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MEDICAID

In 1965 Congress passed Title 19 of


the Social Security Act, establishing
a federally mandated, stateadministered medical assistance
program for individuals with incomes
below the federal poverty level.
The federal name for this program is
Medicaid; several states assign local
designations (e.g., California uses
MediCal; Massachusetts uses
MassHealth; Tennessee uses
TennCare).
Unlike Medicare, which is a
nationwide entitlement program, the
federal government mandated
national requirements for Medicaid
and gave states the flexibility to
develop eligibility rules and
additional benefits if they assumed
responsibility for the programs
support.

Medicaid provides medical and


health-related services to certain
individuals and families with low
incomes and limited resources
(the medically indigent).
It is jointly funded by the federal
and state governments to assist
states in providing adequate
medical care to qualified
individuals. Within broad federal
guidelines, each state:
Establishes its own eligibility
standards.
Determines the type, amount,
duration, and scope of services.
Sets rates of payment for
services.
Administers its own program.

Medicaid policies for eligibility are


complex and vary considerably, even
among states of similar size and
geographic proximity.
a person who is eligible for Medicaid in
one state may not be eligible in another
state
services provided by one state may differ
considerably in amount, duration, or
scope as compared with services
provided in a similar or neighboring state.
state legislatures may change Medicaid
eligibility requirements during the year.

Medicaid does not provide medical


assistance for all poor persons, and it is
important to realize that low income is
only one test for Medicaid eligibility; an
individuals resources are also compared
to limits established by each state in
accordance with federal guidelines.

To be eligible for federal funds, states are required to provide


Medicaid coverage for certain individuals who receive federally
assisted income-maintenance payments and for related groups
that do not receive cash payments.
state-only programs to provide medical assistance for specified
poor persons who do not qualify for Medicaid.
The federal government provides matching funds to state
Medicaid programs when certain healthcare services are
provided to eligible individuals (e.g., children, disabled, seniors).
Each state administers its own Medicaid program, and CMS
monitors the programs and establishes requirements for the
delivery, funding, and quality of services as well as eligibility
criteria

Medicaid eligibility is limited to individuals


who can be classified into three eligibility
groups:
Categorically needy
Medically needy
Special groups

Categorically Needy Groups


State Medicaid programs must be available to
the following mandatory Medicaid eligibility
groups (or mandatory populations) because the
federal government provides matching funds:
Families who meet states Temporary assistance for
Needy Families (TaNF) eligibility requirements in
effect on July 16, 1996.
Pregnant women and children under age 6 whose
family income is at or below 133% of the federal
poverty level (annual income guidelines established
by the federal government).
Caretakers (relatives or legal guardians who take
care of children under age 18,or age 19 if still in
high school)
Supplemental security Income (SSI) recipients (or,
in certain states, aged, blind, and disabled people
who meet more restrictive requirements than those
of the SSI program).
Individuals and couples living in medical institutions
who have a monthly income up to 300% of the SSI
income.

Medically Needy Program


States that establish a medically needy
Medicaid program expand eligibility to
additional qualified persons who may have too much
income to qualify under the categorically needy
group.
This option allows:
Individuals to spend down to Medicaid eligibility by
incurring medical and/orremedial care expenses to offset
their excess income. Thus, their income isreduced to a level
below the maximum allowed by their states Medicaid plan.
Families to establish eligibility as medically needy by paying
monthly premiumsin an amount equal to the difference
between family income (reduced by unpaidexpenses, if any,
incurred for medical care in previous months) and the
incomeeligibility standard.

Medically Needy Program


States that implement a medically needy
Medicaid program are required to include
pregnant women through a 60-day
postpartum period, children underage 18,
certain newborns for one year, and certain
protected blind persons.
States may also choose to provide coverage to
other medically needy persons, including
aged, blind, and/or disabled persons;
caretaker relatives or legal guardians who live
with and take care of children and other
eligible children up to age 21 who are full-time
students.

