Billing Medicaid can feel so nervous when you are new to it, but once you know the process, it becomes a straightforward routine. Whether you operate a solo practice, join a group, or are new to a medicaid plan, this article from DocVaz outlines everything you require to understand – from enrollment to repayment.
What is Medicaid?
Medicaid is a joint federal and state health plan that delivers medical coverage to more than 80 million Americans. It primarily serves:
- Low-income adults.
- Children.
- Pregnant females.
- Individuals with disabilities.
- Seniors who also receive Medicare (dual eligibles).
Each state runs its own medicaid program under federal instructions, which means eligibility rules and coverage details can differ from one state to another.
Medicaid Vs. Medicare: What’s the Difference?
Here are some differences mentioned below:
| Medicare | Medicaid |
| It is a federal insurance program mainly for individuals aged 65 and older.
Some younger people with disabilities. Its rules are uniform nationwide. |
It is designed for low-income persons of all ages.
It is jointly funded by federal and state governments, so benefits and billing rules vary by state. Some individuals qualify for both programs, known as dual eligibility. |
Why Treat Medicaid Patients?
Although Medicaid generally provides reimbursements at decrease rates than private insurance or Medicare, there are key benefits:
Expanding patient base – it also covers a huge and growing segment of the population, especially in underserved regions.
State incentives – multiple states offer bonus payments or value-based rewards to medicaid providers.
Community effects – caring for vulnerable populations improves your clinic’s reputation and fulfills vital community requirements.
The 7 Essential Steps To Bill Medicaid Correctly
Step 01: Enroll as a Medicaid Provider
You must be an approved medicaid provider before you can bill for the facilities. Every state operates its own provider enrollment portal, generally ending in Gov.. Prepare these before applying:
- NPI (National Provider Identifier).
- Tax ID (EIN).
- Medical license and DEA registration.
- Practice address and specialist details.
- Banking details for direct deposits.
After you finish your application process, the state will verify your credentials. This process usually takes 30 to 90 days. Once approved, you can initiate submitting medicaid claims.
Step 02: Verify Patient Eligibility Before Each Visit
The appropriate eligibility verification avoids one of the most common claims denials – patient not eligible. You can check eligibility through:
- The state Medicaid portal.
- Your EHR or clearinghouse.
- The medicaid helpline.
When checking, ensure four things:
- The individual’s coverage is active on the exact date of the facility.
- The type of service is also covered.
- Whether the person is enrolled in a Managed Care Organization such as Molina or United Healthcare Community Plan, claims for these must go to MCO, not the state.
- If the patient has other insurance, which will be the third party, that plan must be billed first.
Step 03: Ensure Medicaid Covers the Facilities
This covers rules that differ across states. Always verify your CPT or HCPCS code that is seen on the state’s Medicaid fee schedule and check for prior authorization needs. For instance, regular practices of adult eye exams might not be covered in Florida, but it might be the opposite in Carolina. To ensure:
- Search for your state’s medicaid fee schedule.
- Check if the facilities are covered, the repayment amount, and any restrictions.
- Preview current provider bulletins for coding updates.
- Call the authorization desk if you are unsure – better to ensure than complicate a denial.
Step 04: Obtain Prior Authorization When Needed
Some facilities – especially pricey, long-lasting treatments that require approval before being done. Medicaid uses PAs to confirm facilities are clinically essential and cost-effective. Common PA needs involve:
- Advanced screening (MRI, CT, PET).
- Elective surgeries.
- Therapy beyond routine restrictions.
- Durable medical equipment (DME).
- Prolonged home fitness or skilled nursing facilities.
Step 05: Submit the Medicaid Claim
Now it’s time to get paid. Selects the right claim form:
- CMS-1500 for expert services.
- UB -04 for services claims.
Confirms accuracy by involving:
- ICD-10 codes (detection).
- CPT/HCPCS (procedures).
- Modifiers (to explain special Circumstances).
- Place of services (POS) codes.
- Rendering and billing NPIs.
Submit claims electronically through your EHR clearinghouse or state portal for faster processing. Always double-check before submission to prevent mistakes that address denials.
Step 06: Track Every Claim and Match Payments
Do not stop at submission -minister your claim’s progress. Check claim status by:
- The state Medicaid portal.
- Your clearinghouse dashboard.
- The remittance advice or explanation of benefits.
Common causes for denial include:
- Incorrect patient data (wrong ID or date of birth).
- Lapsed coverage on the facilities date.
- NPI or Tax ID mismatch.
- Missing prior authorization number.
When payments arrive, every deposit is recorded with its claim. If repayment seems less, review the RA for adjustments or errors and file an appeal promptly.
Step 07: Correct and Resubmit Denied Claims
Denials occur to each provider. The main key is to fix and resubmit quickly – typically within 90 to 180 days from the date of installation.
- Review the denial codes.
- Rectifies the issues, such as adding a modifier.
- Mark the claim as corrected or replacement per state rules.
- Resubmit it via a similar system and note the resubmission date.
- Sustain a denial log to track recurring issues and prevent future errors.
Let’s simplify Medical billing services with DocVaz!
Managing medicaid billing services in-house takes a lot of time and accuracy. At DocVaz, we handle every aspect – from coding and claim submission to payment posting and denial management. Our specialists minister to every claim until it is completely repaid. It permits you to concentrate on patient care instead of paperwork. Let’s start your free consultation right away and let our company turn your medicaid claims into persistent, timely payouts.
