Kentucky Medicaid identifies ambulatory surgical centers (ASC) as Provider Type (36). To enroll in and bill Kentucky Medicaid, ASC service providers must be:
- Licensed in the state in which they operate. In Kentucky, hospitals must contact the Office of Inspector General, Division of Health Care for a survey/license.
- Enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization of any beneficiary it serves.
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.
ASC covered surgical procedures are commonly performed on an inpatient basis in hospitals but may be safely performed in an ASC; are not commonly performed or may be safely performed in physicians offices; are limited to procedures requiring a dedicated operating room or suite and generally requiring a post-operative recovery room or short-term (not overnight) convalescent room.
ASCs must meet the coverage provisions and requirements set forth in
907 KAR 1:008 to provide covered services. ASCs provide outpatient surgical procedures that are medically necessary. Any services performed must fall within the scope of practice for the provider. Listing of service in an administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.
How do I verify eligibility?
You may verify eligibility by contacting the automated voice response system at (800) 807-1301 or using the Web-based KYHealth-Net System.
Services or procedures not covered by Kentucky Medicaid include but are 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.
Maximum reimbursement for facility services furnished with a covered ASC surgical procedure will be the provider's billed charges or 100 percent of the surgical group rate, whichever is less.
When more than one covered procedure is performed in a single operative session, reimbursement for facility services will be 100 percent of the surgical group rate for the primary procedure and 50 percent of the surgical group rate for the secondary procedure.
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.
CareWise provides prior authorizations for any fee-for-service beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process the Kentucky Medicaid fee for service claims. Each MCO processes its own claims.
Kentucky Medicaid uses 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 Gainwell Technologies. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO if appealing an MCO claim.
Claims must be received within 12 months of the date of service (DOS) or six months from the Medicare pay date whichever is longer, or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim.
If you can't find the information you need or have additional questions, please direct your inquiries to:
Regarding licensure - Office of Inspector General (OIG), Division of Health Care - (502) 564-7963
FFS Billing Questions - Gainwell Technologies- (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Recertification - (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 List - Pharmacy Branch - (502) 564-6890
Provider MCO Information
Aetna Better Health of Kentucky - (855) 300-5528
Anthem Blue Cross Blue Shield - (855) 690-7784
Humana Healthy Horizons in Kentucky- (800) 444-9137
Passport Health Plan by Molina - (844) 778-2700
UnitedHealthcare Community Plan - (866) 633-4449
WellCare of Kentucky - (877) 389-9457