Kentucky Medicaid identifies audiology services as Provider Type (70) individual or (709) group. To enroll and bill Kentucky Medicaid, audiology service providers must be:
- Licensed in the state where they practice. In Kentucky, audiology service providers must contact the
Kentucky Board of Speech-Language Pathology and Audiology.
- Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary for whom it provides services.
Eligible services are medically necessary, limited to one complete hearing evaluation per the calendar year and may include a hearing instrument evaluation which includes three follow-up visits:
- Within the six-month period immediately following fitting with a hearing instrument; and
- Related to the proper fit and adjustment of the hearing instrument including one additional follow-up visit at least six months following the hearing instrument fitting and related to the proper fit and adjustment of the hearing instrument.
Referral by a physician to an audiologist is required. The department will not cover an audiology service without a referral from a physician
Additional services may be included if the beneficiaries' health care provider demonstrate that an additional hearing instrument evaluation is medically necessary
Audiologist service providers must meet the coverage provisions and requirements of
907 KAR 1:038 to provide covered services. 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 Kentucky Medicaid regulations. All services must be medically necessary.
How do I verify eligibility?
Verify eligibility by contacting the automated voice response system at (800) 807-1301 or by using the web-based
Kentucky Medicaid does reimburse for routine screening of an individual or group of individuals for identification of a hearing problem; hearing therapy and lip-read reading instruction except as covered through the six-month adjustment counseling following the fitting of a hearing instrument; a service for which the beneficiary has no obligation to pay and for which no other person has a legal obligation to provide or to make payment; a telephone call.
Reimbursement for physician services is in accordance with the Audiology Fee Schedule and
907 KAR 1:039.
When more than one covered procedure is performed in a single operative session, reimbursement for facility services will be 100 percent of the surgical group rate for the primary procedure and 50 percent of the surgical group rate for the secondary procedure.
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 same 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 the Kentucky Medicaid FFS claims. Each MCO processes its own claims.
Kentucky Medicaid uses 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 need to bill Kentucky Medicaid using the correct CPT codes.
Appeals of FFS claim denials must be submitted to Gainwell Technologies. The appeal request must 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 within 12 months of the date of service (DOS) or six months from the Medicare pay date, whichever is longer, or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim.
Provider Contact Information
If you 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
KyHealth.net 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
Provider MCO Information
Anthem - (800) 205-5870
Aetna Better Health of KY - (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