Family planning services are recognized in Kentucky Medicaid as Provider Type (32) entity and may bill Kentucky Medicaid using this provider type number. To serve as a family planning service provider to Kentucky Medicaid members, a provider must:
- Have an administrative director, one physician or physician assistant and one R.N.
- Be enrolled as a Kentucky Medicaid provider and
- Be enrolled with the managed care organization (MCO) of any beneficiary it treats.
What are Family Planning Services? Family planning includes complete medical history, physical examination, laboratory and clinical test supplies, educational material, counseling and prescribed birth control methods to best meet beneficiary needs. Additional medical services are available through referral to private physicians.
Family planning services entities must meet the coverage provisions and requirements of
907 KAR 1:048 to provide covered services. All services must be performed within the scope of practice for any provider. Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow the regulations and must follow the requirements of the MCO for which they participate. All services must be medically necessary.
907 KAR 1:048 Section 2 provides that family planning services will be made available to all persons of child-bearing age, including minors who can be considered sexually active, who desire the services and supplies freed from coercion and providing of choice of method.
Reimbursement: Reimbursement in accordance with the flat fee schedule shall be at the following rates:
Note: The supply-only visit fee will not be paid as an addition to a fee for another type of visit, since the fee for other types of visits includes an amount for contraceptives.
|Services provided by a physician ||Rate|
Initial Clinic visit
Annual clinic visit
Follow-up visit with pelvic exam
|Follow-up visit w/o pelvic exam||$20|
|Services provided by PA/APRN with appropriate training||Rate|
Initial Clinic visit
Annual clinic visit
Follow-up visit with pelvic examination
Follow-up visit w/o pelvic examination
Counseling visit with three-month contraceptive supply
Counseling visit with six-month contraceptive supply
Multiple Services: Multiple services on the same patient at the same session will not be reimbursed. Family planning services are limited to one service per date of service. More than one clinic visit is not allowed on the same day. Anything considered incidental is not be covered by Kentucky Medicaid.
Family planning services requiring prior authorization must contact
Kentucky Medicaid currently contracts with
Gainwell to process Medicaid claims. (Each MCO contracts with its own billing agent.)
Kentucky Medicaid uses National Correct Coding Initiative (NCCI) edits as well as the McKesson Claim Check System to verify codes that are mutually exclusive or incidental.
Coding: Kentucky Medicaid uses Correct 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.
Claim Appeals: Appeal requests made on denied claims must be submitted to
Gainwell. The request must include the reason for the request along with a hard copy 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.
Provider Contact Information
If you can't find the information you need or have additional questions, please direct your inquiries to:
Billing Questions -
Gainwell - (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 - (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