KY Medicaid identifies early periodic screening diagnosis and treatment services (screenings services) as Provider Type (45). To enroll and bill KY Medicaid, EPSDT services providers must be:
- Licensed in the state where they operated.
- Enrolled as an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.
Covered
EPSDT screening services
Required Services for EPSDT aged children from birth to age 21.
- Screening – comprehensive unclothed exam and health/ developmental history, appropriate immunizations health education (including anticipatory guidance), includes lab (Including blood lead) Also called “well-child visits”.
- Vision Services - Including eyeglasses
- Dental Services - Including relief of pain and infections, restoration of teeth, and maintenance of dental health
- Hearing Services - Including hearing aids
- Such other necessary health care, diagnostic services, treatment, and other measures described in section n 1905(a)to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the state plan.
Periodicity Schedule
Periodicity schedules for periodic screening, vision, and hearing services must be provided at intervals that meet reasonable standards of medical practice. A nationally recognized pediatric periodicity schedule (i.e., Bright Futures ). This is the KY Medicaid standard.
A separate dental periodicity schedule is also required.
Reimbursement
Reimbursement for EPSDT services is in accordance with 907 KAR 11:035.
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
Gainwell 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 Gainwell to process the Kentucky Medicaid fee-for-service claims. Each MCO processes its own claims.
Coding
Kentucky Medicaid utilizes 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 need to bill Kentucky Medicaid using the correct CPT codes.
Claim Appeals
Appeal requests made on denied FFS claims must be submitted to Gainwell. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO when appealing an 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 when appealing an MCO claim.
Provider Contact Information
If you can't find the information you need or have additional questions, please direct your inquiries to:
Provider MCO Information