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Medicaid Claims Processing

Best Practices


Updated December 15, 2012

Medicaid Claims Processing
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Readers on the site have been searching for information about best practices for Medicaid claim processing. And while we have covered this issue in the past, it is worth highlighting ways to make the claim process smoother, assure you get paid and avoid scrutiny.

Submit Electronically

Your best bet is to submit claims electronically.

Electronic claims process in one-third the time required for paper claims. Electronic submissions also reduce errors, prevent unnecessary claim denials, increase cash flow, and decrease costs. Electronic claims processing is:

  • Faster
    Most electronically submitted claims process in one to two weeks, compared to paper claims, which typically process in 30-45 days. State like Indiana use a Web InterChange for claims submission. Using that system as an example, you submit claims, view claims status online, view remittance advice, request prior authorization, inquire about checks, maintain your Provider Profile and verify member eligibility. Claims are adjudicated in two hours or less.

  • Easier
    You can easily submit all traditional Medicaid claims, including claims requiring attachments, using the Web.

  • More Accurate
    Electronic claims help reduce keying errors. In addition, claims submitted on paper are often handwritten, which makes them less clear and harder to read. Electronic submission eliminates these problems.

  • Less Expensive
    With electronic claim submission, provider staff members no longer spend their time printing and mailing forms - a costly process.

Other Tips

  • Include valid recipient identification numbers (RIDs) with all claim types.

  • Include a valid National Provider Identifier (NPI) with all claim types. Check that the NPI submitted with your claims is correct - that you have not transposed or omitted numbers, or made other errors.

  • DO NOT use red ink - it disappears when claims are scanned.

  • Be sure Medicare, third-party liability (TPL), and Medicaid information is placed in the proper fields on UB-04 claims.

  • Submit proper invoices for manual pricing.

  • Make sure hand-written paper claims are legible, and those that require signatures include full signatures and NOT JUST initials.

  • Sign up for direct deposit of your Medicaid payments.

  • Familiarize yourself with the Medicaid Provider Handbook.

  • Review general billing instructions.

  • Review service-specific coverage and billing instructions.
    Claims for certain services require special documentation. If you are unsure or unclear about billing requirements, contact your Medicaid Program Specialist.

  • Review billing instructions for Medicare Crossover Claims.
    If you provide Medicare-covered services to dual-eligible clients, Medicare will automatically send ("crossover") claims to the state for processing and payment of coinsurance and deductible. Do not send a claim unless the service you provided is one that is never covered under Medicare.

  • Establish Your Claim Tracking System.
    Important Medicaid claim information and dates to track for each claim includes: Patient Name, Medicaid ID Number, Date of Service, and Patient Account Number; Date Initial Claim Submitted to Medicaid; Date and Reason Claim Returned (or Rejected, for electronic claims), and Date New (Replacement) Claim Submitted; Date and Reason Claim Deleted, and Date New (Replacement) Claim Submitted; Date Claim Reported on " Medicaid Claims In Process Over 30 Days" Report; Date Remittance Advice Received, Status (Paid or Denied), Payment Amount and Denial Reasons; Date Claim Adjustment Submitted, Date Response Received, and Status (Paid or Denied).

  • Track status of your initial claim submission.
    Most claims are processed in less than 30 days, however some claims take longer than 30 days. Review your " Medicaid Claims In Process Over 30 Days" report.

  • Watch for notices about Returned, Rejected or Deleted Claims.
    After you submit a claim, you may receive a notice telling you that your claim could not be entered and/or completely processed.

    "Medicaid Claim Return Notice" - This notice is sent with paper claims if the state is unable to enter the claim for processing because information on the claim is missing or invalid. Make corrections on the claim or complete a new claim and submit it within one year from the date of service.

    "Deleted Medicaid Claim Report" - This report lists paper claims that were unable to be processed completely. The claims on this report were successfully entered, but certain problems with the claim prevent it from final processing. Deleted claims are not considered 'denied' claims; they are claims that must be corrected and reprocessed.

    "Electronic Claim Activity Report" - This notice is for electronic claims. It includes both rejected and deleted claims. It is sent to your electronic submitter/clearinghouse.

  • Review your Medicaid Remittance Advice and follow up promptly.

  • Understand how to submit Claim Adjustment Requests.

  • Track your Claim Adjustment Requests.

While the payment system seems laborious (and well it is), you can avoid headaches by properly submitting and tracking your claims.

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