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Kentucky Medicaid identifies physician service providers as Provider Type (64) individual or (65) group. To enroll and bill Kentucky Medicaid, physician service providers must be: 

  • Licensed in the state in which they operate. In Kentucky, physician service providers must be licensed with the Kentucky Board of Medical Licensure
  • Enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.

Covered Services

What are physician services

Medically necessary services furnished by a physician through face-to-face interaction between the physician and the beneficiary.

Telehealth is billable for this provider type. 

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  

Physician service providers must meet the coverage provisions and requirements of 907 KAR 3:005. 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.

Reimbursement

Reimbursement for physician services is provided in the Physician Fee Schedule. Reimbursement is based on the Kentucky Medicare rate and repricing methodology in 907 KAR 3:010 Section. Other services may be approved on a case-by-case basis and approved by the medical director. A provider may request coverage for a procedure code by submitting a request in writing to the department which includes necessity, CPT code and expected reimbursement. Any codes considered experimental are not covered by Kentucky Medicaid.

Multiple Procedures

Multiple procedures performed by the same physician on the same patient at the same session are reimbursed at the lower of the usual billed charge or at 100 percent of the Physician Fee Schedule for the major procedure and 50 percent for the lesser procedures. Anything considered incidental is not covered by Kentucky Medicaid.

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 service is covered during the same time period.

Prior Authorizations

Prior authorized service codes are indicated on the Physician Fee Schedule and are governed by 907 KAR 3:005 Section 5. CareWise provides prior authorizations 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 the 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 codes that are mutually exclusive or incidental. 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 CMS 1500 billing forms. Providers will need to bill Kentucky Medicaid using the correct CPT codes.

Claim Appeals

Appeal requests of 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 within 12 months of the date of service or 6 months from the Medicare pay date, whichever is longer, or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO 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 - 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 Technologies - (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
Molina - (800) 578-0775
WellCare of KY - (877) 389-9457


Contact Information

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