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Optometrist services are recognized in Kentucky Medicaid as Provider Type (77) individual, or (779) group. To enroll or bill KY Medicaid, Optometrist provider services must be: 

  • Licensed by the state where they practice.  In Kentucky, Optometrist service providers must be licensed with the Kentucky Board of Optometrist Examiners
  • Enrolled as an active Medicaid active provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves. 

Covered Services

 If determined medically necessary, optometrists primarily involve performing eye exams and vision tests, prescribing and dispensing corrective lenses, detecting certain eye abnormalities, and prescribing medications for certain eye diseases. Most examinations and certain diagnostic procedures performed by ophthalmologists and optometrists are covered for all ages.

Optometrists must meet the coverage provisions and requirements set forth in 907 KAR 1:632 in order 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. 

Verify eligibility 

Verify eligibility by calling the automated voice response system at (800) 807-1301, or visit the web-based KYHealth-Net System.

Non-Covered Services

Procedures not considered medically necessary shall not be covered by Kentucky Medicaid. For example, Kentucky Medicaid shall not reimburse for telephone consultation; service with a CPT code or item with an HCPCS code that is not listed on the Department for Medicaid Services Vision Program Fee Schedule.

Reimbursement

Reimbursement for Optometrist services is in accordance with the Vision Fee Schedule and is defined in 907 KAR 1:631.

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 time period.

Prior Authorization

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 the Kentucky Medicaid fee for service (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 mutually exclusive or incidental. KY 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 in question, if appealing an MCO claim.

Timely Filing

Claims must be received within 12 months from the date of service (DOS) or 6 months from the Medicare pay date whichever is longer, or within 12 months from the last Kentucky Medicaid denial. Please refer to the MCO in question, if appealing an MCO claim.

Provider Contact Information

Billing Questions - DXC - (800) 807-1232
Provider Questions - (855) 824-5615
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 

Contact Information

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