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Adult day health care (ADHC) is Kentucky Medicaid provider type 43.  To enroll and bill Kentucky Medicaid, ADHC service providers must be:

  • Licensed to operate in Kentucky by the Office of Inspector General (OIG) Division of Health Care.
  • Enrolled as a Kentucky Medicaid provider

Covered Services

ADHC services are provided on site at a center where individuals 21 and older receive skilled nursing care, routine personal care and health care, meals and are part of daily activities.

An ADHC service provider must meet the requirements of 907 KAR 7:010. Services must be performed in 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.

How do I verify eligibility? 

You may verify eligibility by contacting the KYHealth-Net automated voice response system at (800) 807-130 or using the Web-based KYHealth-Net System.  

Reimbursement

Reimbursement for ADHC services is provided for by 907 KAR 7:015.

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 service is covered during the same period.

Service Authorizations 

Carewise Health no longer approvers services for 1915(c) HCBS waiver participants. Case managers approve most waiver services. Please read the service authorization provider letter for details. Kentucky Medicaid reviews requests for high-cost or high-skill services. If you have questions, please email the 1915(c) Waiver Help Desk or call (844) 784-5614. 

Claims Submission

Kentucky Medicaid currently contracts with Gainwell Technologies to process Medicaid fee-for-service claims. 

Coding

Kentucky Medicaid uses the National Correct Coding Initiative edits and the McKesson Claim Check System to verify incidental or mutually exclusive codes. Kentucky Medicaid also uses Current 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 must bill Kentucky Medicaid using the correct CPT codes.

Claim Appeals

Appeal requests made on denied fee-for-service claims must be submitted to Gainwell Technologies and include the reason for the request along with a hard-copy claim.

Timely Filing

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:
Billing Questions - Gainwell Technologies - (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - (844) 784-5614
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth-Net assistance - Gainwell Technologies - (800) 205-4696
1915(c) HCBS Waiver Policy Questions - (844) 784-5614
OIG Questions - (502) 564-7963

For more specific inquiries, see the 1915(c) HCBS waiver contacts listing.  
 

Contact Information

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