Ambulatory Surgical Center (ASC) are recognized in Kentucky Medicaid as Provider Type 36. In order to enroll as a Ambulatory Surgical Center (ASC) with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
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.
Non-Covered Services
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 and stat handling or processing fees; and dental procedures for routine dental care not considered high risk.
Verifying Eligibility
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Reimbursement
Reimbursement for Ambulatory Surgical Center (ASC) is listed on the Kentucky Medicaid Ambulatory Surgical Center (ASC) fee schedule located on the Fee and Rate Schedule Home Page.
Reimbursement for Ambulatory Surgical Center (ASC) is defined in regulation (907 KAR 1:008)
A provider may request coverage for a CPT or HCPCS procedure code by submitting a request in writing to the department which includes necessity, CPT or HCPCS code, and expected reimbursement. Any codes considered experimental are not covered by Kentucky Medicaid.
Duplication of Service
Kentucky Medicaid 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.
Prior Authorizations
Each MCO provides prior authorization for its beneficiaries.
Gainwell Technologies provides prior authorizations for fee-for-service (FFS) beneficiaries. For more information, visit Prior Authorizations.
Claims Submission
Each MCO processes its own claims.
Kentucky Medicaid contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. For more information, visit KYHealth-Net.
Coding
Kentucky Medicaid requires Ambulatory Surgical Center (ASC) providers to bill on a CMS 1500 billing forms utilizing the following code types where applicable:
- Current Procedure Terminology (CPT) codes, regulated by the American Medical Association (AMA).
- Healthcare Common Procedure Coding System (HCPCS) codes, regulated by the Centers for Medicare and Medicaid Services (CMS).
- Current Dental Terminology (CDT) codes, regulated by the American Dental Association (ADA).
- International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes, maintained by the Centers for Disease Control & Prevention (CDC) and the National Center for Health Statistics (NCHS).
Kentucky Medicaid uses the Medicare National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits, the Medicaid Medically Unlikely Edits (MUEs), and the McKesson Claim Check System to verify codes mutually exclusive or incidental.
Claim Appeals
Appeal requests for denied FFS claims must be submitted to Gainwell Technologies. The request must include the Provider Inquiry Form, reason
for the appeal, and a hard copy claim.
Please refer to the member's MCO if appealing an MCO claim.
Timely Filing
Claims must be received within twelve (12) months from the date the service was provided, twelve (12) months from the date retroactive eligibility was established, or six (6) months of the Medicare adjudication date if the service was billed to Medicare.
Provider Inquiry Resources
If you can't find the information you need or have additional questions, please direct your inquiries to:
- Billing Questions- Gainwell Technologies, (800) 807-1232, ky_provider_inquiry@gainwelltechnologies.com
- Provider Questions- (855) 824-5615
- Prior Authorization- Gainwell Technologies, (800) 292-2392, (800) 644-5725, (800) 807-8842
- Provider Enrollment, Maintenance, and Revalidation- (877) 838-5085
- KYHealth.net assistance- Gainwell Technologies, (800) 205-4696, ky_edi_helpdesk@gainwelltechnolgies.com
- Pharmacy Questions- (502) 564-6890, dmsweb@ky.gov
- Pharmacy Clinical Support Questions- (800) 477-3071
- Pharmacy Prior Authorization- (844) 336-2676
- Physician Administered Drug (PAD) list- (502) 564-6890
- Provider Type Summaries
- Provider Letters
- Fee and Rate Schedules
- Medicaid Assistance Program (MAP) Forms
- Provider Billing Instructions
Managed Care Organizations
*Effective Jan. 1, 2025, Anthem is no longer an active Medicaid Managed Care Organization, or MCO, in Kentucky. However, they are responsible for the payment of claims, appeals, or disputes for dates of service up to and including Dec. 31, 2024.