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Provider Resources

What's New

2018 Medicaid Managed Care Forums

The Cabinet for Health and Family Services, in partnership with the managed care companies, once again is sponsoring Spring forums across Kentucky in April and May 2018.

For dates, locations, times and registration information, please refer to the MCO Forum Announcement.

Review the Agenda

2017 MCO Forum Presentations are now available.

Please refer to the 2017 Medicaid MCO Provider Forum page to view the presentations.

WEBINAR ANNOUNCEMENT – Level of Care Policy and Process Changes

The Department for Medicaid Services (DMS) is beginning a new project to transform its level of care (LOC) policies and processes for nursing facility, hospice, and intermediate care facility for individuals with intellectual disabilities (ICF-IID) services. This project will transition the existing paper-based LOC processes to a technology system where providers will be able to electronically submit their LOCs through a self-service portal.

DMS is hosting a virtual webinar to share the upcoming LOC policy and process changes with providers. This webinar will review changes to the existing process and policies, as well as new policies that will be instituted as a part of the LOC transformation. DMS strongly encourages attendance, as the content will prepare providers to transition to the new processes.

The webinar is offered on two days to best accommodate providers' schedules. The webinar content will be the same on both dates. The webinar lobby will be open 30 minutes prior to each webinar.

Wednesday, August 23rd, 2017
10:00 a.m.-12:00 p.m., Eastern Time

Thursday, August 31st, 2017
10:00 a.m.-12:00 p.m., Eastern Time

Webinar Information
Everyone is a Guest. Guest access and entry into the webinar is blocked until the webinar room opens at 9:30 AM, Eastern Time.

On the date of the webinar, Click Here To Join The Webinar.. The “2017 DMS Webinars” page will open. Click “Enter as a Guest” and type your agency name or your first name and last name in the field marked “Name,” then click on the box that says “Enter Room.”

Provider Complaint Form

A provider may submit a complaint form to report issues with one of the Medicaid Managed Care Organizations (MCO). This may include credentialing, claims reimbursement, provider services, etc. For provider convenience a Provider Complaint Form is available and should be completed with applicable information. It may be mailed, emailed, or faxed using information at the top of the form.

KYHealth Card Update

Effective May 6, 2017, the Department for Medicaid Services will be updating the KyHealth Card as a cost saving measure for the Commonwealth. Currently Fee-For-Service members receive a plastic card containing a magnetic strip on the back for swipe capability. Due to the expense of the card and the minimal functionality of the strip the Department has decided to issue a printed, perforated card without swipe capability. The information printed on the card will remain the same.

Provider Notice regarding Member Cards

Effective March 31, 2017 members who are enrolled in an MCO will no longer be receiving a KyHealth Choices card. Members will only be receiving a card from the MCO in which they are enrolled. This change is being made to reduce duplication of effort as all required Medicaid information is located on their MCO card. This change does not affect Fee For Service members.

In addition, members who have had 6 months or more loss in eligibility will not be receiving a new card.

PASSR Statewide Training Information

(March 10, 2017) -The Departments for Medicaid Services (DMS) and Behavioral Health, Developmental and Intellectual Disabilities (BHDID) have worked with the Centers for Medicare and Medicaid Services (CMS), to develop a more comprehensive Preadmission Screening and Resident Review (PASRR) process. The statewide implementation date for both forms is July 1, 2017.

Read the Nursing Facility/ICF/IID Provider Letter - Pre-admission Screening and Resident Review Revisions (Mar. 10, 2017)

Two statewide training sessions are available as listed below:

First Training Session:
Date: Wednesday, April 26, 2017 (a.m. and p.m. sessions)
AM Session: Registration: 8:30 to 9 a.m. and Training Session: 9 a.m. to noon
PM Session: Registration: 12:30 to 1 p.m. and Training Session: 1 to 4 p.m.
Training site: GAPS Training Room, 801 Teton Trail, Frankfort, KY. 40601
Note: There are no vending machines available at the GAPS Training site

2nd Training Session
Date: Wednesday, May 24, 2107 (a.m. and p.m. sessions)
AM Session: Registration: 8:30 to 9 a.m. and Training Session: 9 a.m. to noon
PM Session: Registration: 12:30 to 1 p.m. and Training Session: 1 to 4 p.m.
Training site: GAPS Training Room, 801 Teton Trail, Frankfort, KY. 40601
Note: There are no vending machines available at the GAPS Training site.

