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Kentucky Medicaid identifies Hospital services as Provider Type (01). In order to enroll and bill Kentucky Medicaid, Hospital service providers must be:

  • enrolled with Medicare
  • Licensed in the state in which they operate. In Kentucky, Hospitals must contact the Office of Inspector General (OIG), Division of Health Care for a survey/license
  • Enrolled as a Medicaid active provider, and if applicable, enrolled with the Managed Care Organization (MCO) of any beneficiary it provides services for.

Hospital Types and Programs

Acute Care Hospital facilities provide both inpatient and outpatient services, including emergency room services.
Critical Access Hospital facilities may qualify as a critical access hospital if the facility meets other state and federal criteria.
Diagnosis-Related Group (DRG) means a clinically-similar grouping of services that can be expected to consume similar amounts of hospital resources.
Disproportionate Share Hospital (DSH) Program prior to billing a patient and submitting hospital service expenses to Medicaid as uncompensated, a hospital uses the Indigent Care Eligibility form to determine if the patient meets DSH guidelines.

Covered Services

What are Hospital services

Most inpatient hospital services are covered as long as the inpatient stay is justified as medically necessary per 907 KAR 3:130. Certain hospital outpatient and emergency room services are also covered as defined in 907 KAR 10:014

How do I verify beneficiaries' eligibility?  

You may verify eligibility by:

  • contacting the Automated Voice Response System at (800) 807-1301
  • using the Web-based KYHealth-Net System  

Hospital service providers must meet the coverage provisions and requirements set forth in 907 KAR 10:012 and 907 KAR 10:014 in order 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. 

Non-Covered Services

Inpatient hospital services not covered shall include a service which is not medically necessary including television, telephone, or guest meals; private duty nursing; supplies, drugs, appliances, or equipment which are furnished to the beneficiary for use outside the hospital unless it would be considered unreasonable or impossible from a medical standpoint to limit the beneficiaries use of the item to the periods during which they are an inpatient; laboratory test not specifically ordered by a physician and not done on a preadmission basis unless an emergency exists; private accommodations unless medically necessary and so ordered by the attending physician.

The following services shall not be considered a covered hospital outpatient service: an item or service that does not meet the requirements established in 907 KAR 10:014 Section 2(1) of this administrative regulation; a service for which: an individual has no obligation to pay, and no other person has a legal obligation to pay; a medical supply or appliance, unless it is incidental to the performance of a procedure or service in the hospital outpatient department and included in the rate of payment established by the Medicaid Program for hospital outpatient services; a drug, biological, or injection purchased by or dispensed to a beneficiary; a routine physical examination; or a nonemergency service, other than a screening in accordance with Section 2(6)(a) of this administrative regulation, provided to a lock-in beneficiary, in an emergency department of a hospital; or if provided by a hospital that is not the lock-in beneficiaries designated hospital.

Reimbursement

 Reimbursement for Hospital Services is in accordance with 907 KAR 10:015.

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 service is covered during the same time period. 

Prior Authorizations

CareWise provides prior authorizations for any For Fee for Service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.

Claims Submission

Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid fee for service claims. Each MCO processes its own claims.

Coding 

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. (eff: 10/1/15) Kentucky Medicaid requires the use of CMS 1500 billing forms. (eff: 02/12)  Providers will need to bill Kentucky Medicaid using the correct CPT codes.

Claim Appeals

Appeal requests made on denied FFS claims must be submitted to DXC. 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.

Timely Filing

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 Information

If you can't find the information you need or have additional questions, please direct your inquiries to:
Regarding licensure - Office of Inspector General (OIG), Division of Health Care - (502) 564-7963        
Billing Questions - DXC- (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Recertification - (877) 838-5085
KyHealth.net assistance - DXC - (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     


Contact Information

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