School-Based Health Services (SBHS) - PT 21

​​Kentucky Medicaid identifies school-based health services (SBHS) as Provider Type (21). To enroll and bill Kentucky Medicaid, a SBHS service provider must be: 

Covered Services

The Kentucky Department of Education allows local education agencies to enroll as Medicaid health service providers for beneficiaries enrolled in or eligible for the Medicaid program and under the Individuals with Disabilities Education Act (IDEA). SBHS are evaluative, diagnostic, preventive and treatment services provided for the maximum reduction of physical or intellectual disability, to allow for functioning of the beneficiary to the best possible level, to prevent loss of current functional level or correct any defects or conditions. 

What is  Expanded Access in Schools?

SBHS services must be medically necessary or listed in the child's individual education plan (IEP) and meet the coverage provisions and requirements of 907 KAR 1:715. All services must be performed in the scope of practice for any provider. Listing of a service in an administrative regulation is not a guarantee of payment. Providers must follow all relevant Kentucky Medicaid regulations.  


  • Children ages three to 21 enrolled in or eligible for Medicaid under provision of and the Individuals with Disabilities Education Act and who have an IEP are eligible for school-based health services.
  • Parents must be advised annually that the school intends to bill Medicaid for a child's services. A parent may refuse to allow the school to bill.
  • Speech therapy, occupational therapy, physical therapy and mental health services may be provided in an individual or group setting.
  • Children who receive school-based health services are not prohibited from receiving services through the EPSDT program. When medically necessary, services may be covered through both programs

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 SBHS is in accordance with 907 KAR 1:715.

​Duplication of Service

The department will 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.

Prior Authorizations

Some services may require prior authorization. Just because a service is listed in the administrative regulation does not guarantee payment for the service.

Claims Submission

KY Medicaid currently contracts with Gainwell Technologies to process FFS claims.


Kentucky Medicaid uses the National Correct Coding Initiative edits as well as the McKesson Claim Check System to verify codes mutually exclusive or incidental. Kentucky Medicaid also uses Current Procedural Terminology codes and Healthcare Common Procedure Coding system (CPT) 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 must bill Kentucky Medicaid using the correct CPT codes.

Claim Appeals

Appeal requests of denied FFS claims must be submitted to Gainwell Technologies. The appeal request must include the reason for the appeal along with a hard copy claim.

Timely Filing

Claims must be received within 12 months of the date of service 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 Technologies - (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Recertification - (877) 838-5085 assistance - Gainwell Technologies - (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071
Pharmacy Prior Authorization - (800) 477-3071
Physician Administered Drugs (PAD) list - Pharmacy Branch - (502) 564-6890​

Report Fraud and Abuse

(800) 372-2970


907 KAR - Cabinet for Health and Family Services - DMS Title page

907 KAR 1:715 School-based health services

907 KAR 3:130 Medical necessity and clinically appropriate determination basis

Provider Resources

Medicaid SBHS Technical Assistance Guide
Medicaid SBHS Program Information from Kentucky Department of Education
PT 21 - SBHS Provider Summary 
Provider Le​tters​ 


MAP-735 - Quarterly Certification of State Expenditures by School Districts

Billing Information

Provider Billing Instruction Home 
School-Based Services Billing Instructions

Fee and Rate Schedule Page

Contact Information