The Primary Care Center (PCC) program is identified by Kentucky Medicaid as Provider Type (31) and may bill Kentucky Medicaid using this provider type number. To provide services to a Medicaid beneficiary a PCC must:
- be under a grant through 42CFR 405.2401.
- be enrolled with Medicare
- be enrolled as a Kentucky Medicaid provider
- be enrolled with the managed care organization (MCO) of any beneficiary it serves.
Covered Services
What are Primary Care Center Services?
If medically necessary, Kentucky Medicaid will cover:
- services and supplies incidental to physician services, nurse practitioner, physician assistant, certified nurse-midwife, clinical psychologist and clinical social worker services;
- Medicare Part B-covered drugs given incidental to PCC practitioner services;
- visiting nurse services to the homebound in an area where the Centers for Medicare and Medicaid Services certified a shortage of home health agencies;
- outpatient diabetes self-management training and medical nutrition therapy for patients with diabetes or renal disease are given by qualified practitioners in a one-on-one, face-to-face visit;
- certain care management services, such as transitional care management, chronic care management, general behavioral health integration and psychiatric collaborative care model services;
- certain virtual communication services such as communications-based technology and remote evaluation service
- pharmacy services that meet the coverage criteria established in 907 KAR 23:010
- nutritional services provided by a nutritionist, including individual counseling relating to nutritional problems or nutritional education or group nutritional services;
- nurse midwifery services provided as a program including prenatal services to expectant mothers, delivery or postnatal services.
A primary care center will provide at least two of the following services: dental services, optometric services, family planning services listed and as limited in
907 KAR 1:048; home health services listed and as limited in
907 KAR 1:030 and social services counseling.
How do I verify eligibility?
Once eligibility is confirmed you may verify continued eligibility by one of the following methods:
- contact the automated voice response system at (800) 807-1301
- use the web-based
KYHealth-Net System
Primary care facilities must meet the coverage provisions and requirements in
907 KAR 1:054 to provide covered services. All services must be performed within the scope of practice for any provider. Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow Kentucky Medicaid regulations and requirements of the MCO for which it participates. All services must be medically necessary.
Not Covered
Procedures considered not medically necessary will 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; and missed appointments.
Limitations and Exclusions
Limitations and exclusions are as follows:
- except when beneficiary suffers an illness or injury requiring additional diagnosis or treatment, an encounter with more than one health care provider or multiple encounters with the same health care provider on the same day and at a single location will constitute a single visit.
- a vaccine is available without charge to a child [ through the Vaccines for Children Program] and the administration of the vaccine will not be reported as a cost to the Medicaid program.
- adult flu vaccine costs are allowed if reported on a universal cost report.
- Kentucky Medicaid will not reimburse for services provided by a PCC to a beneficiary in a hospital unless the PCC has any time prior to the hospital admission provided a service to the beneficiary at its location.
Reimbursement
Reimbursement for primary care services is provided by
907 KAR 1:055.
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. For example, if a beneficiary is receiving a service from an independent mental health service provider, the department will not reimburse for the same service provided to the same beneficiary during the same time period by a primary care center.
Prior Authorizations
Fee-for-service beneficiaries who require prior authorization for additional services deemed medically necessary should 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
DXC to process the Kentucky Medicaid fee-for-service 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 Correct Procedural Terminology 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 using the revenue codes listed in the back of the billing manual.
Claim Appeals
Appeal requests made on denied fee-for-service 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 if appealing an MCO claim.
Timely Filing
Claims must be received within 12 months of the date of service or six 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:
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-Assisted 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