Freestanding birthing center service is recognized in Kentucky Medicaid as Provider Type (73). To enroll and bill Kentucky Medicaid, freestanding birthing center service providers must be:

• In Kentucky, providers must contact the Office of Inspector General (OIG) for a survey/license.
  
• Enrolled as a Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary for whom it provides services. 

Covered Services

A freestanding birth center may provide prenatal visits, including one initial visit and follow-up visits as appropriate standby services with the rendering provider physically present throughout the course of the labor delivery including the actual delivery, necessary supplies and material for the delivery, up to two post-delivery postnatal examination visits within six weeks of the delivery and laboratory services directly related to the freestanding birth center service.

A freestanding birthing center facility provider must meet the coverage provisions and requirements of 907 KAR 1:180 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 KY Medicaid regulations. All services must be medically necessary. 

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

The department will reimburse a professional fee to a rendering provider for a prenatal visit, a standby service or a postnatal visit at the lesser of the rendering provider’s usual and customary charge for the service, the reimbursement for the service provided in 907 KAR 3:130 if the rendering provider is a physician or 75 percent of the reimbursement for the service as provided by 907 KAR 3:010 if the rendering provider is an advanced practice registered nurse, physician assistant or registered nurse.

The department will reimburse for no more than two postnatal visits per beneficiary and not reimburse for a postnatal visit after six weeks since the delivery. Reimbursement of a professional fee to a rendering provider referenced in this subsection is separate from and in addition to the reimbursement referenced in a subsection of this section.

​Services and rates

Referring a beneficiary to an inpatient hospital for delivery services if the freestanding birth center determined before providing delivery-related services - ​$ 25

​Providing delivery-related services to a beneficiary; and determining, after providing delivery-related services to a beneficiary, that the beneficiaries delivery was complicated and needed to be handled in an inpatient hospital - ​$156

Services related to a complete delivery that occurred at the freestanding birth center. - ​$1,557

The department's reimbursement to a freestanding birth center referenced in this subsection is separate from and in addition to the reimbursement referenced in 907 KAR 1:190 Section 1

The department’s reimbursement is considered payment in full for all services, supplies, and devices provided to a beneficiary.

A freestanding birth center will not bill a beneficiary or party other than the department for a service provided to the beneficiary if the service was covered by the department.

A rendering provider will not bill a beneficiary or party other than the department for a service provided to the beneficiary if the service was covered by the department. An MCO reimbursement will be considered payment in full for all services, supplies and devices provided to a beneficiary.

A freestanding birth center or rendering provider will bill a beneficiary or party other than the beneficiary MCO for a service provided to the beneficiary if the service was covered by the MCO.

Prior Authorizations

CareWise provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.

Claims Submission

Kentucky Medicaid currently contracts with DXC to process Kentucky Medicaid FFS claims. Each MCO processes its own claims.

Coding

Kentucky Medicaid uses 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 Current 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. Kentucky Medicaid requires the use of CMS 1500 billing forms. Providers will bill Kentucky Medicaid using the correct CPT codes.

Claim Appeals

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 if appealing a MCO claim.

Timely Filing

Claims must be received within 12 months from the date of service or six months from the Medicare pay date whichever is longer, or within 12 months from the last Kentucky Medicaid denial. Please refer to the MCO if appealing a 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
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 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