How to File a Claim With Medicaid

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Medicaid is a health insurance program for low-income individuals and families who cannot afford health care. The Centers for Medicare and Medicaid Services (CMS) is the federal agency that regulates and oversees all state Medicaid programs. Eligible recipients receive medical care from providers who then bill Medicaid for services. That billing takes place at a local level so every state differs in how the program is administered. Let's learn how to file a claim with Medicaid.

Before You Can Bill You Have to Become a Provider

Providers must be licensed and accredited according to the specific laws and regulations that apply to the service offered.

Prospective Medicaid providers must apply for and be enrolled in the Medicaid program, be assigned a provider number, and agree to certain conditions of participation before payment can be made for services rendered. Check with your state.

Who You Are Affects How You File

The type of claim you file for payment varies by how you are classified as a provider. The following entities submit institutional claims for example:

Professional claims are filed by:

  • Durable medical equipment suppliers
  • Home infusion therapy services
  • Private duty nursing services

Filing a Claim

The following are general guidelines. If there is a theme to this article it is checked with your state. Generally, you have one year from the date of service or last day of service to file.

Here are some acronyms and definitions that can help you as you navigate claim forms.:

MPN: Medicaid Provider Number, Medicaid-issued 7-digit number received upon enrollment.
NPI: National Provider Identifier, NPPES-issued 11-digit number received upon request.
Taxonomy Code: 10-character code that represents provider type and specialty.

  1. Obtain your specific state's claim form. States typically base their claim forms from a national standard set up by the National Uniform Claim Committee. Find a sample claim form.
  2. Much of the claim form is self-explanatory and self-evident as you review so we will cover areas that might be more complex using the sample form in the link above. You may want to print it out. The top half of most forms calls for the demographic information about the patient and the insured person (if different from the patient). The bottom half is dedicated to the provider or supplier information.
  3. Item 14 - Date of Current Illness, Injury — The date of current illness or injury refers to the first date of onset of illness, or the actual date of injury.
  4. Item 17 - Name of Referring Provider - Enter the name and credentials of the professional who referred, ordered, or supervised the service(s) or supply(ies) on the claim. Item 17a - the provider identifiers are assigned to the provider. Item 17b: Enter the NPI number of the referrer.
  5. Item 21 - Diagnosis or Nature of Illness or Injury — The diagnosis or nature of illness or injury refers to the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim. List no more than four ICD-10-CM diagnosis codes.
  6. Item 24B - Enter the appropriate two-digit code from the Place of Service Code list for each item used or service performed. The Place of Service Code identifies the location where the service was rendered.
  7. Item 24D - Procedures, Services, or Supplies — Enter the CPT or HCPCS code(s) from the appropriate code set in effect on the date of service. Find a comprehensive list at the Centers for Medicare and Medicaid Services.
  8. Submit the claim form per the instructions provided by the state's Medicaid office. In many cases, you may only submit the claim electronically. This may require you to download or obtain certain software for transmittal purposes. Otherwise, you will need to fax or mail the claim form to the state's Medicaid claim processing unit.

Because you are dealing with the government you need to follow instructions carefully or face claims being rejected and then having to resubmit them. Understand coding so that you submit claims appropriately while reducing any red flags being raised in the process.

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