Early Periodic Screening, Diagnosis, and Treatment services are billed under the provider type of the rendering provider. To enroll in Kentucky Medicaid, providers must be:
- Licensed in the state where they operate.
- An active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.
Covered
EPSDT Services
The following are the required EPSDT services for children birth to age 21.
- Screening
- Well Child Visits, which include a comprehensive exam, health, and developmental history, appropriate immunizations, health education, and labs.
- Vision Services
- Services include eyeglasses.
- Dental Services
- Services include relief of pain and infections, restoration of teeth, and maintenance of dental health.
- Hearing Services
- Services include hearing aids
- Such other necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) of the Social Security Act to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan.
Periodicity Schedule
Screenings, vision, and hearing services that meet reasonable standards of medical practice must be provided at intervals which follow a nationally recognized pediatric periodicity schedule (i.e., Bright Futures). A separate dental periodicity schedule must also be followed.
Reimbursement
EPSDT services are reimbursed per 907 KAR 11:035.
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 Authorizations
Each MCO provides prior authorization for its beneficiaries.
Gainwell Technologies provides prior authorizations for fee-for-service (FFS) beneficiaries. For more information, visit Prior Authorizations.
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 providers to bill on a CMS-1500 claim form utilizing the following code types where applicable:
- Current Procedure Terminology (CPT) 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.
Questions
If you cannot find the information you need or have additional questions, please review the Kentucky Medicaid Contact List to find additional support from Kentucky Medicaid.