Nursing facility (NF) programs are Kentucky Medicaid Provider Type (12). To bill Kentucky Medicaid, NF providers must be:
- Licensed in Kentucky. NFs must contact the Office of Inspector General
Division of Health Care for a survey/license.
- Enrolled as an active Kentucky Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary for whom it provides services.
Covered Services
NF services are for individuals who require high-intensity nursing care or rehabilitation services. The per diem rate covers room and board, dietary services, nutritional supplements, social services and activities, respiratory therapy and supplies, nursing services, the use of equipment and facilities, medical and surgical supplies, prosthetic devices, laundry services, drugs ordered by the physician and personal items routinely provided by the facility. Other services, if medically necessary and ordered by a physician, may include x-rays, physical therapy, speech therapy, occupational therapy, laboratory services, oxygen, and related oxygen supplies and may be billed separately from the per diem rate.
NF service providers must meet the coverage provisions and requirements of
907 KAR 1:022,
907 KAR 1:023,
907 KAR 1:037, and
907 KAR 1:755. Services must be performed within the scope of practice for any provider. Listing of services in an administrative regulation is not a guarantee of payment. Providers must follow all relevant Kentucky Medicaid regulations and the requirements of the MCO in which they participate, if applicable. All services must be medically necessary.
Eligibility
Individuals may be eligible for nursing facility services if they:
- Reside in a facility participating in the Kentucky Medicaid program and are placed in a Medicaid-certified bed.
- Meet the nursing facility level of care criteria defined in
907 KAR 1:022.
- Meet the income and resource limitations required by the program.
All individuals applying for admission to or residing in a nursing facility must undergo a preadmission screening and resident review (PASRR) evaluation. For information on completing the Level I screening and Level II evaluation, visit the
Department for Behavioral Health, Developmental and Intellectual Disabilities PASRR website where you can access forms, guidance, and regulations.
Nursing facilities must use the
Kentucky Level of Care System (KLOCS) to submit and manage level of care applications for individuals.
Verify Eligibility
Verify eligibility by calling the automated voice response system at (800) 807-1301 or using the web-based KYHealth-Net System.
Reimbursement
Nursing facilities are reimbursed per
907 KAR 1:025,
907 KAR 1:042, 907 KAR 1:065 and
907 KAR 1:780.
Duplication of Service
Kentucky Medicaid 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.
Bed Reserve Days
If certain criteria are met, Medicaid reimburses a nursing facility when a beneficiary is:
- Admitted to an acute care hospital; or
- Receiving therapeutic home visits.
Bed reservation days are not available for beneficiaries admitted to a psychiatric hospital.
When Medicaid is paying bed reservation days, the nursing facility will allow the beneficiary to return any day of the week, including holidays or weekends. If the nursing facility chooses not to reserve a bed for a beneficiary who is eligible for Medicaid bed reservation days, the nursing facility must inform the beneficiary before departure from the facility.
The nursing facility is responsible for assuring services and items ordered by a beneficiary's physician are provided when Medicaid is billed to reserve the bed, except when the beneficiary is hospitalized. During hospitalization, the hospital must provide any required services and items. If the nursing facility cannot provide the required ancillaries directly, the facility must make arrangements with 10 qualified sources (i.e., pharmacy, physical therapist, speech therapist, etc.) for the resident to receive the required services and items. Pharmacies bill Medicaid directly. Therapists and other service providers bill the facility. If the beneficiary receives an ancillary service or item that Medicare Part B covers, the nursing facility must bill Medicare before seeking reimbursement from Medicaid.
Criteria for Bed Reservation Days
- The beneficiary is in Medicaid long-term care vendor payment status and has been a resident of the facility at least overnight. Persons for whom Medicaid is making Part A coinsurance payments are not in Medicaid payment status for purposes of this policy.
- The beneficiary is reasonably expected to return to the same facility with Medicaid as the primary payer. If returning to the same facility with Medicare as the primary payer, bed reservation days will be available only up to the period Medicare eligibility is determined, provided the bed reservation day maximums are not exceeded.
- If, due to a demand for beds at the facility, it is likely that the bed would be occupied by other residents were it not reserved.
- The hospitalization is in an acute care hospital or a Kentucky hospital certified to participate in the acute care hospital program. The hospitalization is approved by Carewise.
- If hospitalization is approved and the bed occupied by the resident also is a Medicaid-certified acute care bed, the resident will have been transferred to a specialty unit of a hospital.
Limitations on Medicaid reimbursement for bed reservation days
- A maximum of 14 days per calendar year due to an acute care hospital stay.
- A maximum of 10 days per calendar year for leaves of absence other than hospitalization.
- Reimbursement is 75 percent of the facility rate if the facility has an occupancy rate of 95 percent or more.
- Reimbursement is 50 percent of the facility rate if the facility has an occupancy rate of less than 95 percent.
Maximums are applied per beneficiary per calendar year. Accumulated bed reserve days will follow a beneficiary rather than starting over at zero at a new relocation.
Prior Authorization
CareWise provides prior authorization for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Claims Submission
Kentucky Medicaid currently contracts with
Gainwell Technologies to process Kentucky Medicaid FFS claims. Each MCO processes its own claims.
Coding
Kentucky Medicaid uses the National Correct Coding Initiative edits as well as the McKesson Claim Check System to verify incidental or mutually exclusive codes. Kentucky Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of UB-04 billing forms. Providers must bill Kentucky Medicaid using the CPT 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. Please refer to the MCO if appealing an MCO claim.
Timely Filing
Claims must be received the longer of either 12 months from the date of service or six months from the Medicare pay date or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim.
Provider Support
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 - (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
Report Medicaid fraud and abuse - (800) 372-2970
MCO Contacts
Anthem - (800) 205-5870
Aetna Better Health of KY - (855) 300-5528
Humana - (800) 444-9137
Molina - (800) 578-0775
United Health Care Community Plan - (866) 633-4449
WellCare of Kentucky - (877) 389-9457