Kentucky KY

KY Medicaid (DMS, within CHFS) expresses prior authorization as a hub-and-spoke documentary shape, NOT a single PA code list or a centralized criteria portal. AUTHORITY: 907 KAR (Kentucky Administrative Regulations, 907 series = Medicaid) is the legal source of coverage + PA requirements, hosted on apps.legislature.ky.gov. OPERATIONAL CRITERIA live per-provider-type: chfs.ky.gov/agencies/dms/provider (newer pages) and .../dms/dpo/bpb (older pages) each carry a provider page listing the governing 907 KAR regs + a DMS 'Provider Summary' PDF (DMSProviderSummaries/<Type>PT<NN>.pdf) that states what requires PA for that provider type. PA REQUEST MECHANISM (FFS): the universal MAP-9 'Prior Authorization for Health Services' form (hosted on kymmis.com / KYHealthNet, the Gainwell-operated MMIS provider portal) submitted via the KY UM LMS portal, phone, or fax. REVIEWER/AUTHORITY (corrected): Gainwell Technologies is the current KY Medicaid Utilization Management (UM) contractor processing FFS PA requests (excluding Waiver, Hospice LOC, NF LOC). CareWise Health is a Gainwell SUBcontractor handling EPSDT Psychiatric, EPSDT Therapy, PPEC, and NF ancillary PAs. (Kepro/Carewise-as-primary is outdated.) PHARMACY is carved OUT to a statewide PBM — historically MedImpact (per state_meta) with Magellan Medicaid Administration as the PA/PDL operator surface (kentucky.magellanmedicaid.com) — covering FFS + all MCOs. MANAGED CARE: 5-6 MCOs (Aetna Better Health, Anthem, Humana Healthy Horizons, Molina, Passport by Molina, UnitedHealthcare Community Plan) hold delegated medical PA; their own criteria live on each MCO site (not harvested here). DEAD PIN: state_meta pharmacy_carve_out.source_url (dpqo/Pages/pharmacy.aspx) returns 404; live DPQO landing is dpqo/Pages/default.aspx. provletters.aspx pa_index is live and is a chronological Provider-Letter feed (PA policy changes arrive here, e.g. 'Behavioral Health Prior Authorization Resumption').

Last award: 2020-05-29. Next due: TBD - no successor RFP publicly issued as of last verified date. Contracts extended through: 2026-12-31 (first 2-year renewal option).

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How KY requires PA Kentucky's Medicaid program requires prior authorization for various services and drugs through a structured but fragmented system. Legal authority is found in the Kentucky Administrative Regulations (KAR), specifically the 907 KAR series, which outlines coverage and PA requirements. Provider Summaries by provider type (e.g., physicians, hospitals) give enrollment/maintenance guidance but do not detail PA criteria. The MAP-9 form is the standard form for health services requiring prior authorization. For dental services, the MAP-9 form must be completed with diagnosis, procedure/supply description, CPT/HCPCS code, and units of service; supporting documentation such as x-rays may be required. ## 2. How KY publishes and reports PA Kentucky's Medicaid program publishes PA requirements through various documents and portals from the Kentucky Cabinet for Health and Family Services (CHFS), Division of Medicaid Services (DMS). The relevant CHFS provider page experienced URL decay but has since been re-discovered and re-pinned. The MAP-9 form and its instructions are the key PA documents. The instructions specify that completed forms be faxed to Gainwell Technologies at (502) 214-3560. There is no centralized online PA criteria repository in the source documents; providers must refer to specific Provider Summaries and the MAP-9 form. ## 3. KY's CMS-0057-F and PA-reform compliance posture Kentucky has not explicitly detailed CMS-0057-F compliance in the source documents. The program includes carve-outs for certain services — pharmacy and behavioral health (BH) are carved into managed care organizations (MCOs), while long-term support services (LTSS) are carved out to fee-for-service (FFS). The fiscal-agent history indicates transitions from ACS-Inc to Conduent/Gainwell Technologies. Kentucky is **not** a WISeR state. (WISeR = the federal "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — not Kentucky.) No WISeR participation should be inferred for KY. ## 4. How KY runs its own program Kentucky's Medicaid program is managed through a combination of MCOs and FFS arrangements. MCOs manage certain carve-in services such as pharmacy and behavioral health, while long-term support services are handled through FFS. The state operates a foster-care MCO program called Supporting Kentucky Youth (SKY). Kentucky also operates under a 1115 waiver known as TEAMKY (formerly KY HEALTH), which likely carries waiver-specific PA requirements. The most recent MCO procurement cycle was awarded on May 29, 2020, with contracts extended through December 31, 2026. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Fragmented Documentation**: PA requirements are spread across documents without a centralized repository or portal. - **Vendor Transitions**: Fiscal-agent transitions (ACS-Inc → Conduent/Gainwell Technologies) may affect continuity/accessibility. - **Specific Provider Guidance**: General enrollment guidance exists, but specific PA criteria are often not detailed. ### What's Missing/Uncertain: - **CMS-0057-F Compliance**: No explicit mention in the source documents. - **Specific Criteria and Codes**: Many documents omit medical-necessity criteria, CPT/HCPCS codes, or effective dates. - **Centralized Portal**: No centralized online portal for submitting/tracking PA requests is described. These gaps highlight areas where additional information would help fully characterize Kentucky's Medicaid PA processes.