Medicaid Billing Requirements

Medical billing is the process of submitting a claim or following up on an existing claim to an insurance company, for any service or treatment rendered by a healthcare provider.  The billing process or cycle usually begins with the consultation between the healthcare provider and the patient.  The doctor fills out the medical record with the summary of the treatment given to the patient and of course, some personal information like the patient’s name, address, telephone number, and the like.  From there, the correct level of service will be used to bill the insurance company, based on the extent of the treatment administered by the patient.  This level of service will now be translated to a five-digit code that will be used for claims processing.

However, before even submitting a claim to Medicaid, you have to make sure that you know the following important points.   These are some things you need to know regarding Medicaid billing requirements.

Make sure you’re eligible. This is the first step, and is the most important of all requirements.  You have to assure that you are found eligible by your state for the Medicaid program.  During the day you will receive your treatment, you will have to show proof of eligibility.  It is only then that Medicaid will shoulder the expense for your treatment.  In addition to checking if you are eligible for the program, you also have to make sure that the healthcare provider that you are acquiring services from honors Medicaid recipients.  Call ahead for an appointment and ask this information ahead of time, so that you can eliminate the possibility of issues upon arriving there for your treatment.

Certain exemptions apply. Healthcare providers and consumers alike should be aware that Medicaid recipients are exempt from co-pays for some services.  Among these include ambulance services, dental services, services for those in nursing homes, services related to pregnancy, and services for patients under 21.  Missed appointments should likewise not be billed to Medicaid as well.

Proper documentation should be kept. Providers and consumers should keep detailed and accurate records of the services provided to them.  These documents should show the details of the service or treatment availed or done to the patient, and show that there is a medical necessity for the procedure that was done or is being done to the patient.  From there, Medicaid will now decide if their policy criteria are met.

Processing is done electronically. Once you bill Medicaid, an electronic machine now processes the claim.  To make sure that providers are paid correctly, they have an audit system.  These keep the facts in check, so that no provider is under-paid or overpaid.  In addition, services must be billed under the appropriate codes from the Healthcare Common Procedure Coding System (HCPCS).  Reimbursement rates apply under state laws and vary from each state.

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