The Independent Lab program is identified in Kentucky Medicaid as Provider Type (37) and may bill Kentucky Medicaid using this provider type number. A laboratory provider may perform Medicaid laboratory services for the Medicaid beneficiary only to the extent authorized by the providers CLIA certificate. The Independent Lab must:
- be licensed in the state they are located
- be CLIA certified (Clinical Laboratory Improvement Amendments by CMS)
- be enrolled with Kentucky Medicaid
- be enrolled with Medicare
- be enrolled with the Managed Care Organization (MCO) of any beneficiary they wish to treat
- be headed by a Laboratory Director with education and experience based on CLIA level of certification
What are Independent Lab services? A laboratory provider may perform Medicaid laboratory services for the Medicaid beneficiary which is prescribed by a physician, physician assistant, podiatrist, dentist, oral surgeon, advanced registered nurse practitioner, or optometrist.
Independent Labs must meet the coverage provisions and requirements set forth in
907 KAR 1:028. All services must be considered medically necessary. All services must be performed within the scope of practice for any provider. Services covered by Kentucky Medicaid are those listed on the Kentucky Medicaid Independent Lab Fee Schedule. Others approved on a case by case basis by Kentucky Medicaid or exceptions approved by the Medical Director. Lab providers must also follow the requirements of the MCO for which they participate.
Non-Covered Services: Procedures not considered medically necessary shall not be covered by Kentucky Medicaid. Non-covered services include: translation services, phone calls, court ordered testing, fertility services, copying of records, office supplies, investigational research, postmortem examinations and missed appointments.
Reimbursement: Reimbursement rates for independent labs are listed on the Kentucky Medicaid Lab fee schedule which is updated by CMS each year.
Laboratory services do not require prior authorization, but must be medically necessary.
Kentucky Medicaid currently contracts with
DXC to process Kentucky Medicaid claims. (Each MCO contracts with their own billing agent.)
Kentucky Medicaid utilizes 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. (eff: 10/1/15) Kentucky Medicaid requires the use of CMS 1500 billing forms. (eff: 02/12)
Claim Appeals: Appeal requests made on denied claims must be submitted to
DXC. The request must include the reason of the request along with a hard copy 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.
Provider Contact Information
If you can't find the information you need or have additional questions, please direct your inquiries to:
Billing Questions -
DXC - (800) 807-1232
Provider Questions - (855) 824-5615
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
CLIA Inquiries/Kentucky Office of Inspector General (OIG) – (502) 564-7963
CLIA (CMS Regional Office in Atlanta) – (404) 562-7451