Adult day health care (ADHC) is Kentucky Medicaid provider type 43. To enroll and bill Kentucky Medicaid, ADHC service providers must be:
Covered Services
ADHC services are provided on-site at a center where individuals receive skilled nursing care, routine personal care and health care, meals, and are part of daily activities.
An ADHC service provider must meet the coverage provisions and requirements of
907 KAR 7:010. Services must be performed in the scope of practice for any provider. Listing of services in an administrative regulation is not a guarantee of payment. Providers must follow all relevant state Medicaid regulations.
Verify Eligibility
Verify eligibility by calling the automated voice response system at (800) 807-1301 or by using the web-based KYHealth-Net System.
Reimbursement
ADHC services are reimbursed per
907 KAR 7:015. Current reimbursement rates for the HCB waiver are available on the
DMS Fee and Rate Schedule webpage.
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 period.
Service Authorization
Case managers approve most 1915(c) HCBS services. Carewise Health reviews requests for
high-cost or high-skill services as part of the
Kentucky Medicaid Utilization Management (UM) Program. If you have questions about service authorization, please contact the UM Call Center at (800) 292-2392.
Claims Submission
Kentucky Medicaid currently contracts with
Gainwell Technologies to process Medicaid fee-for-service claims.
Find FFS Provider Billing Instructions
Coding: Kentucky Medicaid uses the National Correct Coding Initiative edits as well as the McKesson Claim Check System to verify incidental or mutually exclusive codes. Kentucky Medicaid also uses Current Procedural Terminology (CPT) 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 CMS 1500 billing forms. Providers must bill Kentucky Medicaid using the correct CPT codes.
Claim Appeals: Appeal requests made on denied fee-for-service claims must be submitted to
Gainwell Technologies and include the reason for the request along with a hard-copy claim.
Timely Filing: Claims must be received the longer of either 12 months from the date of service or six months from the Medicare pay date or within 12 months from the last Kentucky Medicaid denial.
Regulations
907 KAR - Cabinet for Health and Family Services DMS Title Page
907 KAR 7:005 - Certified waiver provider requirements
907 KAR 7:010 - HCB Waiver
907 KAR 7:015 - Reimbursement for HCB waiver services
907 KAR 1:022 - Nursing facility level of care
Provider Resources
MAP Forms
MAP-10: Physician's Recommendation
MAP-115: Application Intake - Participant Authorization
MAP-116: Service Plan - Participant Authorization
MAP-351: Medicaid Waiver Assessment
MAP-531: Conflict Free Case Management Exemption
Search for all MAP forms
Helpful Links
HCB Waiver Provider Information
Home Delivered Meals Provider Information
ADHC Provider Summary
Medicaid Waiver Management Application (MWMA) Information
Incident Reporting:
Instructional Guide and
FAQ
Service Authorization Crosswalks, Training, and Resources
If you can't find the information you need or have additional questions, please direct your inquiries to:
Billing Questions -
Gainwell Technologies - (800) 807-1232
1915(c) HCBS Waiver Policy Questions - (844) 784-5614
Service Authorization - (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth-Net assistance -
Gainwell Technologies - (800) 205-4696
MWMA Technical Support - (844) 784-5614, option 1
OIG Questions - (502) 564-7963
Report Fraud and Abuse - (800) 372-2970
For more specific inquiries, see the
1915(c) HCBS waiver contacts listing.