Optometrist services are recognized as Kentucky Medicaid Provider Type (77) individual, or (779) group. To enroll or bill Kentucky Medicaid, optometrist provider services must be:
Optometrists primarily perform medically necessary eye exams and vision tests, prescribe and dispense corrective lenses, detect certain eye abnormalities and prescribe medications for certain eye diseases. Most examinations and certain diagnostic procedures performed by ophthalmologists and optometrists are covered for all ages.
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.
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.
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.
Reimbursement for optometrist services is provided in the Vision Fee Schedule and defined in 907 KAR 1:631.
Duplication of Service
Kentucky Medicaid does not reimburse for a service provided by more than one provider of any program in which the service is covered during the same time period.
CareWise provides prior authorizations for fee-for-service beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process the Kentucky Medicaid fee-for-service claims. Each MCO processes its own claims.
Kentucky Medicaid uses the National Correct Coding Initiative 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 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.
Appeal requests made on denied fee-for-service 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 within 12 months pf the date of service or six months from the Medicare pay date, whichever is longer, or within 12 of from the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim.
Provider Contact Information
Billing Questions - Gainwell Technologies - (800) 807-1232
Provider Questions - (855) 824-5615
Provider Enrollment or Revalidation - (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 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
Molina- (800) 578-0775
WellCare of KY - (877) 389-9457
Report Fraud and Abuse
907 KAR Cabinet for Health and Family Services - DMS Title page
907 KAR 1:631 Vision Program reimbursement provisions and requirements
907 KAR 1:632Vision Program coverage provisions and requirement
907 KAR 3:130 Medical necessity and clinically appropriate determination basis
Provider Letter Home
PT 77 - Optometrist Provider Summary
PT 77(9) - Optometrist Group Provider Summary
MAP- 9 - Prior Authorization for Health Services and
Provider Billing Instruction Home
Fee and Rate Schedules
Fee and Rate Schedule Home
2022 Vision Fee Schedule: PDF - Excel