognized in Kentucky Medicaid as Provider Type 35. In order to enroll as a Rural Health Clinic with Kentucky Medicaid, see the Kentucky Medicaid
Provider Enrollment website.
Covered Services
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
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based
KYHealth-Net System.
Reimbursement
Reimbursement for Rural Health Clinics are listed on the Kentucky Medicaid fee schedule located at the following link: Fee Schedules
Reimbursement for Rural Health Clinics is defined in regulation (907 KAR 1:055)
A provider may request coverage for a CPT or HCPCS procedure code by submitting a request in writing to the department which includes necessity, CPT or HCPCS code, and expected reimbursement. Any codes considered experimental are 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 same service is covered, during the same time.
Prior Authorizations
Each MCO provides prior authorization for its beneficiaries.
Gainwell Technologies provides prior authorizations for fee-for-service (FFS) beneficiaries. For more information, visit Prior Authorizations.
Claims Submission
Each MCO processes its own claims.
Kentucky Medicaid contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. For more information, visit KYHealth-Net.
Coding
Kentucky Medicaid requires Rural Health Clinic providers to bill on a CMS-1500, UB-04, or ADA claim form utilizing the following code types where applicable:
- Current Procedure Terminology (CPT) codes, regulated by the American Medical Association (AMA).
- Healthcare Common Procedure Coding System (HCPCS) codes, regulated by the Centers for Medicare and Medicaid Services (CMS).
- Current Dental Terminology (CDT) codes, regulated by the American Dental Association (ADA).
- International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes, maintained by the Centers for Disease Control & Prevention (CDC) and the National Center for Health Statistics (NCHS).
Kentucky Medicaid uses the Medicare National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits, the Medicaid Medically Unlikely Edits (MUEs), and the McKesson Claim Check System to verify codes mutually exclusive or incidental.
Claim Appeals
Appeal
requests for denied FFS claims must be submitted to Gainwell Technologies.
The request must include the Provider Inquiry Form, reason for the appeal, and a hard copy claim.
Please refer to the member's MCO if appealing an MCO claim.
Timely Filing
Claims must be received within twelve (12) months from the date the service was provided, twelve (12) months from the date retroactive eligibility was established, or six (6) months of the Medicare adjudication date if the service was billed to Medicare.
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