Dental services are recognized by Kentucky Medicaid as Provider Type (60) individual or (61) group. To enroll or bill Kentucky Medicaid, dental service providers must be:
- Out-of-state providers must be licensed by the Kentucky Board of Dentistry.
- Be enrolled as active Medicaid providers and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary served.
Dental service provider coverage for adults is limited but includes oral exams, emergency visits, X-rays, extractions and fillings. Dental coverage for children includes oral exams, emergency visits, x-rays, extractions, and fillings.
Dentists must meet the coverage provisions and requirements of
907 KAR 1:026 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.
Limitations: Service limitations are covered in
907 KAR 1:026.
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.
Reimbursement for dental services is in accordance with the Kentucky Medicaid Dental Fee Schedule and defined in
907 KAR 1:626
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.
Prior authorization requirements are covered by
907 KAR 1:026 Section 15. Root canal therapy, crowns and sealants with prior authorization and denture repair braces (in severe circumstances) require prior authorization. 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 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 an MCO claim.
Claims must be received within 12 months of the date of service or six months from the Medicare pay date whichever is longer, or within 12 months of the last KY Medicaid denial. Please refer to the MCO if appealing an MCO claim.
Provider Contact Information
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
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
Provider MCO Information
Anthem - (800) 205-5870
Aetna Better Health of KY - (855) 300-5528
Humana Healthy Horizons in Kentucky- (855) 852-7005
Passport Health Plan by Molina Healthcare- (800) 578-0775
United Health Care Community Plan - (800) 822-5353
WellCare of KY - (877) 389-9457