Medicaid (also called Title XIX after the section of the Social Security Act that created it) is a type of public medical insurance. Financing for Medicaid comes from federal, state and local government money. Eligible patients get medical care from providers who are enrolled in the Medicaid program, who then bill Medicaid for services.
Eligibility
The most important factor in billing Medicaid for services is to make sure the patient is fully eligible for the program. Most states only pay for Medicaid reimbursement if the patient is eligible for Medicaid on the date of service. Eligibility is determined by the county's Department of Social Services (DSS) and is based on income level, available finances, age and disability.
Providers should request that Medicaid recipients show proof of eligibility at the time of service.
When providers bill Medicaid for services, the budget management unit keeps track of the patient's category of eligibility, changes in their eligibility and rate of use of services.
Exemptions
Providers should be aware that Medicaid recipients are exempt from paying any copays in ambulance services, dental services provided in a health department, diagnostic X-rays, family planning services, federally qualified health center core services, health check-related services, hearing aid services, HIV case management, home health services, home infusion therapy, hospice services, emergency room services, hospital impatient services, laboratory services performed in a hospital, non-hospital dialysis, PCS or PCS-Plus, PDN services, rural health clinic core services, services covered by both Medicare and Medicaid, services in state-owned psychiatric hospitals, services for CAP patients, services for residents of nursing facilities, services related to pregnancy and services for patients under the age of 21.
Providers also are prohibited from billing Medicaid patients for any missed appointments.
Documentation
Medicaid providers should keep accurate records of Medicare recipients and the services provided for them. Documentation should show how the service the patient is going to receive will correct or improve a defect, physical or mental illness or condition. Documents need to show the medical necessity for the procedure or service and that Medicare policy criterion are met. If Medicaid needs additional information, the provider will be contacted.
When billing Medicaid for services, providers need to fill out specific forms for each patient and service or procedure. Medicaid provides these forms.
Processing
Once providers bill Medicaid, electronic data systems process the claims. Medicaid has a recipient and provider services unit that is responsible for provider enrollment, claims analysis, time limit overrides and provider education, which is available should providers have any questions when billing.
Audits
Medicaid has audit units that set costs and audit cost reports that providers make. Audit units make sure providers are not over- or under-compensated for services. A Medicaid committee called Program Integrity makes sure what Medicaid money providers get is paid correctly and that the recipients are being treated properly.
It is essential for providers to keep proper documentation when billing Medicaid in case they are audited.
Tags: Medicaid services, billing Medicaid, bill Medicaid, bill Medicaid services, billing Medicaid services
