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Private Duty Nursing (PDN) Services are identified by Kentucky Medicaid as Provider Type (18). In order to enroll and bill Kentucky Medicaid, Private Duty Nursing 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 a Medicaid active provider and, if applicable, enrolled with the managed care organization of any beneficiary for whom it provides services.

Covered Services

PDN services are under the direction of the beneficiaries physician in accordance with 42 C.F.R. 440.80. Prescribed for the beneficiary by a physician, and stated in the beneficiaries' plan of treatment developed by the prescribing physician; Established as being needed for the beneficiary in their home; prior authorized; and medically necessary. 

A private duty nursing service may be covered in a setting other than in the beneficiaries' home if the service is provided during a normal life activity of the beneficiary that requires them to be out of their home.  There shall be a limit of private duty nursing services per beneficiary of 2,000 hours per 12 consecutive month period. 
The limit established in paragraph (a) of this subsection may be exceeded if services in excess of the limit are determined to be medically necessary.

PDN entities must meet the coverage provisions and requirements set forth in 907 KAR 15:010  for services provided by participating providers. All services must be performed within the scope of practice for any provider.  Providers must follow the regulations and requirements of the MCO for which they participate. Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow Kentucky Medicaid regulations and must the requirements of the MCO for which they participate. All services must be medically necessary.

How do I verify eligibility? 

You may verify eligibility by contacting the automated voice response system at (800) 807-1301 or using the Web-based KYHealth-Net System.

Reimbursement

Reimbursement for PDN will be at a rate of nine dollars per 15 minutes, which one unit; not reimbursement for more than 96 units per 24 hour period; 8000 unit per 12 consecutive month period per beneficiary and reimbursement for supplies as established on the PDN Nursing Supplies Fee Schedule and 907 KAR 15:015.

Duplication of Service

The department shall 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

 For Fee for Service beneficiaries who require prior authorization for additional services that are deemed medically necessary, contact CareWise. For MCO beneficiaries who require prior authorization for additional services that are medically necessary, contact the beneficiaries MCO for more information.

Claims Submission

Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid fee for service (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 that are 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 will need to bill Kentucky Medicaid using the correct CPT codes.

Claim Appeals

Appeal requests made on denied FFS claims must be submitted to DXC. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO in question, if appealing an MCO claim.

Timely Filing

Claims must be received within 12 months from the date of service (DOS) or 6 months from the Medicare pay date whichever is longer, or within 12 months from the last Kentucky Medicaid denial. Please refer to the MCO in question, 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 - DXC - (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth.net assistance - DXC - (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 

Contact Information

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