Registration is limited to two employees per ICF/IID and/or nursing facility.

On-line registration

Materials Needed for Training

Ordering, Referring and Prescribing Provider Information

A General Provider Letter - Ordering, Referring and Prescribing Providers (PDF) and FAQ document (PDF) was mailed to provider on Feb. 1, 2017 regarding Ordering, Referring and Prescribing Providers enrolling as a Medicaid Provider.

Questions regarding this notice may be directed to DMS Provider Services at (855) 824-5615, Monday through Friday, 8 a.m. to 5:30 p.m. Eastern time.

HCBS Final Rule - Heightened Scrutiny

(Feb. 8, 2017) - DMS would like for providers to be made aware of upcoming communications that will be distributed to some individuals receiving services in KY's Home and Community Based Services (HCBS) waivers.

Read the HCBS Waiver Provider Letter - Heightened Scrutiny Communication to Individuals

Third Party Review Process (SB20)

Senate Bill 20 established the right for a provider, who has exhausted the written internal appeals process of a Medicaid managed care organization (MCO), to be entitled to an external independent third party review of the MCO's final decision that denies, in whole or in part, a health care service to an enrollee or a claim for reimbursement to a provider for a health care service rendered by the provider to an enrollee of the MCO. the legislation also afforded a provider or an MCO the right to an administrative hearing.

907 KAR 17:035 establishes the process for the external independent third party review and 907 KAR 17:040 establishes the process for an administrative hearing.

Beginning with the dates of service on or after December 1, 2016, providers may submit a request for an external independent third party review within 60 calendar days of receiving a final decision from the MCO's internal appeal process. This request must be submitted to the MCO via the contact information on the final decision letter.

Provider Letter #A-102 Senate Bill 20

MCO Contact Information

Attention Behavioral health Services Organization (BSHO) Providers

(Mar. 25 2015) - For Questions regarding providing BHSO services, please refer to the DBHDID's BHSO page and review the recent "2015 BSHO Webinar". For questions not addressed in the webinar, please email us.

The BHSO Medicaid Billing Manual is currently under development and will be posted in the near future.

View Achieved Provider Resources

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Medicaid Managed Care Information

MCO Provider Workshops

Prompt Payment Update

Read the General Provider Letter #A-93 - Medicaid MCO Prompt Payment Complaints to be Reviewed by the Department of Insurance (DOI)

Read the Letter from Governor Beshear explaining his veto of House Bill 5.

Cabinet Releases Medicaid Managed Care Request for Proposal

June 12, 2013 - The Finance and Administration Cabinet released a Medicaid managed care request for proposal (RFP) Affordable Care Act (ACA)expansion. Services are to begin on Jan. 1, 2014, for members enrolled through Medicaid expansion under the federal ACA in seven Medicaid regions and July 1, 2014, for specified members eligible for Medicaid under eligibility criteria in place prior to the ACA expansion for the same seven managed care regions. The RFP is available on the Commonwealth of Kentucky eProcurement website. Any questions related to this procurement must be directed to the Office of Procurement Services, Finance and Administration Cabinet. Contact information is available on the eProcurement site.

More information and updates on the Medicaid expansion, kynect: Kentucky's Healthcare Connection or adjusted primary care payments

KY Spirit information for members and providers

July 2, 2013 - Read the:

Managed Care Organization (MCO) prior-authorization critical issue resolution mailbox:

Due to providers having critical issues with obtaining MCO Prior-Authorizations, DMS/MCO Oversight Branch has established a resolution mailbox for providers to report:

  • when there has been no response,
  • an untimely response,
  • or any other issues with the MCO Prior Authorization (PA) process.

Note: This mailbox is not to be used in lieu of the normal PA process.

Older Updates

(March 20, 2012) - Dental Comparison Grid

(Nov. 18, 2011) - Managed Care Policy for Out of Network Dental Providers

(Nov. 8, 2011) - Managed Care Policy For Out-Of-Network Providers

(Oct. 25, 2011.) - General Provider Letter #A-86 - regarding the coming Nov. 1 implementation.

