Renal Dialysis Center Services - PT (39)

Kentucky Medicaid recognizes renal dialysis centers as provider type (39). To enroll in and bill Kentucky Medicaid, a renal dialysis centers service providers must be:

a hospital unit approved by Medicare
licensed in Kentucky with the Office of Inspector General, Division of Health Care
Enrolled as a Kentucky Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves
supervised by a a physician medical director who is a nephrologist, internist or pediatriciation with at least 12 months experience or training in the treatment and management of end-stage renal disease. The medical director must be full or part time and immediately available if not on-site in the facility

A hospital does not need to provide renal transplantation to qualify as a renal dialysis center. When patients are undergoing dialysis, at least one currently licensed health professional experienced in ESRD care is on duty to oversee ESRD patient care. The facility must ensure all necessary care, such as CPR and administration of intravenous medications can be delivered by the licensed person on duty.

Covered Services

Renal dialysis services

Renal sialysis services covered by Kentucky Medicaid are inpatient dialysis; outpatient dialysis; self-dialysis; home dialysis; physician services; laboratory services; hemodialysis; drugs; home supplies; and equipment. The service is provided by facility staff or individuals under contract with the facility per 42 CFR 405.2102.

Renal dialysis service providers must meet the coverage provisions of 907 KAR 1:400 to provide covered services. Medicare and private insurance must be billed prior to Kentucky Medicaid. Any services performed fall within the scope of practice for any provider. Listing of a service in the administrative regulation is not a guarantee of payment. Providers must follow the Kentucky Medicaid regulations. All services must be medically necessary.

Verifying eligibility

Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net System.

Reimbursement

The Renal dialysis facility must be able to bill all third-party payers and furnish the full spectrum of diagnostic, therapeutic and rehabilitative services required for the care of ESRD patients (including inpatient dialysis furnished directly or indirectly under arrangement). Reimbursement for renal dialysis services is provided in the payment allowance limits for Medicare Part B drugs.

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 Authorization

CareWise provides prior authorizations for fee-for-service (FFS) beneficiaries. Each MCO provides prior authorization for its beneficiaries.

Claims Submission

Kentucky Medicaid currently contracts with Gainwell Technologies to process FFS claims. Each MCO processes its own claims.

Coding

Kentucky Medicaid uses the National Correct Coding Initiative 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 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 Technologies. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO if appealing an MCO claim.

Timely Filing

Claims must be received within 12 months of the date of service or six months from the Medicare pay date, whichever is longer, or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if 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:
FFS Billing Questions - Gainwell Technologies& - (800) 807-1232
General Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth.net assistance -Gainwell Technologies - (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071
Pharmacy Prior Authorization - (800) 477-3071
Physician Administered Drug (PAD) List - Pharmacy Branch - (502) 564-6890