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Kentucky Medicaid identifies Preventative Services as Provider Type (20).  To enroll and bill Kentucky Medicaid, Preventative Services providers must be:

  • Enrolled with the Kentucky Department of Public Health
  • be enrolled as a Kentucky Medicaid Provider
  • Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary served.

Covered Services

 The following medically-necessary preventive, screening, diagnostic, rehabilitative, and remedial services provided by the Department for Public Health directly or indirectly through its subcontractors shall be covered:

  • A chronic disease service
  • A communicable disease service
  • An early and periodic screening, diagnosis and treatment (EPSDT) service
  • A family planning service
  • A maternity service
  • A pediatric service

Preventative Service providers must meet the coverage provisions and requirements set forth in 907 KAR 1:360 to provide covered services.  All services must be performed within the scope of practice for any provider. Providers must follow Kentucky Medicaid regulations and the requirements of the MCO in which they participate.

Service Limitations

A laboratory procedure shall be limited to a procedure for which the provider has been certified in accordance with 42 C.F.R. Part 493. A service allowed in accordance with 42 C.F.R. 441, Subpart E or Subpart F shall be covered within the scope and limitations of these federal regulations. Coverage for a fetal diagnostic ultrasound procedure shall be limited to two per nine-month period per beneficiary unless the diagnosis code justifies the medical necessity of an additional procedure. 

Verifying eligibility

Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.

Reimbursement

Reimbursement for Preventative Services in pursuant to 907 KAR 1:360 and the Preventative Fee Schedule. 

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.

Prior Authorizations

 For Fee for Service beneficiaries who require prior authorization for additional services that are deemed medically necessary, contact CareWise. For MCO beneficiaries who require prior authorization for additional services that are medically necessary, contact the MCO for more information.

Claims Submission

Kentucky Medicaid currently contracts with Gainwell to process the Kentucky Medicaid fee for service (FFS) claims. Each MCO processes its own claims.

Coding: 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 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) KY Medicaid requires the use of CMS 1500 billing forms. (eff: 02/12) Providers will need to bill Kentucky Medicaid using the correct CPT codes.

Claim Appeals: Appeal requests made on denied FFS claims must be submitted to Gainwell. 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.

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. 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:
Billing Questions - Gainwell - (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

Provider MCO Information

Anthem - (800) 205-5870 
Aetna Better Health of KY - (855) 300-5528 
Humana - (855) 852-7005
Passport Health Plan- (800) 578-0775
WellCare of KY - (877) 389-9457 

Contact Information

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