Kentucky Medicaid identifies Psychiatric Residential Treatment Facilities Level II (PRTF II) as Provider Type (5). In order to enroll and bill Kentucky Medicaid, PRTF II service providers must be:
- Licensed in Kentucky or the state in which they participate. PRTF II 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 (MCO) of any beneficiary it serves.
PRTF Level II facilities are covered for beneficiaries ages 6 to 21 who require treatment on a continuous basis as a result of a severe mental or psychiatric illness. It is designed to serve children who need long-term, more intensive treatment and a more highly structured environment than they can receive in family and other community-based alternatives to hospitalization. Less restrictive and more homelike than hospitals, these facilities also serve children's transitioning from hospitals, but who still are not ready for the demands of living at home or in a foster home.
- Chemical dependency treatment services if the need for the services is the primary diagnosis of the beneficiary. However, chemical dependency treatment services are covered as incidental treatment if minimal chemical dependency treatment is necessary for successful treatment of the primary diagnosis
- Outpatient services
- Pharmacy services covered as pharmacy services in accordance with 907 KAR 23:010
- Durable medical equipment covered as a durable medical equipment benefit in accordance with 907 KAR 1:479
- An admission that is not medically necessary
- An individual with a major medical problem or minor symptoms
- An individual who might only require a psychiatric consultation rather than an admission to a psychiatric facility
- An individual who might need only adequate living accommodations, economic aid or social support services.
PTRF II facilities must meet the coverage provisions and requirements set forth in
907 KAR 9:005 and
907 KAR 9:015. Any services must be performed, fall within the scope of practice for any provider. Listing of a service in the administrative regulation does not guarantee payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.
Exclusions and Limitations
The following are not to be covered as PRTF services:
A PRTF may not charge a beneficiary or responsible party representing a beneficiary any difference between private and semiprivate room charges.
Reimbursement for PRTF Level II services is in accordance with the
907 KAR 9:020.
Gainwell provides prior authorizations for any fee for service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries
Kentucky Medicaid currently contracts with
Gainwell to process the Kentucky Medicaid 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 codes that are mutually exclusive or incidental. Kentucky Medicaid uses Correct 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 UB 04 billing forms. Providers will need to bill Kentucky Medicaid using the correct Revenue codes.
Appeal requests made on denied claims must be submitted to Gainwell. The request must include the reason for the request along with a hard copy claim.
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.
Provider Contact Information
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Provider MCO Information