Kentucky Medicaid identifies psychiatric residential treatment facility level I (PRTF I) as Provider Type (4). To enroll and bill Kentucky Medicaid, a PRTF I facility must be:
- Licensed in Kentucky. PRTF I service providers must contact the Office of Inspector General Division of Health Care for a survey/license.
- Enrolled as a Kentucky Medicaid provider and, if applicable, enrolled with the Managed Care Organization (MCO) of any beneficiary it serves.
PRTF I facilities are covered for beneficiaries ages 6 to 21 who require treatment on a continuous basis as a result of a severe mental or psychiatric illness. It is designed to serve children who need long-term, more intensive treatment and a more highly structured environment than they can receive in family and other community-based alternatives to hospitalization. Less restrictive and more homelike than hospitals, these facilities also serve children transitioning from hospitals who still are not ready for the demands of living at home or in a foster home.
PTRF I service providers must meet the coverage provisions and requirements of
907 KAR 9:005 and
907 KAR 9:015 to provide covered services. Any services performed must fall within the scope of practice for any provider. Listing of a service in the administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.
Exclusions and Limitations
The following are not covered as PRTF services:
- Chemical dependency treatment services if the need for the services is the beneficiary's primary diagnosis. However, chemical dependency treatment services are covered as incidental treatment if minimal chemical dependency treatment is necessary for successful treatment of the primary diagnosis
- Outpatient services
- Pharmacy services covered as pharmacy services in accordance with
907 KAR 23:010
- Durable medical equipment covered as a durable medical equipment benefit in accordance with
907 KAR 1:479
A PRTF may not charge a beneficiary or responsible party representing a beneficiary any difference between private and semiprivate room charges.
Services are not be covered if appropriate alternative services are available in the community. The following are not covered:
- Admissions that are not medically necessary
- Individuals with a major medical problem or minor symptoms
- Individuals who might only require a psychiatric consultation rather than an admission to a psychiatric facility
- Individuals who might need only adequate living accommodations, economic aid or social support services.
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Reimbursement for PRTF I services is provided by 907 KAR 9:020.
CareWise provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with DXC to process Medicaid claims. Each MCO contracts with its own billing agent.
Kentucky Medicaid uses 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 UB-04 billing forms. Providers will need to bill Kentucky Medicaid using the correct Revenue codes.
Appeal requests made on denied claims must be submitted to DXC. The request must include the reason for the request along with a hard copy claim.
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.
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
General Provider Questions - (855) 824-5615
Office of Transportation Delivery at (888) 941-7433
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth.net assistance -DXC - (800) 205-4696
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