1. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 12 Medicaid Medical Billing

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicaid Guidelines for Each State  Establishes own eligibility standards  Determines the type, amount, duration, and scope of services  Sets rate of payment for services  Administers its own program

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Required Eligibility Groups  Categorically needy  Medically needy  Special groups

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Categorically Needy  Families who meet state’s aid to families with dependent children eligibility requirements as of July, 16, 1996  Pregnant women and children under age 6: Income must be 133% under federal poverty level  Children ages 6–19 with family income up to 100% of federal poverty level.

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Categorically Needy  Caretakers (relatives or guardians) who take care of children under the age of 18 (19 if still in high school)  SSI recipients  Persons living in medical institutions with monthly income up to 300% of SSI standard

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medically Needy  Persons having too much money (as in a savings account) to qualify for categorically needy  Allows states to extend eligibility to additional people

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medically Needy  Spend-down program: Individual is required to spend a portion of their income or resources until below, or at, state income level.  May be highly restrictive: Federal requirements designate who is to be included.

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Special Groups  Immigrants: Eligibility is determined at federal level.  Temporary Assistance for Needy Families (TANF): Eligibility is determined at the county level.

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Special Groups  State Children’s Health insurance Program (SCHIP): Provides more federal funds to expand Medicaid eligibility to include more uninsured children

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicaid Services Mandated by the Federal Government  Inpatient services  Outpatient services  Prenatal care  Vaccines for children  Physician services  Nursing facility services for persons 21 years of age and older

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicaid Services Mandated by the Federal Government  Family planning services and supplies  Rural health clinic services  Home health care for persons eligible for skilled nursing services  Laboratory and x-ray services  Pediatric and family nurse practioner services  Nurse midwife services

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicaid Services Mandated by the Federal Government  Federally Qualified Health Center (FQHC)  Early and periodic screening, diagnostic, and treatment services for children under 21 years of age (EPSDT)

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Optional Medicaid Services  Diagnostic services  Clinic services  Intermediate care facilities for people with mental retardation

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes PACE (Programs of All-inclusive Care for the Elderly)  Provides an alternative to institutional care for persons age 55 or older who require a nursing facility level of care.  Offers and manages all health, medical, and social services

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes PACE (Programs of All-inclusive Care for the Elderly)  Mobilizes other services: Preventative, rehabilitative, curative, and supportive care  Care is provided in day health centers, hospitals, and nursing homes.

16. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Amount and Duration of Medicaid Services  State may impose limitations.  Limitations are restricted by federal guidelines.

17. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicaid Verification  Always verify patient status prior to seeing the physician  Some electronic verification available  Check for restricted status, which requires the patient to see a specific physician (e.g., PCP) and/or pharmacy.

18. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicaid Claims Filing  Time limits for submitting claims  Claims must be submitted within 95 days from each date of service (DOS).  Appeal time limits –All appeals of denied claims and requests for adjustments must be received within 180 days from the date of disposition, the date of the Remittance and Status (R&S) report on which that claim appears

19. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicaid Claims Filing  Claims with incomplete information and zero paid claims –Claims lacking the information necessary for processing are listed on the R&S report with an explanation of benefits (EOB) code requesting the missing information

20. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medicaid Claims Filing  Newborn claim hints –When filing a claim for a newborn, if the mother’s name is “Jane Jones,” use “Boy Jane Jones” for a male child and a “Girl Jane Jones” for a female child. Do not use “NBM” for newborn male or “NMF” for newborn female