The Office for Children with Special Health Care Needs (OCSHCN) Program is recognized in Kentucky Medicaid as Provider Type (22) and may bill Kentucky Medicaid using these provider type numbers. In order for any OCSHCN provider to provide services to a Medicaid beneficiary, it must:
- be licensed
- be enrolled as a Kentucky Medicaid Provider
- be enrolled with the Managed Care Organization (MCO) of any beneficiary they wish to treat.
Covered Services
What are the Office for Children with Special Health Care Needs provider services? The Office for Children with Special Health Care Needs (OCSHCN), formerly the Commission for Children with Special Health Care Needs, provides comprehensive care to children and youth with special health care needs who are KY residents; are younger than 21; meet medical eligibility and meet financial eligibility.
How do I verify eligibility? Once eligibility has been obtained, you may verify continued eligibility by one of the following methods:
- by contacting the Automated Voice Response System at (800) 807-1301
- by using the Web-based KYHealth-Net System
The OCSHCN provider must meet the coverage provisions and requirements set forth in to 911 KAR 1:01. All services must be performed within the scope of practice for any provider. Just because a service is listed in the administrative regulation does not guarantee payment of the service. Providers must follow Kentucky Medicaid regulations and requirements of the MCO for which they participate. All services must be medically necessary.
Non-Covered Services: Procedures not considered medically necessary shall not be covered by Kentucky Medicaid.
Reimbursement: Reimbursement for OCSCHN services shall be reimbursed per 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 service is covered during the same time period.
Prior Authorizations
For Fee for Service beneficiaries who require prior authorization for additional services that are deemed medically necessary, contact CareWise. For MCO beneficiaries who require prior authorization for additional services that are medically necessary, contact the beneficiaries MCO for more information.
Claims Submission
Kentucky Medicaid currently contracts with DXC to process the Kentucky Medicaid fee for service (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 Correct 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) KY Medicaid requires the use of CMS 1500 billing forms. (eff: 02/12) 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 DXC. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO in question, if appealing an MCO claim.
Timely Filing: Claims must be received within 12 months from the date of service (DOS) or 6 months from the Medicare pay date whichever is longer, or within 12 months from the last Kentucky Medicaid denial. Please refer to the MCO in question, 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:
Billing Questions - DXC - (800) 807-1232
Provider Questions - (855) 824-5615
Prior Authorization - CareWise - (800) 292-2392
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth.net assistance - DXC - (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