Audiologists are recognized in Kentucky Medicaid as Provider Type 70. In order to enroll as an Audiologist with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
Eligible services are medically necessary, limited to one complete hearing evaluation per the calendar year and may include a hearing instrument evaluation which include three follow-up visits which shall be:
- Within the six-month period immediately following fitting with a hearing instrument; and
- related to the proper fit and adjustment of the hearing instrument; and
- include one additional follow-up visit at least six months following the hearing instrument fitting; and
- related to the proper fit and adjustment of the hearing instrument.
Referral by a physician to an audiologist is required.
Additional services may be included if the beneficiaries' health care provider demonstrate that an additional hearing instrument evaluation is medically necessary.
Audiologist service providers must meet the coverage provisions and requirements of
907 KAR 1:038 to provide covered services. Any services performed must fall within the scope of practice for the provider. Listing of a service in an administrative regulation is not a guarantee of payment. Providers must follow Kentucky Medicaid regulations. All services must be medically necessary.
Multiple Procedures
When more than one covered procedure is performed in a single operative session, reimbursement for facility services will be 100 percent of the surgical group rate for the primary procedure and 50 percent of the surgical group rate for the secondary procedure.
Not Covered
The department will not cover or reimburse:
- An audiology service without a referral from a physician.
- A procedure that is a part of a comprehensive service.
- Routine screening of an individual or group of individuals for identification of a hearing problem.
- Hearing therapy unless covered within the six (6) month adjustment counseling following the fitting of a hearing instrument.
- Lip-read reading instructions unless covered within the six (6) month adjustment counseling following the fitting of a hearing instrument.
- A service in which a beneficiary has no obligation to pay and for which no other person has a legal obligation to provide or to make payment.
- Telephone call
- A service associated with investigational research.
- A replacement hearing instrument for the purpose of incorporating a recent improvement or innovation unless the replacement results in appreciable improvements in the recipient's hearing ability determined by the audiologist.
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 Audiologist is listed on the Kentucky Medicaid Audiology fee schedule.
A provider may request coverage for a CPT or HCPCS procedure code by submitting a request in writing to the department which includes necessity, CPT or HCPCS code, and expected reimbursement. Any code considered experimental are not covered by Kentucky Medicaid.
Duplication of Service
The department does not reimburse for a service provided to a beneficiary by more than one provider of any program in which the same service is covered, during the same time period.
Prior Authorizations
Each MCO provides prior authorization for its beneficiaries.
Gainwell Technologies provides prior authorizations for fee-for-service (FFS) beneficiaries. For more information, visit Prior Authorizations.
Claims Submission
Each MCO processes its own claims.
Kentucky Medicaid contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. For more information, visit KYHealth-Net.
Coding
Kentucky Medicaid requires Audiology 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 for denied FFS claims must be submitted to Gainwell Technologies. The request must include the Provider Inquiry Form, reason for the appeal, and a hard copy claim.
Please refer to the member's MCO if appealing an MCO claim.
Timely Filing
Claims must be received within twelve (12) months from the date the service was provided, twelve (12) months from the date retroactive eligibility was established, or six (6) months of the Medicare adjudication date if the service was billed to Medicare.
Provider Resources
If you cannot find the information you need or have additional questions, please direct your inquiries to:
- Billing Questions- Gainwell Technologies, (800) 807-1232,
- ky_provider_inquiry@gainwelltechnologies.com
- Provider Questions- (855) 824-5615
- Prior Authorization- Gainwell Technologies, (800) 292-2392, (800) 644-5725, (800) 807-8842
- Provider Enrollment, Maintenance, and Revalidation- (877) 838-5085
- KYHealth.net assistance- Gainwell Technologies, (800) 205-4696, ky_edi_helpdesk@gainwelltechnolgies.com
- Pharmacy Questions- (502) 564-6890, dmsweb@ky.gov
- Pharmacy Clinical Support Questions- (800) 477-3071
- Pharmacy Prior Authorization- (844) 336-2676
- Physician Administered Drug (PAD) list- (502) 564-6890
Managed Care Organizations
*
Effective Jan.1, 2025, Anthem is no longer an active Medicaid Managed Care Organization, or MCO, in Kentucky. However, they are responsible for the payment of claims, appeals, or disputes for dates of service up to and including Dec. 31, 2024.