Kentucky Medicaid identifies Rural Health Clinics (RHC) as Provider Type (35). In order to enroll and bill Kentucky Medicaid, RHC service providers must be:
- Enrolled with Medicare
Enrolled as an active Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.
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-Midwives (CNMs), in rural areas. Rural Health Clinics are federally designated through the Centers for Medicare and Medicaid Services (CMS).
RHC facilities must meet the coverage provisions and requirements set forth in 907 KAR 1:082 in order to provide covered services. Any services performed must fall within the scope of practice for any provider. Listing of a service in an administrative regulation is not a guarantee of payment. Providers must follow all relevant Kentucky Medicaid regulations. All services must be medically necessary.
Non covered Services
The following services shall not be covered as RHC: services provided in a hospital as defined in
42 U.S.C. 1395x(e); institutional services such as housekeeping, babysitting, or other similar homemaker services; services that are not provided in accordance with restrictions imposed by law or administrative regulation.
How do I verify eligibility?
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.
Reimbursement for RHC services is in accordance with 907 KAR 1:055.
No 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 service is covered, during the same time period.
CareWise provides prior authorizations for any Fee for Service beneficiary. Each MCO provides prior authorizations for its beneficiaries
Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid fee for service (FFS) claims. Each MCO processes its own claims.
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. KY Medicaid requires the use of CMS 1500 billing forms. Providers will need to bill Kentucky Medicaid using the correct CPT codes.
Appeal requests made on denied FFS 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 in question, if appealing an MCO claim.
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:
FFS Billing Questions - DXC - (800) 807-1232
General Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (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
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