Kentucky Medicaid recognizes Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Special Services as Provider Type (45). To enroll as an EPSDT Special Services provider with KY Medicaid, an EPSDT Special Services provider must:
- Contact the DMS EPSDT coordinator at (502) 564-9444 prior to enrollment.
- Be licensed in the state in which it operates.
- Become an active Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any member for whom it provides services.
Covered Services
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for Kentucky Medicaid members from birth to age 21. EPSDT Special Services is key to ensuring that children and youth receive appropriate preventive, dental, mental health, developmental, and specialty services or treatments. Children with special health care needs are those who have or are suspected of having a serious or chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond what is generally required by children. Any service that is available through Medicaid fee-for-service is available for children. This includes some services that may not be available to adults. Some examples of services include:
- physician and clinic services
- inpatient and outpatient hospital services
- laboratory and x-ray services
- home health services
- private duty nursing
- personal care services
- care coordination or case management services
- physical therapy
- occupational therapy
- speech therapy
- ABA therapy
- durable medical equipment
- dental services
- respiratory care services
- nursing facilities
- prescribed pediatric extended care (PPEC)
- psychiatric hospitals and outpatient psychiatric treatment
- nurse practitioner services
Under EPSDT/Special Services, a child can receive medically necessary services or equipment covered under the federal Medicaid program whether or not Kentucky Medicaid covers the service. Children can also get more of a service or treatment than would be provided to an adult. For example, a child can get more physical therapy than what is provided for an adult or more dental care than an adult would receive. This means that a child can get the type (e.g., therapy, nursing, personal care, etc.), amount (how much of the service), and duration (how long the service will be provided) of a service that is recommended as medically necessary by a Medicaid provider.
EPSDT service providers must meet the coverage provisions and requirements of 907 KAR 11:034 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.
How does a child get medically necessary services?
All EPSDT special services require prior authorization. Your child’s doctor or health care professional will help your child get the services they need by submitting a request for the service. Only Medicaid providers can request medically necessary treatment or services. Providers should review the Prior Authorization section for additional information.
Non-Covered Services
There are some services the EPSDT Special Services does not cover, which include:
- Respite care
- Environmental services
- Educational services
- Home modifications
- Vocational services
- Cosmetic services
- Convenience services
- Experimental services
- Over-the-counter items
Verifying Eligibility
Verify eligibility by contacting the automated voice Response System at (800) 807-1301 or using the Web-based KYHealth-Net System .
Reimbursement
EPSDT Special Services are reimbursed per 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 Technologies provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.
- For a child who is not enrolled in an MCO, the Medicaid provider shall submit a request for the treatment or services to Gainwell, using the MAP-9.
- For a child enrolled in an MCO, the provider should contact the plan’s prior authorization department to request treatment or services.
Claims Submission
KY Medicaid currently contracts with Gainwell Technologies to process FFS service claims. Each MCO processes its own claims.
Coding
Kentucky Medicaid requires providers to bill on a CMS 1500 claim form 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 for denied FFS claims must be submitted to Gainwell Technologies. The request must include the Provider Inquiry Form, reason for the appeal, and a hard copy claim.
Please refer to the member's MCO if appealing an MCO 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.
Questions
If you have questions or need more information, please review the Medicaid Contact List to find additional support from Kentucky Medicaid.