Special Groups
States are required to assist the following
special groups:
Qualified Medicare beneficiaries (QMB) (states
pay Medicare premiums, deductibles and
coinsurance amounts for individuals whose
income is at or below100 percent of the federal
poverty level and whose resources are at or
below twice the standard allowed under SSI)

Special Groups
States are required to assist
the following special groups:
Qualified working disabled
individuals (QWDI) (states pay
Medicare Part a premiums for
certain disabled individuals
who lose Medicare coverage
because of work; these
individuals have incomes
below 200 percent of the
federal poverty level and
resources that are no more
than twice the standard
allowed under SSI)

Special Groups
States are required to assist the
following special groups:
Qualifying individual (QI) (states pay
Medicare Part B premiums for
individuals with incomes between
120 percent and 175 percent of the
federal poverty level)

Specified low-income
Medicare beneficiary (SLMB)
(states pay Medicare Part B
premiums for individuals with
incomes between 100 percent
and 120 percent of the
federal poverty level)

Special Groups
States may also improve access to
employment, training, and
placement of people with
disabilities who want to work by
providing expanded Medicaid
eligibility to:
Working disabled people between ages
16 and 65 who have income and
resources greater than that allowed
under the SSI program.
Working individuals who become
ineligible for the group described above
because their medical conditions
improve. (states may require these
individuals to share in the cost of their
medical care.)

Special Groups
Two additional eligibility groups are related to
specific medical conditions, and states may
provide coverage under their Medicaid plans:
Time-limited eligibility for women who have breast
or cervical cancer
Individuals diagnosed with tuberculosis (TB) who
are uninsured.

Women with breast or cervical cancer receive


all Medicaid plan services. TB patients
receive only services related to the treatment
of TB.

State Childrens Health Insurance Program


Implemented in accordance with the Balanced
Budget Act (BBA), which allows states to create or
expand existing insurance programs, providing more
federal funds to states for the purpose of expanding
Medicaid eligibility to include a greater number of
currently uninsured children.
With certain exceptions, these include low-income
children who would not otherwise qualify for
Medicaid.
SCHIP may also be used to provide medical
assistance to children during a presumptive eligibility
period for Medicaid.

State Childrens Health Insurance


Program
Medicaid coverage can begin as early as the third
month prior to application if the person would have
been eligible for Medicaid had he or she applied
during that time.
Medicaid coverage is usually discontinued at the
end of the month in which a person no longer
meets the criteria for any Medicaid eligibility group.
The BBA allows states to provide 12 months of
continuous Medicaid coverage (without
reevaluation) for eligible children under the age of
19.

Programs of All-Inclusive Care


for the Elderly (PACE)
Capitated payment system to provide
a comprehensive package of
community-based services as an
alternative to institutional care for
persons age 55 or older who require a
nursing facility level of care.
PACE is part of the Medicare program,
but is an optional service for state
Medicaid plans.
PACE programs operate only in states
that have selected to include this
option.
PACE programs enter into contracts
with various types of providers,
physicians, and other entities to
furnish care to participants.

Programs of All-Inclusive Care for


the Elderly (PACE)
This PACE team offers and manages all
health, medical, and social services and
mobilizes other services as needed to
provide preventive, rehabilitative, curative,
and supportive care.
The care is provided in day health centers,
homes, hospitals, and nursing facilities, and
its purpose is to help the person maintain
independence, dignity, and quality of life.

Programs of All-Inclusive Care for


the Elderly (PACE)
PACE providers receive payment only
through the PACE agreement and must
make available all items and services
covered under both Medicaid and Medicare,
without amount, duration, or scope
limitations and without application of any
deductibles, copayments, or other costsharing.
The individuals enrolled in PACE receive
benefits solely through the PACE program.

Spousal Impoverishment Protection


The Medicare Catastrophic Coverage Act of
1988 (MCCA) implemented Spousal
Impoverishment Protection Legislation in
1989 to prevent married couples from being
required to spend down income and other
liquid assets (cash and property) before one
of the partners could be declared eligible for
Medicaid coverage for nursing facility care.
The spouse residing at home is called the
community spouse
Before monthly income is used to pay
nursing facility costs, a minimum monthly
maintenance needs allowance (MMMNA) is
deducted.

