Independent physical therapist (PT) services are recognized in Kentucky Medicaid as Provider Type (87) individual or (879) group. To enroll or bill Kentucky Medicaid, PT service providers must be:
- Licensed in the state in which they operate. In Kentucky, SLP service providers must contact the
Kentucky Board of Physical Therapist per 327.020 for license information.
- Enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization of any beneficiary for whom it provides services.
If deemed medically necessary, physical therapy is used to improve beneficiaries' physical functions through physical examination, diagnosis, prognosis, physical intervention, rehabilitation and patient education. It is practiced by physical therapists. To receive services from a PT, an order must be signed by a KY Medicaid participating physician, advanced practitioner registered nurse (APRN), physician assistant (PA) or psychiatrist. (when applicable). A beneficiary may receive 20 visits per the calendar year,
PT providers must meet the coverage provisions and requirements set forth in
907 KAR 8:020 in order 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.
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 PT services is provided in
907 KAR 8:025 and the PT Rates Schedule.
Duplication of Service
If a beneficiary is receiving a PT service from a physical therapist enrolled with the Kentucky Medicaid Program, the department will not reimburse for the PT service provided to the same beneficiary during the same time period via the home health program.
907 KAR 8:020 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 service that exceeds the limit for a beneficiary not enrolled with a MCO. CareWise provides prior authorizations for any fee-for-service (FFS) beneficiary. Each MCO provides prior authorizations for its beneficiaries
Kentucky Medicaid currently contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. Each MCO processes its own claims.
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 Correct 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. KY Medicaid requires the use of CMS 1500 billing forms. Providers will need to bill Kentucky 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 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
General 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 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