KY Medicaid identifies advanced practitioner registered nurse (APRN) services as Provider Type (78) individual or (789) group. To enroll or bill KY Medicaid, APRN service providers must be:
- Licensed in the state in which they operate. In Kentucky, APRN service providers must be licensed with the Kentucky Board of Nursing.
- Enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary for which it provides services.
APRN services are medically necessary and provided by an APRN through face-to-face interaction between the APRN and the beneficiary. APRN services can be provided by a pediatric nurse practitioner, obstetric nurse practitioner, family nurse practitioner, nurse practitioner, certified nurse-midwife, psychiatric nurse practitioner or an addictionology specialist.
Telehealth is billable for this provider type.
APRN service providers must meet the coverage provisions and requirements of
907 KAR 1:102 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 KY Medicaid regulations. All services must be medically necessary.
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Reimbursement for APRN services is described in the Physician Fee Schedule. Providers are paid at 75 percent of the physician fee schedule for codes within the scope of practice according to
907 KAR 1:104 Section 2(b). Any codes considered experimental are not covered by KY Medicaid.
Multiple procedures performed by the same APRN on the same patient at the same session will be reimbursed at the lower of the usual billed charge or at 100 percent of the physician fee schedule (minus 25 percent) for the major procedure and 50 percent (minus 25 percent) for the lesser procedures. Anything considered incidental will not be covered by Kentucky Medicaid.
Duplication of Service
The department will not reimburse for a service provided to a beneficiary by more than one provider of any program in which the same service is covered during the same time period.
Prior authorized service codes are indicated on the Physician Fee Schedule and are regulated by
907 KAR 3:005 Section 5. CareWise provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
KY Medicaid currently contracts with Gainwell Technologies to process the FFS claims. Each MCO processes its own claims.
KY Medicaid uses the National Correct Coding Initiative (NCCI) edits as well as the McKesson Claim Check System to verify codes mutually exclusive or incidental. Kentucky Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system (HCPCS) codes. KY 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 need to bill KY 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 a MCO claim.
Claims must be received within 12 months of the date of service or 6 months from the Medicare pay date, whichever is longer, or within 12 months of the last KY Medicaid denial. Please refer to the MCO if appealing a 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
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 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 by Molina- (800) 578-0775
United Healthcare Community Plan - (866) 633-4449
WellCare of Kentucky - (877) 389-9457