The Ambulatory Surgical Center (ASC) service program is identified in Kentucky Medicaid as Provider Type (36) and may bill Kentucky Medicaid using this provider type number. In order for an ASC facility to provide services to a Medicaid beneficiary, it must:
- be enrolled as a Kentucky Medicaid provider
- be enrolled with the Managed Care Organization (MCO) of any beneficiary it wishes to treat.
In order to be covered as an ASC operated by a hospital, a facility must:
- elect that status, unless determined otherwise;
- be a separately identified entity, physically, administratively and financially independent from other operations of the hospital with costs treated as a non-reimbursable cost center on the hospital cost report; and
- meet all requirements for health and safety and agree to the assignment, coverage and reimbursement rules as they apply to freestanding ASCs.
To be eligible to enter into an agreement with Medicare, Medicaid, and other third-party payers, ASC facilities must be surveyed and certified as complying with all conditions for coverage as an ASC as directed in 42 CFR 416.40-416.49.
What are ASC services? Covered surgical procedures are those surgical and other medical procedures that are commonly performed on an inpatient basis in hospitals, but may be safely performed in an ASC; are not of a type that is commonly performed, or that may be safely performed, in physicians offices; are limited to those requiring a dedicated operating room (or suite), and generally requiring a post-operative recovery room or short-term (not overnight) convalescent room.
How do I verify eligibility? Once eligibility has been obtained, you may verify continued eligibility by one of the following methods:
- by contacting the Automated Voice Response System at (800) 807-1301
- by using the Web-based KYHealth-Net System
ASCs must meet the coverage provisions and requirements set forth in
907 KAR 1:008 in order to provide covered services. All services must be performed within the scope of practice for any provider. ASCs provide outpatient surgical procedures that are medically necessary. Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow Kentucky Medicaid regulations and must follow the requirements of the MCO in which they participate.
Not Covered: Services or procedures not covered by Kentucky Medicaid shall include but not limited to acupuncture services; any services not performed in compliance with state and federal requirements (i.e. sterilization, hysterectomy and induced termination of pregnancy procedures); services determined as not medically necessary; artificial insemination or procedures for the treatment of infertility including procedures for the reversal of voluntary sterilization; biofeedback services; call back/stat and handling or processing fees; and dental procedures for routine dental care not considered "high risk."
Reimbursement: Maximum reimbursement for facility services furnished with a covered ASC surgical procedure shall be the provider's billed charges or 100% of the surgical group rate, whichever is less.
Multiple Procedures: When more than one covered procedure is performed in a single operative session, reimbursement for facility services shall be 100% of the surgical group rate for the primary procedure and 50% of the surgical group rate for the secondary procedure.
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 same service is covered, during the same time period.
For Fee for Service beneficiaries who require prior authorization for additional services that are deemed medically necessary, contact CareWise. For MCO beneficiaries who require prior authorization for additional services that are medically necessary, contact the beneficiaries MCO for more information.
Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid fee for service (FFS) claims. Each MCO processes its own claims.
Coding: 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 Correct 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. (eff: 10/1/15) KY Medicaid requires the use of CMS 1500 billing forms. (eff: 02/12) Providers will need to bill Kentucky Medicaid using the correct CPT codes.
Claim Appeals: 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.
Timely Filing: 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:
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