Kentucky Medicaid identifies early periodic screening diagnosis and treatment services as Special Services Type (45). To enroll and bill KY Medicaid, EPSDT services provider must:
- Contact the DMS EPDST coordinator at (502) 564-9444 prior to enrollment
- Be licensed in the state in which it operates.
- Be enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary for whom it provides services.
What are EPSDT Special services?
EPSDT special services may be preventive, diagnostic/treatment or rehabilitative. Examples of covered services include:
- Additional pairs of eyeglasses after the Medicaid Vision Program has paid for the first two pair in a year.
- Additional dental cleanings after the Medicaid Dental Program has paid for one cleaning.
- Nitrous oxide used in dental treatment.
- Nutritional products used as a supplement rather than as the child's total nutrition.
All EPSDT special services require prior authorization.
Some services the EPSDT special services does not cover include:
- Respite care
- Environmental services
- Educational services
- Vocational services
- Cosmetic services
- Convenience services
- Experimental services
- Over-the-counter items
How do I verify beneficiary eligibility?
Verify eligiblity by contacting the automated voice Response System at (800) 807-1301 or using the Web-based KYHealth-Net System .
EPSDT service providers must meet the coverage provisions and requirements of 907 KAR 11:034 to provide covered services. Any services performed must fall within the scope of practice for the provider. Listing of a service in an administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.
Reimbursement for EPSDT services regulation: 907 KAR 11:035.
Duplication of Service
The department 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 period.
CareWise provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
KY Medicaid currently contracts with DXC to process FFS service claims. Each MCO processes its own claims.
KY 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. KY Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system (HCPCS) codes. KY Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. KY Medicaid requires the use of CMS 1500 billing forms. Providers will need to bill KY Medicaid using the correct CPT codes.
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 if appealing an MCO claim.
Claims must be received within 12 months from the date of service or six months from the Medicare pay date, whichever is longer, or within 12 months of the last KY 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:
Billing Questions - DXC - (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Recertification - (877) 838-5085
KyHealth.net assistance - DXC - (800) 205-4696
CHFS DMS BH and SU Inquires - (502) 564-6890
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071
Pharmacy Prior Authorization - (800) 477-3071
Physician Administered Drugs (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
Report Fraud and Abuse
907 KAR - Cabinet for Health and Family Services - DMS Title page
907 KAR 3:130 Medical necessity and clinically appropriate determination basis
907 KAR 11:034 Early and periodic screening, diagnosis, and treatment services and early and periodic screening, diagnosis, and treatment special services
907 KAR 11:035 Payments for early and periodic screening, diagnosis, and treatment services and early and periodic screening, diagnosis, and treatment special services
MAP-005 - EPSDT Dental Evaluation Form MAP-9 - Prior Authorization for Health Services and Instructions MAP-650 - EPSDT Home Health Fax Form
Statement of Diligent Search
Provider Billing Instruction Home
EPSDT Services Billing Instructions