Private Duty Nursing (PDN) services are Kentucky Medicaid Provider Type (18). To bill Kentucky Medicaid, PDN service providers must be:
- Licensed in the state in which they operate. In Kentucky, PDN service providers must contact the Office of Inspector General, Division of Health Care for a survey/license.
- Enrolled as an active Kentucky Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary for whom it provides services.
PDN services are provided to individuals who require more continuous care than what is available through Home Health or is routinely provided by a hospital or skilled nursing facility. PDN services are prescribed and managed by a physician and provided in the individual's home. PDN may be covered in other settings if the service is provided when the individual is taking part in normal life activities outside of the home.
PDN service providers must meet the coverage provisions and requirements of 907 KAR 13:010. Services must be performed within the scope of practice for any provider. Listing of services in an administrative regulation is not a guarantee of payment. Providers must follow all relevant state Medicaid regulations and the requirements of the MCO in which they participate, if applicable. All services must be medically necessary.
Verify eligibility by calling the automated voice response system at (800) 807-1301 or using the web-based KYHealth-Net System.
PDN services are reimbursed per 907 KAR 13:015.
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 period.
CareWise provides authorizations for fee-for-service beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process Kentucky Medicaid FFS 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 incidental or mutually exclusive codes. 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 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 from the date of service or six months from the Medicare pay date or within 12 months from the last Kentucky Medicaid denial. Please refer to the MCO if 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 - CareWise - (800) 292-2392
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 Kentucky - (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