​Kentucky Medicaid identifies durable medical equipment (DME) suppliers as Provider Type (90). To enroll and bill Kentucky Medicaid DME suppliers must be:  

• active Medicare DME providers
  
• Out-of-state providers may enroll but must be licensed by the state where they practice. In Kentucky, DME service providers must be licensed with the Kentucky DME Suppliers
  
• Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves. 
  

Covered Services

DME is equipment that withstands repeated use and primarily is used to serve a definite medical purpose. It is generally not useful to a person in the absence of an illness or injury. Medicaid covers DME such as wheelchairs, hospital beds, orthotic appliances (foot/leg braces) and prosthetic devices (artificial limbs), etc. and disposable medical equipment ordered by an accepted prescriber that is medically necessary and suitable for use in the home.​

DME must meet the coverage provisions and requirements of 907 KAR 1:479 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.

Verify eligibility 

Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.

Reimbursement

Reimbursement for DME services is listed in the Kentucky Medicaid DME Fee Schedule and defined in 907 KAR 1:479.

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 Authorizations

CareWise processes prior authorizations (MAP-9) for any fee-for-service (FFS) beneficiaries. Each MCO processes its own prior authorizations.

Most items that require FFS prior authorization also require a certificate of medical necessity, MAP-1000 for durable medical equipment and MAP-1000B for metabolic formulas and food.

MAP-1001 advance member notice must be completed and signed by the member if an item or service was denied for failing to meet medical necessity or the supplier failed to obtain a prior authorization in a timely manner and the item and/or service already  were provided to the member. This form allows the member to opt out of receiving the item with no financial responsibility or receive the item and be responsible for paying for the item or service.

Claims Submission

Kentucky Medicaid currently contracts with Gainwelll Technologies to process FFS claims. Each MCO processes its own claims.

Coding

Kentucky Medicaid utilizes the National Correct Coding Initiative 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 and HCPCS codes.

Claim Appeals

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 and documentation. Please refer to the MCO if appealing an MCO claim.

Timely Filing

Claims must be received within 12 months of the date of service (DOS) or six months from the Medicare pay date, whichever is longer, or within 12 months of the last Kentucky 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:
FFS Billing Questions - Gainwell Technologies - (800) 807-1232
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 - (800) 444-9137
Molina - (800) 578-0775
WellCare of KY - (877) 389-9457
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