Home- and Community-Based (HCB) waiver is Kentucky Medicaid provider type 42. To bill Kentucky Medicaid, an HCB waiver provider must be:
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 uses the National Correct Coding Initiative edits and 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-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
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
HCB Waiver Policy Questions - (877) 315-0589
Service Authorization - (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KYHealth-Net assistance - Gainwell Technologies - (800) 205-4696
HCB waiver questions - (844) 784-5614
MWMA Techincal Support - (844) 784-5614, option 1
Report Fraud and Abuse (800) 372-2970
For more specific inquiries, view the 1915(c) waiver contacts listing.