Kentucky Medicaid identifies Psychiatric Distinct Part Unit (DPU) providers as Provider Type (92). To enroll and bill Kentucky Medicaid, DPU service providers must:
- be an active Medicare DPU provider.
- meet the requirements of 42 CFR 412.25.
- contact the Office of Inspector General Division of Health Care for a survey/license.
- be enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.
In addition to 25 in-patient critical access hospital (CAH) beds, a CAH also may operate a psychiatric and/or rehabilitation DPU with up to 10 beds. These units must comply with the hospital conditions of participation.
Psychiatric DPUs must meet the coverage provisions and requirements in 906 KAR 1:110 to provide covered services. Any services performed must fall within the scope of practice for the provider. Listing of services in an administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Psychiatric DPU services are reimbursed per 907 KAR 10:815.
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 period.
CareWise provides prior authorizations for any fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process FFS claims. Each MCO processes its own claims.
Kentucky Medicaid utilizes the National Correct Coding Initiative (NCCI) edits as well as 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 (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 will need to bill Kentucky Medicaid using the correct CPT codes.
Appeal requests made on denied FFS claims must be submitted to Gainwell Technologies. The 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 the longer of either 12 months of the date of service or six months from the Medicare pay date 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
General Provider Questions - (855) 824-5615
Office of Transportation Delivery at (888) 941-7433
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth.net assistance - (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 KY -(855) 300-5528
Humana - (855) 852-7005
Passport Health Plan- (800) 578-0775
WellCare of KY - (877) 389-9457