Notice 

In response to the COVID-19 state of emergency, the Centers for Medicare and Medicaid Services has authorized delay of certain Medicare cost reports. As a result, the Department for Medicaid Services also will grant any cost report extensions that Medicare has officially granted. At this time, the following fiscal year-end cost report extensions have been granted:

Please call (502) 564 - 8196 if you have any questions and ask for the staff referenced below based on provider type.

Kentucky Medicaid identifies Acute Care Hospital service providers under the Hospital service program as Provider Type (01). In order to enroll and bill Kentucky Medicaid, Acute Care Hospital service providers must be:

• enrolled with Medicare
• Licensed in the state in which they operate. In Kentucky, Hospitals must contact the Office of Inspector General (OIG), Division of Health Care for a survey/license
• Enrolled as a Medicaid active provider, and if applicable, enrolled with the Managed Care Organization (MCO) of any beneficiary it provides services for
  

Covered Services

Inpatient services which are medically necessary and clinically appropriate pursuant to the criteria individualized in 907 KAR 10:012 Section 3 states that an admission primarily indicated in the management of acute or chronic illness, injury or impairment, or for maternity care that could not be rendered on an outpatient basis are covered.

Outpatient services may include the following when medically necessary and clinically appropriate pursuant to 907 KAR 3:130: emergency room services; drug therapy (administered while the patient is being treated in the emergency room or outpatient area); laboratory; radiology; pathology; medical/surgical anesthesia; rehabilitative services excluding occupational therapy include respiratory therapy; physical therapy; speech therapy.

Acute Care hospital service providers must meet the coverage provisions and requirements set forth in 907 KAR 10:012 and 907 KAR 10:014 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. 

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

The department shall not reimburse an acute care hospital reimbursed via a DRG methodology pursuant to 907 KAR 10:820 for treatment for or related to a never event.

Reimbursement for Acute Care Hospital Services is in accordance with and 907 KAR 10:015 and 907 KAR 10:830. 

Duplication of Service

The department shall not reimburse for a service provided to a beneficiary by more than one provider of any program in which the service is covered during the same time period.

Provider FAQs

1. Do outpatient services require review approval or prior authorization? Some outpatient services do require prior approval through the Department for Medicaid (DMS) designated Peer Review Organization (PRO). Emergency admissions do not require pre-admission approval. Providers have two working days from the date of the emergency to obtain approval from the PRO. CareWise provides prior authorizations for any For Fee for Service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
2. What codes are covered by Medicaid? There is a list of covered revenue codes for inpatient and outpatient billing in the appendix of the Hospital Services Billing Instructions.
3. How does a hospital participate in the DSH program? Prior to billing a patient and/or submitting the cost of the hospital services to Medicaid as uncompensated, a hospital is to use the indigent care eligibility form (DSH-001) to assess a patient's financial situation to determine if the patient meets the DSH guidelines. The patient must be a Kentucky resident. Resources, financial and others, belonging to the patient and the patient's family are taken into consideration during the determination. The patient cannot have any other medical insurance coverage including private insurance, any type of government-funded coverage, KCHIP, or be eligible for Medicaid. Questions regarding the DSH program may be directed to DMS at (502) 564- 6890.
   

4. How does a hospital qualify as a critical access hospital? An acute care facility may qualify as a critical access hospital if the acute care facility is non-profit, public or for profit. Questions regarding the Critical Access Hospitals may be directed to DMS at (502) 564-6890