Home- and Community-Based (HCB) waiver is Kentucky Medicaid provider type 42. To bill Kentucky Medicaid, an HCB waiver provider must be:
- An adult day health care center, home health agency, center for independent living, public health department, home-delivered meal provider or area agency on aging and independent living.
- Certified and/or licensed as required by 907 KAR 7:010.
- Enrolled as a Kentucky Medicaid provider.
Covered Services
The HCB waiver provides services traditional Medicaid typically does not cover to adults 65 and older or individuals of any age with a physical disability. Services include attendant care, environmental and minor home adaptations or respite. HCB waiver services help individuals live in the community as independently as possible.
An HCB waiver service provider must meet the coverage provisions and requirements of 907 KAR 7:010. Services must be performed within 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. All services must be medically necessary.
Eligibility
Verify eligibility by calling the automated voice response system at (800) 807-1301 or by using the web-based KYHealth-Net System.
Reimbursement
HCB waiver 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 (FFS) claims.
Find FFS Provider Billing Instructions
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 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 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.
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-116: Service Plan - Participant Authorization
MAP-531: Conflict Free Case Management Exemption
Search for all MAP forms
Helpful Links
Search for Provider Letters
HCB Waiver Information
HCB Waiver Provider Summary
Home Delivered Meals Provider Information
Electronic Visit Verification
Medicaid Waiver Management Application (MWMA) Guides and Information
Incident Reporting: Instructional Guide and FAQ
Service Authorization Crosswalks, Training and Resources
Provider Inquiry Resources