Kentucky Medicaid identifies certified registered nurse anesthetist (CRNA) as Provider Type (74) individual or (749) group. To enroll or bill KY Medicaid CRNA service providers must be:

• Licensed in the state in which they operate. In Kentucky, CRNA service providers must be licensed with the Kentucky Board of Nursing.
• Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it provides services for

Covered Services

Covered services are provided during a procedure which includes preoperative and postoperative visits; administration of the anesthetic; administration of intravenous fluids, blood or blood products incidental to the anesthesia or surgery; postoperative pain management; and monitoring services.

CRNA providers must meet the coverage provisions and requirements of 907 KAR 1:102 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. Other services may be approved on a case-by-case basis and approved by the medical director. Providers may request to have a procedure code covered by submitting a request in writing to the department which includes necessity, CPT code and expected reimbursement.

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 CRNA services is in accordance with the Physician Fee Schedule. Providers are paid at 75 percent of the physician fee schedule for codes within the scope of practice pursuant to 907 KAR 1:104 Section 2(b). Any codes considered experimental are not covered by KY Medicaid.

Multiple Procedures

Multiple procedures performed by the same CRNA on the same patient at the same session will be reimbursed at the lower of the usual billed charge or at 100 percent of the physician fee schedule (minus 25 percent) for the major procedure and 50 percent (minus 25 percent) for the lesser procedures. Anything considered incidental will not be covered by KY Medicaid.

Duplication of Service 

The department will 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

Prior authorized service codes are indicated on the physician fee schedule and regulated by 907 KAR 3:005 Section 5. CareWise provides prior authorizations for any fee-for-Service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.

Claims Submission

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

Coding

KY Medicaid uses the National Correct Coding Initiative (NCCI) edits as well as the McKesson Claim Check System to verify codes mutually exclusive or incidental. KY Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system (HCPCS) codes. KY 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 must bill KY 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 (DOS) 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 Drugs (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