Kentucky Medicaid recognizes Renal Dialysis Centers as Provider Type (39). In order to enroll and bill Kentucky Medicaid, a Renal Dialysis Centers service providers must be:
- a hospital unit which must be approved by Medicare
- Licensed in Kentucky or the state in which they participate. Renal Dialysis Centers must be licensed with the Office of Inspector General, Division of Health Care
- Enrolled as a Kentucky Medicaid provider, and if applicable, enrolled with the Managed Care Organization (MCO) of any beneficiary it provides services for
- Must have a physician medical director, responsible for supervising the staff of the facility, who must be a nephrologist, internist, or pediatrician with at least 12 months experience or training in the treatment and management of end-stage renal disease (ESRD) patients. The medical director shall be a full or part-time staff member and must be "immediately available" if not on-site in the facility
A hospital does not need to provide renal transplantation to qualify as a renal dialysis center. Whenever patients are undergoing dialysis, Federal Regulation 42 CFR 405.2162 states that at least one currently licensed health professional (e.g., physician, registered nurse, or licensed practical nurse) experienced in rendering ESRD care is on duty to oversee ESRD patient care. The facility must ensure that all necessary care, such as CPR and administration of intravenous medications, can be delivered by the licensed person on duty.
What are Renal Dialysis services?
The types of Renal Dialysis services covered by Kentucky Medicaid are inpatient dialysis; outpatient dialysis; self-dialysis; home dialysis physician services; laboratory services; hemodialysis; drugs; home supplies; and equipment. The service is provided by the facilities own staff or through individuals contracted to furnish such services for the facility, as stated in
42 CFR 405.2102.
Renal Dialysis service providers must meet the coverage provisions set forth in
907 KAR 1:400 to provide covered services. Medicare and private insurance must be billed prior to Kentucky Medicaid. Any services performed fall within the scope of practice for any provider. Listing of a service in the administrative regulation is not a guarantee of payment. Providers must follow the Kentucky Medicaid regulations. All services must be medically necessary.
How do I verify eligibility?
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.
The Renal Dialysis facility must be able to bill all third-party payers and furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or indirectly under arrangement). Reimbursement for Renal Dialysis services is in accordance with the Payment Allowance Limits for Medicare Part B Drugs.
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 same service is covered, during the same time period.
CareWise provides prior authorizations for any For Fee for Service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process FFS claims. Each MCO processes its own claims.
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.
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 in question, if appealing an MCO claim.
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 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
General Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (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
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