This process can seem confusing. However, since Medicaid is a government program, it’s very important to get it right. If you know the basics of Medicaid claims data and how all the pieces fit together, you’ll do a much better job of properly filing the Medicaid claims you need.
In this guide, we’ll walk you through everything you need to know about filing with Medicaid. Whether you’re a patient or a provider, you’ll benefit from understanding just how the system works. Keep reading to learn more!
Why Medicaid Claims Matter
It’s important to follow these very specific coding guidelines for Medicaid because it’s a government program. Without these coding processes, the billing for the procedures can’t go through.
Medicaid exists for low-income Americans who need help paying their medical bills. Both Medicaid and Medicare were created in the Social Security Act of 1965. Although the program is governed federally, it’s administered locally.
There are two basic types of Medicaid:
- Community Medicaid exists to help beneficiaries who have little to no medical coverage
- Medicaid nursing home coverage covers the cost of a nursing home for eligible beneficiaries. These people put a majority of their income toward nursing home care
The U.S. Department of Health and Human Services (DHS) administers Medicaid. However, each state has to implement its own unique Medicaid program. They also must meet the requirements for the program and comply with the federal procedures and policies.
Medicaid By State
Medicaid is voluntary to participate in, but each state still has to meet the federal protocols for eligibility and quality of service.
The federal government regulates the minimum services that have to be offered to Medicaid patients. These services include pregnancy care, prenatal care, inpatient treatment, and dental surgery. If a state has the funding, they might offer other services, too.
A number of states combine other programs with their Medicaid programs, such as offering programs for children of low-income families. Other states administer the Medicaid program through private insurance companies. Still others have service providers that they work with directly.
Funding for Medicaid comes in part from the state, and in part from the government. Some states also pull funding from their counties.
Medicaid Claims and Eligibility
An important part of the Medicaid claims process is understanding eligibility. Eligibility for Medicaid is determined based on two main factors. First, there’s access to financial resources, and income level. Having few financial assets is an important eligibility factor.
Medicaid recipients also have to be in certain eligibility categories. These categories include citizenship or immigration status, blindness, pregnancy, age, and disability.
Certain exceptions exist for disabled children who still live at home, and for people who live in a nursing home. For example, some children might be eligible even though their guardians or parents aren’t.
When people are otherwise eligible but don’t meet the requirements for financial assets or income, they have what’s called a spend down. Spend downs are allowed under the federal guidelines. However, some states don’t permit them.
When patients have a spend down, they have to pay for their healthcare services out of pocket at first. They can stop spending out of pocket when their financial assets meet the Medicaid requirements.
Medicaid Claims Data and Coding
When you’re billing a patient through Medicaid, you’ll need to start by thoroughly understanding the Medicaid requirements of that state. It can be difficult to verify their Medicaid eligibility. Still, you can at least verify that the patient has Medicaid and whether or not they need a referral.
If there is a spend down, you won’t be able to determine that until the claim has already been submitted.
Medical billing and coding can be very challenging, but also very rewarding. You play a very important role in making medical care accessible to everyone. Successful billers and coders can file claims free of error, understand the acronyms needed, and know how to properly read a payer contract.
Let’s take a look at what you need to know to succeed in the world of Medicaid claims.
How to File Error-Free Medicaid Claims
Clean, error-free claims with no mistakes are faster and easier to process. With these claims, no information is necessary from any third parties or from the provider.
An error-free claim meets a few different requirements. First, the healthcare provider must be licensed to give the services (and have been licensed when services were provided). They also can’t be in the middle of a fraud investigation.
Next, the code for each procedure has to have its supporting code for diagnosis. This gets rid of any questions about the need for medical care. The codes also can’t have been deleted or expired.
The Medicaid coverage for the patient needs to have been effective on the date the service was provided, and the patient’s insurance must cover that service.
Make sure to dot your I’s and cross your t’s, too. The details of information about the patient need to appear in the right places. These details include name, identification number, group number, and date of birth.
The form has to identify the payer correctly and have the correct identification number and mailing address for the payer. Finally, it’s important to always submit Medicaid claims on time.
Medicaid Acronyms to Know
You’ll be better able to file accurate claims when you know these acronyms by heart.
- CMS: The Centers for Medicare & Medicaid Services is the section of the DHS that’s in charge of Medicaid
- EDI: Electronic Data Interchange, or the electronic system that carries Medicaid encounter data to the clearinghouse where it’s distributed to carriers
- EOB: The explanation of benefits document given by the insurance company in reply to the claims submitted
- HMO: A Health Maintenance Organization is a management plan that requires patients to use primary care providers
- PPO: The Preferred Provider Organization is a management plan that lets patients use any provider, as long as the provider is contracted by the patient’s insurance company
The more Medicaid acronyms you can learn and memorize, the faster and more accurate the Medicaid claims and billing process will be.
Medicaid Changes to Watch For
When you’re working with Medicaid claims, you need to not only understand how Medicaid currently operates, but also keep abreast of ongoing changes to the program.
Wondering how Medicaid is changing now and in the future? Check out this guide for more.