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Kentucky Medicaid Managed Care Commercial Coding List

Background:

The six Kentucky Medicaid Managed Care Organization (MCOs), worked to develop a centralized commercial insurance coding list for those specific procedure codes and modifiers typically deemed as not covered outside of Medicaid. This list allows providers to bill the KY Medicaid MCO for Primary coverage without the need to provide evidence of Commercial coverage on their claims. Kentucky healthcare providers must still bill the primary carrier as Kentucky Medicaid is the payer of last resort.

The referenced list will be available on each of the respective Kentucky Medicaid MCOs provider web portals. As a reminder, the process allows providers to bill directly to the Kentucky Medicaid MCO without submitting an Explanation of Benefits (EOB) if only procedure codes or modifiers on the list are on the claim submitted. Otherwise, an EOB is still required.

Attestation Form:

If an EOB cannot be obtained from the commercial payer, then a centralized attestation form can be attached to the claim. The attestation form must be complete, legible, and applicable to the right member and provider in order to be considered valid and accepted by the Kentucky Medicaid MCOs for primary insurance processing. This form can be found on the MCO’s provider web portal.

Effective:

This process is effective for dates of service beginning May 1st, 2023, and subject to change with advance notice. This commercial coding process does not apply to any dates of service prior to May 1st, 2023.

Provider Action Needed:

Claims must adhere to the Kentucky Department for Medicaid Services (DMS) billing instructions specific to each provider type and specialty. Claims received that do not meet billing requirements may be subject to denial when submitted without the EOB or attestation form for appropriate coordination of benefits.

Questions:

For questions, please reach out to your respective provider contact within each of Kentucky Medicaid MCOs.

This list is not utilized or maintained by DMS. All fee for service DMS COB processes still apply.