Kentucky Medicaid identifies the Nursing Facility (NF) program as Provider Type (12). In order to enroll and bill Kentucky Medicaid, NF service providers must be:
- 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
What are Nursing Facility Services?
NF services included in per diem rate are room and board, dietary services, nutritional supplements, social services, 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 if ordered by the physician, are 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.
A beneficiary 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;
- They require and meet the nursing facility level of care criteria (as defined by Section 4 of 907 KAR 1:022 giving consideration for the medical diagnosis, age-related dependencies, care needs, services, and health personnel required to meet these needs and the feasibility of meeting the needs through alternative institutional or non-institutional services; and
- Meet the income and resource limitations required by the program.
For information on completing the Level I Screening and Level II evaluation, visit the
Department for Behavioral Health, Developmental and Intellectual Disabilities PASSR website. You may access forms, manual and regulations from this site.
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
NF service providers must meet the coverage provisions and requirements set forth in
907 KAR 1:022,
907 KAR 1:023, 907 KAR 1:037 , and
907 KAR 1:755 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.
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
The department shall 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
Medicaid shall reimburse a nursing facility during a beneficiaries' absence for acute care hospitalization and therapeutic home visits provided certain criteria are met. Bed reservation days shall not be available for beneficiaries admitted to a psychiatric hospital.
Facilities shall allow beneficiaries Medicaid is paying to reserve a bed, return to that bed when they are ready for discharge from the hospital or when returning from therapeutic home visits, regardless of the day of the week (this includes holidays and weekends.) If the facility chooses not to reserve a bed for a resident for whom bed reservation days are available, the facility shall advise the beneficiary prior to their departure from the facility.
It shall be the responsibility of the nursing facility to assure that services and items ordered by a beneficiaries physician are provided while the beneficiary is out of the facility (other than for hospitalization) and Medicaid will be billed to reserve the bed.) The nursing facility shall not be responsible if the beneficiary was on bed reservation days for hospitalization as the hospital would be providing required services and items. If the nursing facility cannot provide the required ancillaries directly, the facility shall make arrangements with 10 qualified sources (i.e., pharmacy, physical therapist, speech therapist, etc.) for the resident to obtain the required services and items. Pharmacies shall bill Medicaid directly therapists, etc. shall bill the facility. As always, if the beneficiary receives an ancillary service or item that Medicare Part B can cover, the nursing facility shall ensure that the carrier is billed prior to seeking reimbursement from Medicaid.
Criteria for approved bed reservation shall be:
- 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 shall not be considered to be 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 shall only be available up to the days Medicare eligibility is determined, provided the bed reservation day maximums are not exceeded.
- Due to a demand for beds at the facility, there is a likelihood that the bed would be occupied by some other residents were it not reserved.
- The hospitalization shall be in an acute care hospital or a Kentucky hospital certified to participate in the acute care hospital program. The hospitalization shall be approved by Carewise.
- If hospitalization is approved, and the bed occupied by the resident is also a Medicaid certified acute care bed, the resident shall have been transferred to a specialty unit of a hospital.
Medicaid reimbursement for bed reservation days shall be limited as follows:
- 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 shall be 75% of a facility’s rate if the facility has an occupancy percentage of 95 % or higher.
- Reimbursement shall be 50% of a facility’s rate if the facility has an occupancy percentage lower than 95%.
Maximums are applied per beneficiary per the calendar year. Accumulated bed reserve days shall follow a beneficiary if the other facility rather than starting over at zero to a new relocation.
CareWise provides prior authorizations for any For Fee for Service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with
DXC to process the Kentucky Medicaid FFS claims. Each MCO processes its own claims.
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. Kentucky Medicaid requires the use of CMS 1500 billing forms. Providers will need to bill Kentucky Medicaid using the correct CPT codes.
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.
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 Contact Information
If you can't find the information you need or have additional questions, please direct your inquiries to:
FFS Billing Questions - DXC
- (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization -
- (800) 292-2392Provider Enrollment or Revalidation
- (877) 838-5085KyHealth.net
- (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071Pharmacy Prior Authorization
- (800) 477-3071
Physician Administered Drug (PAD) List - Pharmacy Branch - (502) 564-6890