Physician
Assistants are recognized in Kentucky Medicaid as Provider Type 95. In
order to enroll as a Physician Assistant with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website
Covered Services
PA service must be medically necessary, clinically appropriate, provided by direct physician contact and eligible for reimbursement as a physician service.
Telehealth is billable for this provider type.
PA providers must meet the coverage provisions and requirements of 907 KAR 3:005 Section 7. All services must be performed within the scope of practice for any provider.
Verifying eligibility
Verify
eligibility by contacting the automated voice response system toll-free at
(800) 807-1301 or use the web-based KYHealth-Net System.
Reimbursement
Reimbursement for Physician
Assistants is listed on the Kentucky Medicaid Physician fee schedule located at
the Fee and Rate Schedule Home Page.
Reimbursement for Physician Assistants is defined in regulation 907 KAR 3:010 Section 10 and also states that reimbursement for a service provided by a PA is 75 percent of the amount reimbursable on the Physician Fee Schedule. Reimbursement is based on the Kentucky Medicare rate than the repricing per methodology in 907 KAR 3:010 Section 3. Any codes considered experimental are not covered by Kentucky Medicaid.
Multiple Procedures
Multiple procedures performed for one patient by the same PA at the same session are reimbursed at the lower of the usual billed charge or at 100 percent of the Physician Fee Schedule (minus 25 percent) for the major procedure and 50 percent (minus 25 percent) for the lesser procedures. Anything considered incidental is not covered by Kentucky Medicaid.
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 Physician Assistants 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.
Provider Inquiry Resources
If you cannot find the information you need or have additional questions, please direct your inquiries to:
- Billing Questions- Gainwell Technologies, (800) 807-1232, ky_provider_inquiry@gainwelltechnologies.com
- Provider Questions- (855) 824-5615
- Prior Authorization- Gainwell Technologies, (800) 292-2392, (800) 644-5725, (800) 807-8842
- Provider Enrollment, Maintenance, and Revalidation- (877) 838-5085
- KYHealth.net assistance- Gainwell Technologies, (800) 205-4696, ky_edi_helpdesk@gainwelltechnolgies.com
- Pharmacy Questions- (502) 564-6890, dmsweb@ky.gov
- Pharmacy Clinical Support Questions- (800) 477-3071
- Pharmacy Prior Authorization- (844) 336-2676
- Physician Administered Drug (PAD) list- (502) 564-6890
Managed Care Organizations
*Effective Jan. 1, 2025, Anthem is no longer an active Medicaid Managed Care Organization, or MCO, in Kentucky. However, they are responsible for the payment of claims, appeals, or disputes for dates of service up to and including Dec. 31, 2024.