FQHCs are recognized in Kentucky Medicaid as Provider Type 31. In order to enroll as a FQHC with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
If medically necessary, Kentucky Medicaid will cover:
FQHC/Non-FQHC facilities will provide at least two of the following services: dental services, optometric services or family planning services listed and as limited in 907 KAR 1:048; home health services listed and as limited in 907 KAR 1:030 and social services counseling.
- Services and supplies incidental to physician services, nurse practitioner, physician assistant, certified nurse-midwife, clinical psychologist and clinical social worker services;
- Medicare Part B-covered drugs given incidental to FQHC/Non-FQHC practitioner services;
- Visiting nurse services to the homebound in areas where the Centers for Medicare and Medicaid Services certifies there is a shortage of home health agencies;
- Outpatient diabetes self-management training and medical nutrition therapy for patients with diabetes or renal disease;
- Certain care management services;
- Certain virtual communication services;
- Pharmacy services which will meet the coverage criteria established in 907 KAR 23:010
- Obstetric services provided as part of a program that includes prenatal services to expectant mothers, delivery or postnatal services.
- Dental services;
- Optometric services;
- Behavioral health and support counseling.
Non-Covered Services
- Duplicative services: Services provided to the same beneficiary by more than one provider during the same time-period;
- Services in hospitals or institutional settings;
- Non-Medically necessary services;
- Services under third-party contracts: Any care arranged or delivered via external contracts (e.g., with schools or courts) is excluded;
- Vaccines for Children: Administration fees for vaccines available free via the Vaccines for Children Program cannot be billed to Medicaid;
Verifying eligibility
Verify eligibility by contacting the automated voice response system toll-free at (800) 807-1301 or use the web-based KYHealth-Net System.
Reimbursement
Reimbursement for FQHCs is defined in regulation 907 KAR 1:055.
A provider may request coverage for a CPT or HCPCS procedure code by submitting a request in writing to the department which includes necessity, CPT or HCPCS code, and expected reimbursement. Any codes considered experimental are not covered by Kentucky Medicaid.
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 same service is covered, during the same time.
Prior Authorizations
Each MCO provides prior authorization for its beneficiaries.
Gainwell Technologies provides prior authorizations for fee-for-service (FFS) beneficiaries. For more information, visit Prior Authorizations.
Claims Submission
Each MCO processes its own claims.
Kentucky Medicaid contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. For more information, visit KYHealth-Net.
Coding
Kentucky Medicaid requires FQHC providers to bill on a CMS-1500, UB-04, or ADA 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.
Provider Inquiry 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, ky_provider_inquiry@gainwelltechnologies.com
- Provider Questions- (855) 824-5615
- Prior Authorization- Gainwell Technologies, (800) 292-2392, (800) 644-5725, (800) 807-8842
- Provider Enrollment, Maintenance, and Revalidation- (877) 838-5085
- KYHealth.net assistance- Gainwell Technologies, (800) 205-4696, ky_edi_helpdesk@gainwelltechnolgies.com
- Pharmacy Questions- (502) 564-6890, dmsweb@ky.gov
- Pharmacy Clinical Support Questions- (800) 477-3071
- Pharmacy Prior Authorization- (844) 336-2676
- Physician Administered Drug (PAD) list- (502) 564-6890
Managed Care Organizations
*Anthem - (855) 661-2028
Aetna - (855) 300-5528
Humana - (855) 852-7005
Passport Health Plan- (800) 578-0775
WellCare of KY - (877) 389-9457
*
Effective Jan. 1, 2025, Anthem is no longer an active Medicaid Managed Care Organization, or MCO, in Kentucky. However, they are responsible for the payment of claims, appeals, or disputes for dates of service up to and including Dec. 31, 2024.