(Oct. 10, 2011) - Important prior authorization information regarding respiratory syncytial virus (RSV) vaccine: Magellan Medicaid Administration, the pharmacy benefit administrator for the Department for Medicaid Services, is handling prior authorizations (PAs) for the RSV vaccine for dates of service prior to Nov. 1, 2011. For services rendered on or after that date, the member's assigned managed care organization (MCO) will be responsible for authorizations. The MCOs will honor all existing PAs issued by Magellan for at least 30 days on or after November 1.

(Aug. 23, 2011) - Kentucky Medicaid is pleased to announce that it now has a new managed care website for members and providers.

(Aug. 19, 2011) General Provider Letter #A-84 - Additional information and guidance relating to the expansion of Managed Care in the Kentucky Medicaid program.

(Aug. 5, 2011) - refer to the DMS MCO Payment Policy Clarification for Hospital Questions and Answers.

(July 22, 2011) General Provider Letter #A-83 - Expansion of managed care in the KY Medicaid program.

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Provider Updates

Attention Providers: Policy Clarification Updates

Older Provider Updates

Attention all providers: As of Jan. 1, 2012, all electronic claims submissions must be in the X12 5010 format. Please refer to your billing instructions for additional information required on the CMS1500 and UB04 paper claim forms due to 5010 implementation.

Attention KY Health Net users: All claims paid prior to Dec. 29, 2011. will not have the Copy Claim or the Adjust Claim function through KY Health Net. Any adjustments to claims paid prior to Dec. 29, 2011, will require paper adjustment submission to: HP Enterprise Services, P.O. Box 2108 Frankfort, KY 40602-2108 Attn: Financial Services.

Provider Enrollment Notice (Sept. 28, 2011) - When sending any type of correspondence to Kentucky Medicaid provider enrollment, please write your NPI and/or Kentucky Medicaid provider number on each document. If you submit documents for multiple providers submitted in the same envelope, please staple or paperclip each providers own documents separately. Although, we prefer that you do not attach multiple providers' documents in the same envelope.

Physician Pricing Update - The procedure code J7300 new pricing will be $645.84 with an effective date of 7-1-11. This change has been made on the physicians fee schedule located on the Fee and Rate Schedule page.

Physician Provider Update - ESSURE In-Office Placement - Effective Date of Service (DOS) 1/1/2011, Physicians performing in-office placement of Essure will be reimbursed for A4264 at a rate of $1400 for Place of Service (POS) 11 (office). Physicians can continue to bill 58565 for the placement of the product and payment will remain at $338.62. These two codes must be billed on the same DOS and supporting documentation retained in the patient's chart for placement of product. Prior Authorization will continue to be required. If 58565 is billed with Place of Service (POS) 22, the payment for the profession fee will be $338.62.

Nursing Facilities Update June 2011 - New Significant Change in Condition/Disposition Form. For more information, refer to the revised (MAP-4095) - PASRR Significant Change/Discharge Data.

Physician Provider Update as of June 2011- Refer to the Physician NDC Code Update for changes in billing.

Provider Enrollment Update as of June 2011 - Update for KY non-Medicaid Prescribing Providers as of June 2011

Provider Enrollment Update effective June 1, 2011 - MAP Form Update

Provider Enrollment Update effective March 25, 2011 - Final Rule indicates that certain providers will be required to pay an application fee..

Provider Enrollment Update - Medicaid Provider Updated Licenses. Refer to the Provider Enrollment or Credentialing website for more information.

EHR Incentive Program Information - In order to keep Kentucky Medicaid providers updated on the new EHR incentive program, a new website has been developed for hospitals and providers. You may view this website by either using the left hand navigation button for Kentucky EHR Initiative Program or go directly to the website

DME updates (November 2010)

DRG Information Released (Oct. 2007)

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Resource Information

Provider Forms


Archive Conference Call Information - June 16, 2010, CMS Payment Error Rate Measurement (PERM) Project Information documents.

