Medicaid is a health insurance program for low-income individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities. 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 enrolled in the program, who then bill Medicaid for services. That billing takes place at a local level so every state may have nuances in how the program is administered.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. To get an idea whether the services you offer are covered and what you can expect to be reimbursed check this Kaiser Family Foundation site.
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 to Medicaid recipients. The effective date on the participation agreement is the earliest date a provider may begin billing for services. So check with your state.Who You Are Affects How You File - Institutional Claims versus Professional Claims
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:
- adult care homes
- home health agencies
- hospice services
- intermediate care facilities for individuals with mental retardation
- nursing facilities
Professional claims are filed by:
- durable medical equipment suppliers
- home infusion therapy services
- private duty nursing services
Assuming you are a provider and you know the type of claim to file, let's get started with the claims process. The following are general guidelines. If there is a theme to this article it is check 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.
- 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 here. And instructions here.
- 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. 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.
- 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.
- Item 15 - If Patient Has Had Same or Similar Illness - Enter the first date the patient had the same or a similar illness.
- Item 17 - Name of Referring Provider or Other Source Instructions - 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 either by a specific payer or by a third party in order to uniquely identify the provider. Item 17b: Enter the NPI number of the referrer.
- 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-9-CM diagnosis codes.
- 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. Find them here.
- 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. The procedures, services or supplies refer to a listing of identifying codes for reporting medical services and procedures. Here is where you need to know and enter the HCPCS code for your service. Find a comprehensive list at the Centers for Medicare and Medicaid Services.
- 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. Of course that wreaks havoc with your accounts receivable. It is suggested that you and/or your staff research resources available to you to better understand coding so that you submit claims appropriately while reducing any red flags being raised in the process.