Critical
Access Hospital is recognized in Kentucky Medicaid as Provider Type 01.
In order to enroll as a Critical Access Hospital with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
A Critical Access Hospital shall provide the services in accordance with KRS 216.380 which includes Twenty-four (24) hour emergency-room care, basic laboratory radiologic, pharmacy, and dietary services.
A Critical Access Hospital may provide the following services:
- Swing beds or a distinct unit of the hospital which is a nursing facility in accordance with KRS Chapter 216B and subject to approval under certificate of need.
- Surgery
- Normal obstetrics
- Primary care
- Adult day health care
- Respite care
- Rehabilitative and therapeutic services
- Ambulatory care
- Home health services which may be established upon obtaining a certificate of need
- Mobile diagnostic services with equipment not exceeding the major medical equipment cost threshold pursuant to KRS Chapter 216B
Service providers must meet the coverage provisions and requirements set forth in 906 KAR 1:110 to provide covered services. Any services performed must fall within the scope of practice for the provider. All services must be medically necessary.
Non-Covered Services
- Services from providers who are not Kentucky Medicaid providers
- Services that are not medically necessary
- Cosmetic surgery
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
The department shall reimburse for outpatient hospital services in a Critical Access Hospital as established in 42 C.F.R. 413.70. A Critical Access Hospital shall comply with the cost reporting requirements established in 907 KAR 10:015.
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 Services
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 Authorization
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 (Critical Access Hospital) providers to bill on a (CMS UB-04) claim form 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.
Claims 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 cannot 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- (877) 403-6034
- Pharmacy Prior Authorization- (877) 403-6034
- Physician Administered Drug (PAD) list- (502) 564-6890
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.