Medicaid Billing Guidelines

March 29th, 2010

by Trina Cuppett, CPC, CPC-H

Billing for Medicaid can be tricky, as both federal and state guidelines apply. The Centers for Medicare and Medicaid (CMS) administers Medicaid under the direction of the Department of Health and Human Services (HHS).

The federal guidelines always take precedence over the state guidelines, as the federal guidelines sets the minimum requirements that each state must follow. The individual states may then expand their programs as long as they do not contradict federal guidelines. Expanding a program means that an individual state may opt to add additional coverage, such as: prescription drugs, dental services and prescription eyeglasses, that is not required by the federal guidelines.

While providers and facilities may choose whether to participate in the Medicaid program, those who do must comply with all applicable guidelines, including “balance billing.” It’s also important for providers to understand that Medicaid is considered to be the payer of last resource, meaning that if the patient has other coverages, they should be billed prior to billing Medicaid.

It goes against the Medicaid guidelines to balance bill a Medicaid patient, their family or their power of attorney for any unpaid balance once Medicaid has paid what they allow under the Medicaid fee schedule. This simply means that the provider must adjust off the leftover balance once any applicable charges for a copayment, deductible or coinsurance is met.

NOTE: A balance does not constitute, “coinsurance” due.

42 C.F.R. § 447.15 Acceptance of State payment as payment in full

A state plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual.

Basically, this means that a provider is not to bill the difference between the amount paid by the state Medicaid plan and the provider’s customary charge to the patient, the patient’s family or a power of attorney for the patient.

Billing and coding personnel should be familiar with their state guidelines pertaining the proper procedures and requirements for billing Medicaid.

Example: In North Carolina the Basic Medicaid Billing Guide (April, 2010) contains a wealth of information that is not limited to billing information as it also contains items such as: The List of Standards for Office Wait Times.

It is imperative that billing and coding personnel, providers and administrative staff are knowledgeable of pertinent guidelines to ensure billing and plan participation compliance to avoid exclusion from participating in the state Medicaid plans as well as possible civil or criminal sanctions for noncompliance issues such as improper billing procedures involving balance billing.

Billing personnel can refer to the CMS website: http://www.cms.hhs.gov/home/medicaid.asp for additional information.

North Carolina’s link is attached which will take you directly to the Basic Medicaid Billing Guide (April, 2010) which is a great example of the type of information that is available and it is a free resource.

http://www.dhhs.state.nc.us/dma/basicmed/Section4.pdf


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2 Responses to Medicaid Billing Guidelines

  1. Dwayne Walton Says:

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  2. carol harrison Says:

    i would like to verify the state law for georgia pertaining to medicaid billing in reference to patient

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