The RHC program is identified in Kentucky Medicaid as Provider Type (35). An RHC may bill as an entity (35). In order for a RHC entity to provide services to a Medicaid beneficiary, it must be
Covered Services
A RHC entity must meet the coverage provisions and requirements set forth in 907 KAR 1:082 in order to provide covered services. All services must be performed within the scope of practice for any provider. Rural Health Clinics (RHCs) were established to address the shortage of physicians serving patients in rural areas. The establishment of RHCs would also help to increase the use of non-physician providers, including Nurse Practitioners (NPs), Physician Assistants (PA-Cs), and Certified Nurse Midwifes (CNMs), in rural areas. Rural Health Clinics are federally designated through the Centers for Medicare and Medicaid Services (CMS). Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow the regulations and must follow requirements of the MCO for which they participate.
Prior Authorizations
Some services may require prior authorization. RHC Services requiring prior authorization must contact
CareWise.
Claims Submission
Kentucky Medicaid currently contracts with DXC to process 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 RHC Program uses Correct Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system (HCPCS) codes. KY Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. (eff: 10/1/15)
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 Assisted Drug (PAD) List - Pharmacy Branch - (502) 564-6890