Nursing Facility Services - PT (12)

​​​​​​​​​​​​​​​​​​​​​​Nursing facility (NF) programs are Kentucky Medicaid Provider Type (12). To bill Kentucky Medicaid, NF ​providers must be:

  • Licensed in Kentucky. NFs must contact the Office of Inspector General Division of Health C​are 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. 

Covered Services

NF services are for individuals who require high-intensity nursing care or rehabilitation services. The per diem rate covers room and board, dietary services, nutritional supplements, social services and activities, respiratory therapy and supplies, nursing services, the use of equipment and facilities, medical and surgical supplies, prosthetic devices, laundry services, drugs ordered by the physician and personal items routinely provided by the facility. Other services, if medically necessary and ordered by a physician, may include x-rays, physical therapy, speech therapy, occupational therapy, laboratory services, oxygen, and related oxygen supplies and may be billed separately from the per diem rate.​

NF service providers must meet the coverage provisions and requirements of 907 KAR 1:022, 907 KAR 1:023, 907 KAR 1:037, and 907 KAR 1:755. 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 Kentucky Medicaid regulations and the requirements of the MCO in which they participate, if applicable. All services must be medically necessary.


Individuals may be eligible for nursing facility services if they: 

  • Reside in a facility participating in the Kentucky Medicaid program and are placed in a Medicaid-certified bed. 
  • Meet the nursing facility level of care criteria defined in 907 KAR​ 1:022.
  • Meet the income and resource limitations required by the program.

All individuals applying for admission to or residing in a nursing facility must undergo a preadmission screening and resident review (PASRR) evaluation.  For information on completing the Level I screening and Level II evaluation, visit the Department for Behavioral Health, Developmental and Intellectual Disabilities PASRR website where you can access forms, guidance, and regulations.

Nursing facilities must use the Kentucky Level of​ Care System (KLOCS)​ to submit and manage level of care applications for individuals. ​

Verify Eligibility

Verify eligibility by calling the automated voice response system at (800) 807-1301 or using the web-based KYHealth-Net System.


Nursing facilities are reimbursed per 907 KAR 1:025, 907 KAR 1:042, 907 KAR 1:065 and 907 KAR 1:780.

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 period.

Bed Reserve Days

If certain criteria are met, Medicaid reimburses a nursing facility when a beneficiary is:

  • Admitted to an acute care hospital; or 
  • Receiving therapeutic home visits.

Bed reservation days are not available for beneficiaries admitted to a psychiatric hospital.

When Medicaid is paying bed reservation days, the nursing facility will allow the beneficiary to return any day of the week, including holidays or weekends. If the nursing facility chooses not to reserve a bed for a beneficiary who is eligible for Medicaid bed reservation days, the nursing facility must inform the beneficiary before departure from the facility.

The nursing facility is responsible for assuring services and items ordered by a beneficiary's physician are provided when Medicaid is billed to reserve the bed, except when the beneficiary is hospitalized. During hospitalization, the hospital must provide any required services and items. If the nursing facility cannot provide the required ancillaries directly, the facility must make arrangements with 10 qualified sources  (i.e., pharmacy, physical therapist, speech therapist, etc.) for the resident to receive the required services and items. Pharmacies bill Medicaid directly. Therapists and other service providers bill the facility. If the beneficiary receives an ancillary service or item that Medicare Part B covers, the nursing facility must bill Medicare before seeking reimbursement from Medicaid.

Criteria for Bed Reservation Days 

  • The beneficiary is in Medicaid long-term care vendor payment status and has been a resident of the facility at least overnight. Persons for whom Medicaid is making Part A coinsurance payments are not in Medicaid payment status for purposes of this policy.
  • The beneficiary is reasonably expected to return to the same facility with Medicaid as the primary payer. If returning to the same facility with Medicare as the primary payer, bed reservation days will be available only up to the period Medicare eligibility is determined, provided the bed reservation day maximums are not exceeded.
  • If, due to a demand for beds at the facility, it is likely that the bed would be occupied by other residents were it not reserved.
  • The hospitalization is in an acute care hospital or a Kentucky hospital certified to participate in the acute care hospital program. The hospitalization is approved by Carewise.
  • If hospitalization is approved and the bed occupied by the resident also is a Medicaid-certified acute care bed, the resident will have been transferred to a specialty unit of a hospital.

