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
What are Acute Care 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.
How do I verify beneficiaries' eligibility?
You may verify eligibility by:
- contacting the Automated Voice Response System at (800) 807-1301
- using the Web-based KYHealth-Net System
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.
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.
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.
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.
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.
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
Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid FFS for service 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 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 made on denied FFS claims must be submitted to DXC. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO in question, if appealing an MCO claim.
Claims must be received within 12 months from the date of service (DOS) or 6 months from the Medicare pay date whichever is longer, or within 12 months from the last Kentucky Medicaid denial. Please refer to the MCO in question, 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 - DXC - (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - 800-292-2392
Provider Enrollment or Recertification - (877) 838-5085
KyHealth.net assistance - DXC - (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
Passport Health Plan- (800) 578-0775
WellCare of KY - (877) 389-9457