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
The EPSDT Screening Program provides routine physicals or well-child checkups for Medicaid-eligible children from birth to age 21 at certain specified ages. Services are considered preventive care. Children are checked for medical problems early and tests and treatments are recommended as children get older.
Specific services include preventive check-ups; growth and development assessments; vision, hearing and dental checks; immunizations; and laboratory tests.
Verify eligibility by:
- Contacting the automated voice response system at (800) 807-1301
- Using the Web-based KYHealth-Net System
EPSDT service providers must meet the coverage provisions and requirements of 907 KAR 11:034 to provide covered services. 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.
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.
CareWise provides prior authorizations for any fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid fee-for-service claims. Each MCO processes its own claims.
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.
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 when appealing an MCO claim.
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:
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
CHFS DMS BH and SU Inquires - (502) 564-6890
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