Skip to main navigation Skip to main content

Kentucky Medicaid identifies Critical Access Hospital (CAH) services providers under the Hospital service program as Provider Type (01).  In order to enroll or bill Kentucky Medicaid, CAH service providers must be:

  • enrolled with Medicare
  • Licensed in the state in which they operate. In Kentucky, Hospitals must contact the Office of Inspector General (OIG), Division of Health Care for a survey/license
  • Enrolled as a Medicaid active provider, and if applicable, enrolled with the Managed Care Organization (MCO) of any beneficiary it provides services for

​An Acute Care facility may qualify as a CAH if the acute care facility is non-profit, public or for profit. The Office of Inspector General, Division of Healthcare shall certify the acute care facility as a necessary provider of health services.

Critical Access Hospital Criteria

To meet CAH criteria, the facility must be:

  • located in a rural county more than 35 miles from another acute care facility, 15 miles if in a mountainous area
  • 24- hour emergency room availability
  • must be in compliance with 42 CFR 485.645(d)(1–9)
  • maintain no more than 25 inpatient beds. When a CAH has Medicare approval to furnish swing bed services, for Kentucky Medicaid it may use any of its 25 inpatient beds for either acute care or SNF-level care. A yearly average length of stay may not exceed 96 hours.
  • According to 906 KAR 1:110, the acute care facility also needs to meet one of the following criteria:
    1. Be located in a county where the percentage of the population with income less than 200 percent of poverty is greater than the state average, based on data published by the UK Center for Rural Health
    2. Be located in a county that has an unemployment rate higher than the state average unemployment rate, based on data published by the Cabinet for Health and Family Services(CHFS)
    3. Be located in a county with a greater number of people aged 64 or older than the state average, based on data published by the UK Center for Rural Health
    4. Treat on average a higher than state average percentage of Medicare patients, based on data published by CHFS

Covered Services

What are CAH services

A CAH shall provide the services in accordance with KRS 216.380(5). A CAH shall provide, either directly or through the contract the following services:

  • Laboratory: Basic laboratory services essential to the immediate diagnosis and treatment of the beneficiary. If the critical access hospital provides laboratory services directly, the service shall be in compliance with 902 KAR 20:016, Section 4(4). If the critical access hospital contracts for laboratory services, the laboratory it contracts with shall be in compliance with KRS Chapter 333.
  • Emergency Room: A CAH hospital shall provide medical emergency procedures as the first response to common life-threatening injuries and acute illness, and shall have available the drugs and biologicals commonly used in life-saving procedures, such as analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids.
  • Examination services: These services shall be provided by the critical access hospital in accordance with 902 KAR 20:012. There shall be a physician, nurse practitioner, or physician assistant with training or experience in emergency care on-call and immediately available by telephone or radio contact, and available on-site within 30 minutes on a 24-hour per-day basis. A registered nurse shall be on duty at the hospital to provide immediate emergency care on a 24-hour per day basis
  • Pharmacy Services: In accordance with KRS 216.380(5)(b), a critical access hospital shall provide, either directly or through the contract, basic pharmacy services essential to the treatment of the patient. If the critical access hospital provides pharmacy services directly, it shall be in compliance with 902 KAR 20:016, Section 4(5). If the critical access hospital contracts for pharmacy services, the pharmacy it contracts with shall be in compliance with KRS Chapter 315. In accordance with KRS 216.380(5)(b), a critical access hospital shall provide, either directly or through the contract, basic radiology services essential to the immediate diagnosis and treatment of the patient.
  • Radiology: If the critical access hospital provides radiology services directly, it shall be in compliance with 902 KAR 20:016, Section 4(6). (b) If the critical access hospital contracts for radiology services, the radiology service it contracts with shall have a current license or registration pursuant to KRS 211.842 to 211.852.
  • Dietary Services: Pursuant to KRS 216.380(5)(b), dietary services shall be provided either directly or by contract, in accordance with 902 KAR 20:016, Section 4(3), if a patient is admitted to the critical access hospital and remains for more than 12-hours.
  • Psychiatric Unit: A critical access hospital that has established a psychiatric unit in accordance with KRS 216.380(7)(a), shall be in compliance with 902 KAR 20:180.
  • Rehabilitation Unit: A critical access hospital that has established a rehabilitation unit in accordance with KRS 216.380(7)(b), shall be in compliance with 902 KAR 20:240.

How do I verify beneficiaries' eligibility?  

You may verify eligibility by:

  • contacting the Automated Voice Response System at (800) 807-1301 
  • using the Web-based KYHealth-Net System  

CAH service providers must meet the coverage provisions and requirements set forth in 906 KAR 1:110 in order 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 Kentucky Medicaid regulations. All services must be medically necessary. 

Reimbursement
The department shall reimburse for outpatient hospital services in a critical access hospital as established in 42 C.F.R. 413.70(b) through (d). A critical access hospital shall comply with the cost reporting requirements established in 907 KAR 10:015 Section 6.

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 service is covered during the same time period. 

Prior Authorizations

CareWise provides prior authorizations for any For Fee for Service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.

Claims Submission

Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid 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 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.

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 Information

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 - 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 

Contact Information

53