Optometrist are recognized in Kentucky Medicaid as Provider Type PT-77. In order to enroll
as an Optometrist with Kentucky
Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
Vision benefits expanded to adults effective 1/1/2023, all codes payable to adults and children except V2744. TPL Vision Insurance must be billed primary to Medicaid. For Medicare/Medicaid dually eligible members, bill as a straight claim. (This does not apply to QMB members) It is the reasonability of the provider to check member eligibility. One pair of glasses per calendar year per member.
- More than one (1) pair of eyeglasses per recipient per calendar year require submission of a claim and signed documentation by Optometrists/Ophthalmologists stating the reason the additional pair is required. The provider will submit the claim on paper and attach documentation stating why the second pair of glasses is needed in a calendar year and that document must be signed by the eye doctor or the provider can submit a claim on KYHealth Net, the provider portal, and attach the document required.
Optometrists must meet the coverage provisions and requirements of in 907 KAR 1:632 to provide covered services. Any services performed must fall within the scope of practice for the provider. A service listing in an administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.
Non-Covered Services
Contact Lenses must be medically necessary per regulation. Procedures not considered medically necessary shall not be covered by Kentucky Medicaid. For example, Kentucky Medicaid shall not reimburse for
- telephone consultation;
- service with a CPT code or item with an HCPCS code that is not listed on the Department for Medicaid Services Vision Program Fee Schedule
Verify eligibility
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based
KYHealth-Net System.
Reimbursement
Reimbursement for Optometrist is listed
on the Kentucky Medicaid Vision
fee schedule which can be found on the Fee and Rate Schedule Home Page.
Reimbursement for optometrist services is provided in the Vision Fee Schedule and defined in
907 KAR 1:631.
A provider may request coverage for a CPT or HCPCS procedure code by submitting a request in writing to the department which includes necessity, CPT or HCPCS code, and expected reimbursement. Any codes considered experimental are not covered by Kentucky Medicaid.
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.
Prior Authorization
Each MCO provides prior authorization for its beneficiaries.
No Prior Authorization is needed for Vision fee-for-service(FFS) beneficiaries.
Claims Submission
Each MCO processes its own claims.
Kentucky Medicaid contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. For more information, visit KYHealth-Net.
Coding
Kentucky Medicaid requires Optometrist providers to bill on a CMS-1500 claim form utilizing the following code types where applicable:
- Current Procedure Terminology (PT) codes, regulated by the American Medical Association (AMA).
- Healthcare Common Procedure Coding System (HCPCS) codes, regulated by the Centers for Medicare and Medicaid Services (CMS).
- Current Dental Terminology (CDT) codes, regulated by the American Dental Association (ADA).
- International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes, maintained by the Centers for Disease Control & Prevention (CDC) and the National Center for Health Statistics (NCHS).
Kentucky Medicaid uses the Medicare National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits, the Medicaid Medically Unlikely Edits (MUEs), and the McKesson Claim Check System to verify codes mutually exclusive or incidental.
Claim Appeals
Appeal requests for denied FFS claims must be submitted to Gainwell Technologies. The request must include the Provider Inquiry Form, reason for the appeal, and a hard copy claim.
Please refer to the member's MCO if appealing an MCO claim.
Timely Filing
Claims must be received within twelve (12) months from the date the service was provided, twelve (12) months from the date retroactive eligibility was established, or six (6) months of the Medicare adjudication date if the service was billed to Medicare.
Provider Inquiry Resources
If you cannot find the information you need or have additional questions, please direct your inquiries to:
- Billing Questions- Gainwell Technologies, (800) 807-1232, ky_provider_inquiry@gainwelltechnologies.com
- Provider Questions- (855) 824-5615
- Prior Authorization- Gainwell Technologies, (800) 292-2392, (800) 644-5725, (800) 807-8842
- Provider Enrollment, Maintenance, and Revalidation- (877) 838-5085
- KYHealth.net assistance- Gainwell Technologies, (800) 205-4696, ky_edi_helpdesk@gainwelltechnolgies.com
- Pharmacy Questions- (502) 564-6890, dmsweb@ky.gov
- Pharmacy Clinical Support Questions- (800) 477-3071
- Pharmacy Prior Authorization- (844) 336-2676
- Physician Administered Drug (PAD) list- (502) 564-6890
Provider MCO Information
*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.