Independent occupational therapist (OT) services are recognized in Kentucky Medicaid as Provider Type (88) individual or (889) group. To enroll and bill Kentucky Medicaid, OT service providers must be:
If medically necessary, OT services are the assessment and intervention to develop, recover or maintain the meaningful activities or occupations of individuals, groups or communities. To receive services from an OT, an order must be signed by a KY Medicaid participating physician, advanced practitioner registered nurse, physician assistant or psychiatrist. (when applicable). A beneficiary may receive 20 visits per calendar year,
An OT provider must meet the coverage provisions and requirements of
907 KAR 8:010 to provide covered services. All services must be performed within the scope of practice for any provider. Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow Kentucky Medicaid regulations and requirements of the MCO for which it participates. All services must be medically necessary.
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Reimbursement for OT services is provided in 907 KAR 8:015 and the OT Rate Schedule.
Duplication of Service
If a beneficiary is receiving an occupational therapy service from an occupational therapist enrolled with the Medicaid Program, the department will not reimburse for the same occupational therapy service provided to the same beneficiary during the same time period via the home health program.
907 KAR 8:010 Section 2(2b) states the limits may be exceeded if services are determined to be medically necessary. Prior authorization by the department is required for each OT service that exceeds the limit for a beneficiary who is not enrolled with a MCO.
CareWise provides prior authorizations for any fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. Each MCO processes its own claims.
KY Medicaid uses the National Correct Coding Initiative (NCCI) edits as well as the McKesson Claim Check System to verify codes 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 must bill KY Medicaid using the correct CPT codes.
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.
Claims must be received within 12 months of the date of service or 6 months from the Medicare pay date, whichever is longer, or within 12 months of the last Kentucky 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:
FFS Billing Questions - Gainwell Technologies - (800) 807-1232
General Provider Questions - (855) 824-5615
Prior Authorization -
CareWise - (800) 292-2392
Provider Enrollment or Recertification - (877) 838-5085
KyHealth.net assistance -Gainwell Technologies - (800) 205-4696
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
Molina- (800) 578-0775
WellCare of KY - (877) 389-9457