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Solving a Medicaid Claim Mystery

Believe it or not there are some things about the Medicaid program that are simple.  For example, while there seems to be a great mystery surrounding what makes a Medicaid claim payable, it is it is really not a mystery at all.

Three simple fact items must be present to pay a Medicaid claim.  A claim must be submitted:

1. by an Eligible Provider: A provider submitting a claim for Medicaid reimbursement must be properly enrolled as an official Medicaid provider.   Each state conducts separate provider enrollment providers must enroll in every state where they provide services.

2. on behalf of an Eligible Recipient: To become eligible for Medicaid, a person must be determined eligible by the state in which he or she lives.  A Medicaid application must be completed and a variety of documents must be submitted. Generally, there are five specific components of the determination. The applicant must prove their identity.  They must be a citizen of the U.S. and a resident of the state in which they are applying for assistance. Finally, the applicant must meet certain maximum dollar amounts for assets and income. Once eligibility is determined, the individual will remain eligible until a change in circumstances renders them ineligible. Redeterminations are conducted on a regular basis, generally annually.

3. for an Eligible Service: Medicaid program services that are available to recipients vary from state to state. Providers have some flexibility but must render services in accordance with approved services.  Many rules and regulations govern the provision and frequency of these services.  For example, many states require high cost or unusual services to undergo a process called prior authorization before the service can be rendered and payment remitted.  

With each of these three items properly documented, Medicaid claims should sail through a state’s Medicaid payment system.

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