5920 Purchase Limitations and Guidelines for Medicaid

 

Medicaid pays for eligible services furnished by enrolled providers.  

 

1. Kan Be Healthy (KBH) is the name for the federally mandated Early and Periodic Screening, Diagnosis Treatment (EPSDT) program in Kansas. Details on the Kan Be Healthy program are located on the Kansas Department of Health & Environment website at kdheks.gov.
   1. KBH is a preventative health screening program for Medicaid eligible children under the age of 2.
      1. A KBH screen includes a vision and dental check.
      2. Children whose KBH screenings are current are eligible for expanded Medicaid services.
      3. Children in the custody of DCF or KDOC-Community Based Services (CBS) shall receive timely KBH screenings (screen dates can be reviewed in MMIS)

2. Services Delivered Outside of Kansas
   1. May require prior authorization.
   2. May have a limited geographical area in which services may be delivered to qualify for payment.
      1. This is more prevalent in border cities (Kansas Medical Services Manual).

3. Third Party Liability (TPL)
   1. If the child is receiving services through DCF or KDOC-JS and has other health insurance, PPS Eligibility Specialists will enter the third-party insurance information into the Kansas Eligibility Enforcement System (KEES).
   2. Third-party insurance information is sent from KEES to the Kansas Modular Medicaid System (KMMS) via an interface.
   3. Medical providers must first bill other health insurance before they can bill Medicaid.
   4. If third-party insurance ends, the information should be updated in KEES.
4. Payment for Services
   1. Medicaid pays for eligible services furnished by enrolled providers.
   2. Each MCO has different providers in their network and payment rates vary by MCO.
   3. Specific services covered, prior authorization requirements, and the proper payment rate are established by the Kansas Department of Health and Environment (KDHE). KDHE reviews and adjusts rates periodically.
   4. At times payment is determined on a case by case basis.
5. Denied Claims
   1. When DCF is notified medical claims for a child in custody have been denied and eligibility is in the MMIS, DCF contacts the MCO to request an investigation.
   2. If the expense is a non-eligible expense the claim should be submitted to the CWCMP for payment.
   3. If the youth is in KDOC custody, KDOC-CBS works with the Department of Health Policy and Finance to resolve Medicaid claims.