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HIPPA 5010/ICD-10 Information

Notice Final Rule posting

This final rule changes the compliance date from Oct. 1, 2014 to Oct. 1, 2015 for the ICD-10-CM for diagnosis coding and the ICD-10-PCS for inpatient hospital procedure coding, including the official ICD-10-CM and ICD-10-PCS guidelines for coding and reporting. It also requires the continued use through Sept. 30, 2015 of the ICD-9-CM for diagnoses and procedures including the ICD-9-CM guidelines for coding and reporting.

For more information, refer to the DMS ICD-10 website.

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Billing Information

Urgent Notice from our Fiscal Agent HP.

Due to a systems upgrade, the following functions will be delayed or stopped on Friday, Oct. 10, 2014 until approximately 2 a.m., Monday, Oct. 13, 2014.

  • Friday 10 a.m. - All claims submitted via a vendor/clearinghouse will be stopped and held in a queue. Acknowledgements will be sent once processing starts on Monday at approximately 2 a.m.
  • Friday noon - The financial cycle will start at noon instead of 6 p.m.
  • Friday 3 p.m. to Saturday 3 a.m. - The DMS and HP member helpdesks will not be able to perform member updates until approximately 3 a.m. Saturday.
  • Friday 9 p.m. KYHealth Net will become unavailable. This includes presumptive eligibility confirmations and applications. It will become fully available on Sunday, Oct. 12 at 3 p.m. with intermittent availability on Saturday.

Attention Providers who bill paper, professional crossover claims.

The Medicare coding sheet has been revised. You may obtain the newest revision at Kentucky Medicaid Management Information System along with the updated billing instructions. For questions, please contact Provider Inquiry at (800) 807-1232


Policy Update -DMS does not provide guidance on billing - The Department for Medicaid Services does not provide guidance on how companies should bill for services, but will direct you to applicable regulations. If you receive direction from staff about how to bill, the department will not be bound by such instruction, unless it was given by a director or commissioner.

Important Information for Kentucky Medicaid Providers Regarding Overpayments - Read the General Medicaid Provider Letter regarding Overpayments dated Feb. 21, 2011.

Kentucky Medicaid has implemented the National Correct Coding Initiative (NCCI) - As specified in the Affordable Care Act, Kentucky Medicaid has implemented the NCCI. For more information, please review the Provider Letter #A-81 - National Correct Coding Initiative (NCCI) dated Oct. 1, 2010. If you have additional questions, you may: Email the CHFS DMS Webmaster; Call Provider Relational at (800) 807-1232; Visit the CMS National Correct Coding Initiative website

Information regarding CT Scan Diagnoses

Direct Deposit System for Medicaid Provider Payments

Have you enrolled yet with the new direct deposit system for Medicaid provider payments? Direct deposit guarantees rapid availability of funds and eliminates lost payments. For more information, contact Provider Enrollment at (877) 838-5085.



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Prior Authorization
Program Integrity

Medicaid Partnering with Revenue for Tax Intercept - Effective May 15, the Department for Medicaid Services and the Department of Revenue have combined efforts to collect outstanding debts due to any Commonwealth of Kentucky agency. To learn more how this may affect you, refer to the Revenue Tax Intercept Letter.

Information Regarding Medicaid Provider Updated License.- Please refer to the Kentucky Provider Enrollment website for more information.

Information regarding Excluded Providers - On Jan. 16, 2009, the Centers for Medicare and Medicaid Services issued a letter to state Medicaid directors repeating a long standing policy and clarifying federal statutory and regulatory prohibitions regarding providers from participation in federal health care programs. For more information, refer to the following letters.

Kentucky Medicaid General provider Letter regarding excluding providers

You may also visit the Office of the Inspector General Exclusions Program website for the List of Excluded Individuals/Entities.

DMS List of Excluded Providers
Excluded/termed provider list

To view more information about Program Integrity, refer to their website.

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Contact Us

For questions or assistance on:

  • Provider Services, call 855- 824-5615
  • Provider Enrollment, email Provider Enrollment or call 877- 838 5085
  • ICD-10 questions or KyHealth-net assistance, email EDI helpdesk or call 800- 205-4696

    Last Updated 3/15/2018