Kentucky Medicaid identifies school-based health services (SBHS) as Provider Type (21). To enroll and bill Kentucky Medicaid, an SBHS service provider must be:
Covered Services
The Kentucky Department of Education allows local education agencies to enroll as Medicaid health service providers for beneficiaries enrolled in or eligible for the Medicaid program and under the
Individuals with Disabilities Education Act (IDEA). SBHS are evaluative, diagnostic, preventive, and treatment services provided for the maximum reduction of physical or intellectual disability, to allow for functioning of the beneficiary to the best possible level, to prevent loss of current functional level, or correct any defects or conditions.
SBHS services must be medically necessary or listed in the child's individual education plan (IEP) and meet the coverage provisions and requirements of 907 KAR 1:715. All services must be performed 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.
Eligibility
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Children ages three to 21 enrolled in or eligible for Medicaid under provision of and the Individuals with Disabilities Education Act and who have an IEP are eligible for school-based health services.
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Parents must be advised annually that the school intends to bill Medicaid for a child's services. A parent may refuse to allow the school to bill.
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Speech therapy, occupational therapy, physical therapy and mental health services may be provided in an individual or group setting.
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Children who receive school-based health services are not prohibited from receiving services through the Early Periodic Screening, Diagnosis, and Treatment program. When medically necessary, services may be covered through both programs
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 SBHS is in accordance with 907 KAR 1:715.
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.
Prior Authorizations
Some services may require prior authorization. Just because a service is listed in the administrative regulation does not guarantee payment for the service.
Claims Submission
KY Medicaid currently contracts with Gainwell Technologies to process FFS claims.
Coding
Kentucky Medicaid requires providers to bill on a CMS-1500 claim form utilizing the following code types where applicable:
- Current Procedure Terminology (CPT) codes, regulated by the American Medical Association (AMA).
- Healthcare Common Procedure Coding System (HCPCS) codes, regulated by the Centers for Medicare and Medicaid Services (CMS).
- Current Dental Terminology (CDT) codes, regulated by the American Dental Association (ADA).
- International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes, maintained by the Centers for Disease Control & Prevention (CDC) and the National Center for Health Statistics (NCHS).
Kentucky Medicaid uses the Medicare National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits, the Medicaid Medically Unlikely Edits (MUEs), and the McKesson Claim Check System to verify codes mutually exclusive or incidental.
Claim Appeals
Appeal requests of denied FFS claims must be submitted to Gainwell Technologies. The appeal request must include the reason for the appeal along with a hard copy claim.
Timely Filing
Claims must be received within 12 months of the date of service or within 12 months of the last Kentucky Medicaid denial.
Provider Inquiry Resources
If you cannot find the information you need or have additional questions, please review the Kentucky Medicaid Contact List to find additional support from Kentucky Medicaid.