The Office for Children with Special Health Care Needs (OCSHCN) Program is recognized by Kentucky Medicaid as provider type (22). To enroll as an OCSHCN provider, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
OCSHCN provides comprehensive services to children and youth age 21 or younger with special health care needs who meet medical eligibility and financial eligibility.
OCSHCN providers must meet the coverage provisions and requirements of 911 KAR 1:010. 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 KY Medicaid regulations. All services must be medically necessary.
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 OCSCHN is defined in 911 KAR 1:020.
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 authorization for fee-for-service (FFS) beneficiaries. For more information, visit the Prior Authorizations webpage.
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 OCSHCN providers to bill on a CMS-1500 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 have questions or need more information, please review the Medicaid Contact List to find additional support from Kentucky Medicaid.