To bill Medicaid as secondary insurance, healthcare providers must first submit claims to the patient’s primary insurance company. Once the primary insurance company has processed the claim and made a payment, the provider can then submit a claim to Medicaid for the remaining balance. The Medicaid claim must include the patient’s name, date of birth, Social Security number, and Medicaid ID number. It must also include the dates of service, the type of services provided, and the amount of charges for each service. The provider must also submit a copy of the primary insurance company’s explanation of benefits (EOB) with the claim. Medicaid will then review the claim and make a payment to the provider for the amount that is not covered by the primary insurance company.
Verifying Patient Eligibility
Before billing Medicaid as secondary insurance, it is essential to verify the patient’s eligibility.
- Contact the Medicaid office: Call or visit the state Medicaid office to confirm if the patient is enrolled and eligible for benefits.
- Check the Medicaid website: Most states have a website where you can verify eligibility online.
- Review the patient’s Medicaid card: The card should include the patient’s name, Medicaid ID number, and the effective dates of coverage.
It is important to note that Medicaid eligibility can change frequently, so it is recommended to verify eligibility each time the patient receives services.
Once you have verified the patient’s Medicaid eligibility, you can proceed with billing the insurance company.
| Provider | Patient | Date of Service | Procedure Code | Amount Billed | Amount Paid |
|---|---|---|---|---|---|
| Acme Medical Group | John Smith | 03/08/2023 | 99214 | $150.00 | $100.00 |
| ABC Dental Care | Jane Doe | 04/01/2023 | D0120 | $120.00 | $80.00 |
In this example, Acme Medical Group billed Medicaid $150.00 for a patient’s office visit. Medicaid paid $100.00, and the patient is responsible for the remaining $50.00.
ABC Dental Care billed Medicaid $120.00 for a patient’s dental cleaning. Medicaid paid $80.00, and the patient is responsible for the remaining $40.00.
Obtaining Prior Authorization
When a Medicaid recipient selects a healthcare provider who does not participate in Medicaid, the provider is not allowed to directly bill Medicaid. Instead, they must bill the Medicaid recipient and the Medicaid recipient’s primary insurance. If the recipient has no primary insurance or if their primary insurance denies the claim, the provider can submit a claim to Medicaid
Prior authorization is permission from Medicaid to receive certain medical services or supplies. Getting prior authorization can be a complex process, but it is essential to getting paid for your services.
- Step 1: Medicaid Eligibility
- Step 2: Check for Medical Necessity
- Step 3: Get Prior Authorization
- Step 4: Wait for Approval
- Step 5: Provide the Service or Supply
Determine if the patient is eligible for Medicaid. You can do this by checking the patient’s Medicaid card or by calling the state Medicaid office.
Determine if the service or supply is medically necessary. You’ll need to provide documentation that supports the medical necessity of the service or supply.
Contact the Medicaid office to get prior authorization for the service or supply. You’ll need to provide the patient’s name, Medicaid ID number, date of birth, and the service or supply you are requesting prior authorization for.
The Medicaid office will review your request and make a decision. The decision can take several weeks.
Once you receive approval from Medicaid, you can provide the service or supply to the patient.
| State | Medicaid Website | Medicaid Phone Number |
|---|---|---|
| California | www.dhcs.ca.gov | 1-800-977-2273 |
| Florida | www.medicaid.florida.gov | 1-800-342-0821 |
| New York | www.health.ny.gov/health_care/medicaid | 1-800-541-2831 |
Filing Claims to Medicaid as Secondary Insurance
When filing claims to Medicaid as secondary insurance, it’s important to follow specific steps to ensure proper reimbursement. Here’s a guide to help you navigate the process:
Prior Authorization
Check if the service or procedure requires prior authorization from Medicaid. If so, obtain authorization before providing the service to the patient.
Coordination of Benefits (COB)
- Determine the patient’s primary insurance.
- File a claim with the primary insurance first.
- Attach a copy of the Explanation of Benefits (EOB) from the primary insurance to the claim you submit to Medicaid.
Claim Form and Information
- Use the appropriate claim form required by Medicaid.
- Include the patient’s Medicaid ID number.
- Enter the primary insurance information, including the name, address, and ID number.
- Attach copies of the patient’s insurance card and the EOB from the primary insurance.
Claim Submission
- Submit the claim electronically, if available. Otherwise, submit it by mail or through a clearinghouse.
- Ensure you meet the claim submission deadlines set by Medicaid.
Following Up on Claims
- Monitor the status of your claims regularly.
- Respond promptly to any requests for additional information or documentation.
- If a claim is denied, review the reason for denial and take appropriate action to resubmit the claim.
Appealing Denied Claims
- If a claim is denied, you have the right to appeal the decision.
- Follow the instructions provided in the denial letter to initiate the appeal process.
- Submit additional documentation or evidence to support your appeal.
Medicaid Secondary Payer Recovery
- Medicaid may seek reimbursement from the patient or their estate if the patient received benefits from Medicaid that should have been covered by the primary insurance.
- To avoid this, ensure that you bill the primary insurance correctly and promptly.
| State | Electronic Claims | Paper Claims |
|---|---|---|
| California | 30 days | 45 days |
| New York | 14 days | 30 days |
| Texas | 10 days | 20 days |
Remember, the specific requirements for billing Medicaid as secondary insurance may vary by state. Always refer to the Medicaid guidelines in your state for the most up-to-date information.
Alright folks, this wraps up our guide to billing Medicaid as secondary insurance. It might sound like a lot to take in, but just remember that you’re not alone in this journey. There are plenty of healthcare professionals out there who are happy to lend a hand, and even more resources to help you navigate the ever-changing landscape of medical billing.
We know medical billing can be a headache, but guess what? So can migraines! But we power through and make it through, right? And you can do the same! After all, you’re the rockstar medical biller of your practice, and I know you’ll figure this out. Keep your head held high and keep pushing forward.
I want to thank you for taking the time to read this article, and I hope you found it informative and helpful. If you have any questions, please don’t hesitate to reach out. And remember, always stay on top of the latest billing updates and policies.
Now go forth and conquer the world of Medicaid billing! And if you ever need a refresher or just want to say hello, feel free to visit us again later. Catch you on the flip side!