Chiropractor service is recognized by Kentucky Medicaid as Provider Type (85) individual or (859) group. To enroll and bill Kentucky Medicaid, a chiropractor service provider must be:
- Enrolled with Medicare
- Licensed in the state in which they operate. In Kentucky, chiropractor service providers must be licensed with the Board of Chiropractic Examiners
- Enrolled as an active Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.
Chiropractic services are the diagnoses and therapeutic adjustment or manipulation of the subluxations of the articulations of the human spine and its adjacent tissues performed by and within the scope of licensure of a licensed chiropractor.
Chiropractor providers must meet the coverage provisions and requirements of
907 KAR 3:125 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.
26 visits per beneficiary in a 12-month period.
Verify eligibility by calling the automated voice response system at (800) 807-1301, or visit the web-based KYHealth-Net System.
Reimbursement for chiropractor services will be paid the lesser of the chiropractor's usual and customary actual billed charged or an amount determined according to the physician fee schedule and 907 KAR 3:125.
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 fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process the Kentucky Medicaid fee-for-service (FFS) 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 mutually exclusive or incidental. KY 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 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 a MCO claim.
Claims must be received within 12 months from the date of service (DOS) or six months from the Medicare pay date whichever is longer, or within 12 months from the last KY Medicaid denial. Please refer to the MCO if appealing a MCO claim.
Provider Contact Information
If you can't find the information you need or have additional questions, please direct your inquiries to:
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 (PAD) List - Pharmacy Branch - (502) 564-6890
Provider MCO Information
- (800) 205-5870Aetna Better Health of KY
- (855) 300-5528 Humana
- (855) 852-7005Molina
- (800) 578-0775WellCare of KY
- (877) 389-9457