KY Medicaid classifies behavioral health services (BHSO) as provider type (03). To enroll in or bill Kentucky Medicaid, BHSO service providers must be:
Covered Services
BHSO services are medically necessary services provided by behavioral health specialists through face-to-face interaction with a beneficiary who has a mental and/or substance abuse disorder. Services include assessment, service planning, Individual outpatient therapy, group outpatient therapy, collateral outpatient therapy and crisis intervention services, family outpatient therapy and other behavioral health services.
BHSO must meet coverage provisions and requirements of 907 KAR 15:020 and 907 KAR 15:022 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 KY Medicaid regulations. All services must be medically necessary.
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
Reimbursement for BHMSG services as described in the Behavioral Health Fee Schedule and 907 KAR 15:015.
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 same service is covered during the same time period.
Prior Authorizations
Gainwell Technologies provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Claims Submission
KY Medicaid currently contracts with Gainwell Technologies to process FFS claims. Each MCO processes its own claims.
Coding
Kentucky Medicaid uses the National Correct Coding Initiative (NCCI) edits as well as the McKesson Claim Check System to verify codes 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 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. Please refer to the MCO when appealing an MCO claim.
Timely Filing
Claims must be received within 12 months of the date of service 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 when appealing an MCO claim.
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 - Gainwell Technologies - (800) 292-2392
Provider Enrollment or Recertification - (877) 838-5085
KyHealth.net assistance - Gainwell Technologies - (800) 205-4696
CHFS DMS BH and SU Inquiries - (502) 564-6890
Pharmacy Questions - (502) 564-6890 or dmsweb@ky.gov
Pharmacy Clinical Support Questions - (877) 403-6034
Pharmacy Prior Authorization - (877) 403-6034
Physician Administered Drugs (PAD) list - (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- (800) 578-0775
UnitedHealthCare Commmunity Plan - (866) 633-4449
WellCare of KY - (877) 389-9457
*Effective Jan. 1, 2025, Anthem is no longer an active Medicaid Managed Care Organization, or MCO, in Kentucky. However, they are responsible for the payment of claims, appeals, or disputes for dates of service up to and including Dec. 31, 2024.