Limitations on Medicaid reimbursement for bed reservation days

  • A maximum of 14 days per calendar year due to an acute care hospital stay.
  • A maximum of 10 days per calendar year for leaves of absence other than hospitalization.
  • Reimbursement is 75 percent of the facility rate if the facility has an occupancy rate of 95 percent or more.
  • Reimbursement is 50 percent of the facility rate if the facility has an occupancy rate of less than 95 percent.

Maximums are applied per beneficiary per calendar year. Accumulated bed reserve days will follow a beneficiary rather than starting over at zero at a new relocation.

Prior Authorization

CareWise provides prior authorization for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.

Claims Submission

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 UB-04 billing forms. Providers must bill Kentucky Medicaid using the CPT codes.

Claim Appeals

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.

Timely Filing

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 of the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim.

Provider Support

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 assistance - Gainwell - (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
Report Medicaid fraud and abuse - (800) 372-2970

MCO Contacts 

Anthem - (800) 205-5870
Aetna Better Health of KY - (855) 300-5528
Humana - (800) 444-9137
Molina - (800) 578-0775
United Health Care Communit​​y Plan - (866) 633-4449
WellCare of Kentucky - (877) 389-9457​


902 KAR - Department of Public Health
902 KAR 20:046 - Facility specifications; nursing homes
902 KAR 20:048 - Operation and services; nursing homes
907 KAR - Cabinet for Health and Family Services - DMS Title page 
907 KAR 1:022 Nursing facility services and intermediate care facility services
907 KAR 1:023 Review and approval of selected therapies as ancillary services in an NF
907 KAR 1:025 Payment for services provided by an intermediate care facility for individuals with an intellectual disability, a dually-licensed pediatric facility, an institution for mental diseases, or a nursing facility with an all-inclusive rate unit. 
907 KAR 1:037 Hospital furnished nursing facility services
907 KAR 1:042 Amounts payable for hospital furnished skilled nursing and intermediate care facility services
907 KAR 1:065 Payments for price-based nursing facility services
907 KAR 1:563 Medicaid covered services appeals and hearings unrelated to managed care 
907 KAR 1​​:755 Preadmission Screening and Resident Review Program 
907 KAR 1:780 Converted dual-licensed hospital-based nursing facility beds 
907 KAR 3:130 Medical necessity and clinically appropriate determination basis

PASRR Information​

PASRR guidance, forms, and regulations ​
How to Complete a Significant Change

Level of Care Information

Kentucky Level of Care System (KLOCS)
KLOCS NF Hospice ICF User Guide

Policy Information

Kentucky Medicaid Provider Directory 
Nursing Facility Listing
PT 12 - Nursing Facility Provider Summary

Provider Letters

Find Provider Letters 
Nursing Facility PL #​A-265 - MAP-350 Changes
Nursing Facility PL #A-259 - Nurse Aide Training and Testing Updates

Nursing Facility Resources

​Technical Criteria for Reviewing Ancillary Services - Adults and Pediatrics​ ​
Nurse Aide Training Information
CMS Nursing Home Quality Initiative (NHQI)
Nursing Home Compare
OIG Nursing Home Inspection Findings
Program of All-Inclusive Care for the Elderly


Find MAP Forms
MAP-350 - Certification Form
MAP-703 - Request for Reconsideration Ancillary Therapy Billing

​Billing Information

Find Provider Billing Instructions

Fee Schedules

Find Fee and Rate Schedules 
Nursing Facility Rates
Jan. 2024: PDF - Excel
Oct. 2023: PDF - Excel
July 2023: PDF - Excel
April 2023: PDF - Excel
Jan. 2023: PDF - Excel
Oct. 2022: PDF - Excel
July 2022: PDF - Excel
April 2022: PDF - Excel
Jan. 2022: PDF - Excel​​
Oct. 2021 Nursing Facility Rates
April 2021 Nursing Facility Rates 

Contact Information