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The Physician Program is identified in Kentucky Medicaid as Provider Type (64) or (65). A Physician may bill as an individual (64) or as a group (65). In order for any Physician or Physician group to provide services to a Medicaid beneficiary, they must be:

  • licensed
  • enrolled as a Kentucky Medicaid Provider
  • enrolled with the Managed Care Organization (MCO) of any beneficiary they wish to treat.

Covered Services

Physicians must meet the coverage provisions and requirements set forth in 907 KAR 3:005 for services provided by participating providers. 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 Physician Fee Schedule. Others services may be approved on a case by case basis and approved by the Medical Director. Providers may request to have a procedure code covered by submitting a request in writing to the department which includes necessity, CPT code and expected reimbursement. Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow the regulations and requirements of the MCO for which they participate.
All services must be medically necessary.

Not Covered: Procedures not considered medically necessary shall not be covered by KY Medicaid. Non-covered services include: cosmetic surgery (except DMS approved), translation services, phone calls, court ordered testing, fertility services, copying of records, office supplies, investigational research, postmortem examinations, missed appointments.

Reimbursement: Reimbursement for physician services is in accordance to the Physician Fee Schedule. Reimbursement is based on the Kentucky Medicare rate then the repricing per methodology in 907 KAR 3:010 Section 3. 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 shall be reimbursed at the lower of the usual billed charge or at 100% of the Physician Fee Schedule for the major procedure and 50% for the lesser procedures. Anything considered incidental shall not be covered by Kentucky Medicaid.

Prior Authorizations

Prior authorized service codes are indicated on the Physicians Fee Schedule, and are governed by 907 KAR 3:005 Section 5. Physician Services requiring prior authorization must contact CareWise.

Claims Submission

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: The Physician Program 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
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

Contact Information

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