The ASC program is identified in Kentucky Medicaid as Provider Type (36). An ASC entity may bill as an entity (36). In order for an ASCs entity to provide services to a Medicaid beneficiary, they must be:
- enrolled as a Kentucky Medicaid provider
- 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 free-standing ASCs.
To be eligible to enter into 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.
An ASC 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 surgery 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 the regulations and must follow requirements of the MCO for which they participate.
Non Covered Services: 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 not determined as 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;
- 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 perform 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.
Some services may require prior authorization. ASC Services requiring prior authorization must contact
Kentucky Medicaid currently contracts with
DXC to process Medicaid claims. (Each MCO contracts with their own billing agent.)
Kentucky Medicaid utilizes National Correct Coding Initiative (NCCI) edits as well as the McKesson Claim Check System to verify codes that are mutually exclusive or incidental.
Coding: The ASC Program 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) Kentucky Medicaid requires the use of CMS 1500 billing forms. (eff: 02/12)
Claim Appeals: Appeal requests made on denied claims must be submitted to
DXC. The request must include the reason of the request along with a hard copy 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.
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