Notice 

In response to the COVID-19 state of emergency, the Centers for Medicare and Medicaid Services has authorized delay of certain Medicare cost reports. As a result, the Department for Medicaid Services also will grant any cost report extensions that Medicare has officially granted. At this time, the following fiscal year-end cost report extensions have been granted:

Please call (502) 564 - 8196 if you have any questions and ask for the staff referenced below based on provider type.

Kentucky Medicaid identifies hospital services as Provider Type (01). In order to enroll and bill Kentucky Medicaid, hospital service providers must be:

• Enrolled with Medicare.
• Licensed in the state in which they operate. In Kentucky, Hospitals must contact the Office of Inspector General Division of Health Care for a survey/license.
• Enrolled as a Medicaid active provider, and if applicable, enrolled with the managed care organization (MCO) of any beneficiary it serves.
  

Hospital Types and Programs

Acute care hospitals provide both inpatient and outpatient services, including emergency room services.
Critical access hospitals must meet other state and federal criteria.
Diagnosis-related groups (DRG) are clinically-similar grouping of services that can be expected to consume similar amounts of hospital resources.
Disproportionate share hospital (DSH) program Prior to billing a patient and submitting hospital service expenses to Medicaid as uncompensated, a hospital uses the indigent care eligibility form to determine if the patient meets DSH guidelines.

Covered Services

Most inpatient hospital services are covered as long as the inpatient stay is medically necessary as defined in 907 KAR 3:130. Certain hospital outpatient and emergency room services also are covered as defined in 907 KAR 10:014. 

Hospital service providers must meet the coverage provisions and requirements of 907 KAR 10:012 and 907 KAR 10:014 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. 

Non-Covered Services

Inpatient hospital services not covered include services that are not medically necessary including television, telephone or guest meals; private duty nursing; supplies, drugs, appliances or equipment furnished to the beneficiary for use outside the hospital unless considered unreasonable or impossible from a medical standpoint to limit the beneficiary's use of the item to the inpatient period; laboratory test not specifically ordered by a physician and not performed on a preadmission basis unless an emergency exists; private accommodations unless medically necessary and ordered by the attending physician.

The following services are not covered hospital outpatient services: items or services that do not meet the requirements of 907 KAR 10:014 Section 2(1); services for which an individual has no obligation to pay and no other person has a legal obligation to pay; medical supplies or appliances unless incidental to the performance of a procedure or service in the hospital outpatient department and included in the rate of payment established by the Medicaid program for hospital outpatient services; a drug, biological or injection purchased by or dispensed to a beneficiary; a routine physical examination; or non-emergency service, other than screening in accordance with Section 2(6)(a) of the above-referenced administrative regulation, provided to a lock-in beneficiary, in an emergency department of a hospital; or if provided by a hospital that is not the lock-in beneficiary's designated hospital.

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 hospital services is regulated under 907 KAR 10:015.

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 service is covered during the same time period. 

Prior Authorizations

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

Claims Submission

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

Coding

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. (eff: 10/1/15) Kentucky Medicaid requires the use of UB-04 billing forms. Providers will need to bill Kentucky Medicaid using the correct Revenue codes.

Claim Appeals

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 if appealing an MCO claim.

Timely Filing

Claims must be received within 12 months of the date of service (DOS) 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 Information

If you can't find the information you need or have additional questions, please direct your inquiries to:
Regarding licensure - Office of Inspector General (OIG), Division of Health Care - (502) 564-7963
FFS Billing Questions - Gainwell Technologies - (800) 807-1232
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

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