Acute care hospitals provide both Inpatient services and outpatient services.
Inpatient services which must be medically necessary and clinically appropriate pursuant to the criteria individualized in 907 KAR 3:130. 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 shall be 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)
- medical/surgical anesthesia
- rehabilitative services excluding occupational therapy include:
- respiratory therapy*
- physical therapy*
- speech therapy *
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 the approval from the PRO.
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 Manual
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 other, 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.
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
Provider Contact Information
- For billing questions, contact DXC at (800) 807-1232 or visit the website
- For provider questions, contact the Provider Services Call Center at (855) 824 5615
- For provider enrollment or revalidation questions, contact Provider Enrollment at (877) 838-5085
- For KyHealth-net assistance, email DXC
- To report fraud and abuse, contact Fraud Hotline at (502) 564-2348
- For pharmacy questions, contact Pharmacy Support Center at (800) 432-7005
- For pharmacy prior authorization questions, contact Pharmacy Prior Authorization at (800) 477-3071