The PA Program is identified in Kentucky Medicaid as Provider Type (95) individual or (959) group. To enroll and bill Kentucky Medicaid, PA service providers must be:
- Licensed in the state where they practice. In Kentucky the
Kentucky Board of Medical Licensure
- Enrolled as a Kentucky Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.
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. Services covered by Kentucky Medicaid are listed on the Kentucky Medicaid Physician Fee Schedule. Other services may be approved on a case-by-case basis and approved by the Medical director. Providers may request a procedure code by submitting a request in writing to the department which includes necessity, CPT code and expected reimbursement. Services being listed in the administrative regulation does not guarantee payment. Providers must follow Kentucky Medicaid regulations and requirements of the MCO with which they participate. All services must be medically necessary.
How do I verify eligibility?
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.
Reimbursement for PA services is provided in thePhysician Fee Schedule.
907 KAR 3:010 Section 9 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 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
Service provided by a physical therapist enrolled in the Kentucky Medicaid Program is not reimbursed if provided to the same beneficiary during the same time period via the home health program.
Prior authorized service codes are provided in the Physician Fee Schedule and are governed by
907 KAR 3:005 Section 5.
CareWise provides prior authorizations for 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.
Coding: Kentucky 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. Kentucky Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system (HCPCS) codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of CMS 1500 billing forms. Providers will need to bill Kentucky Medicaid using the correct CPT codes.
Appeal requests of 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 six 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
Provider Questions - (855) 824-5615
Prior Authorization -
CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (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 Drug (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