Spousal Impoverishment
Protection
To determine whether the spouse
residing in a facility meets the
states resource standard for
Medicaid, a protected resource
amount (PRA) is subtracted from
the couples combined resources.
The PRA is the greatest of the:
Spousal share, up to a maximum of
$109,560 in 2011.
State spousal resource standard,
which a state could set at any amount

Spousal Impoverishment Protection


To determine whether the spouse residing in a
facility meets the states resource standard for
Medicaid, a protected resource amount (PRA) is
subtracted from the couples combined
resources. The PRA is the greatest of the:
Amount transferred to the community spouse for her
or his support as directed by a court order.
Amount designated by a state officer to raise the
community spouses protected resources up to the
minimum monthly maintenance needs standard.

Confirming Medicaid Eligibility


Any time patients state that they receive
Medicaid, they must present a valid
Medicaid identification card.
Eligibility, in many cases, will depend on
the patients monthly income.
Confirmation of eligibility should be
obtained for each visit; failure to do so
may result in a denial of payment.
Some states have a point-of-service
device similar to those used by credit
card companies.

Confirming Medicaid Eligibility


Beneficiaries carry plastic cards containing
encoded data strips.
Retroactive eligibility is sometimes granted
to patients whose income has fallen below
the state-set eligibility level and who had
high medical expenses prior to filing for
Medicaid.
When patients notify the practice that they have
become retroactively eligible for Medicaid
benefits, confirm this information before
proceeding.
A refund of any payments made by the patient
during the retroactive period must be made and
Medicaid billed for these services.

Medicaid allows considerable flexibility


within state plans, but some federal
requirements are mandatory if federal
matching funds are to be received.
A states Medicaid program must offer
medical assistance for certain basic
services to eligible groups.

Mandatory Services
To receive federal matching funds, states must
offer the following services:
Services for Categorically Needy Eligibility
Groups
Services for Medically Needy Eligibility
Groups
Preauthorized Services

Services for Categorically Needy Eligibility


Groups
Medicaid eligibility groups classified as
categorically needy are entitled tot he following
services unless waived under the Medicaid law
Inpatient hospital (excluding inpatient services in
institutions for mental disease).
Outpatient hospital including Federally Qualified Health
Centers (FQHCs) and ifpermitted under state law, rural
health clinic (RHC) and other ambulatory
servicesprovided by a rural health clinic that are
otherwise included under states plans.
Other laboratory and x-ray.
Certified pediatric and family nurse practitioners (when
licensed to practice understate law).

Services for Categorically Needy Eligibility


Groups
Medicaid eligibility groups classified as
categorically needy are entitled tot he following
services unless waived under the Medicaid law
Nursing facility services for beneficiaries age 21 and
older.
Early and periodic screening, diagnosis, and treatment
(EPSDT) for children underage 21.
Family planning services and supplies.
Physicians services.
Medical and surgical services of a dentist.
Home health services for beneficiaries entitled to
nursing facility services under the states Medicaid plan.

Services for Categorically Needy Eligibility


Groups
Medicaid eligibility groups classified as
categorically needy are entitled tot he following
services unless waived under the Medicaid law
Intermittent or part-time nursing services provided by
home health agency or by a registered nurse when
there is no home health agency in the area.
Home health aides.
Medical supplies and appliances for use in the home.
Nurse mid-wife services.
Pregnancy-related services and service for other
conditions that might complicate pregnancy.
Sixty (60) days postpartum pregnancy-related services.

Services for Medically Needy Eligibility


Groups
States must provide at least the following
services when the medically needy are
included under the Medicaid plans:
Prenatal and delivery services
Post-partum pregnancy-related
services for beneficiaries who are
under age 18 and are entitled to
institutional and ambulatory services
defined in a states plan
Home health services to beneficiaries
entitled to receive nursing facility
services under the states Medicaid
plan

Services for Medically Needy Eligibility Groups


States may provide different services to
different groups of medically needy
individuals
Specified services (if included as medically needy)
Beneficiaries under age 21 and/or over age 65
in institutions for mental disease (IMDs)
Intermediate care facilities for the mentally
retarded (ICF/MRs)

The services provided to a particular group


must also be available to everyone within
that group (unless the state has obtained a
waiver).

Preauthorized Services
Most states that have not placed all
Medicaid beneficiaries into a
prepaid HMO have some form of
prior approval or preauthorization
for recipients.
Preauthorization guidelines include:
Elective inpatient admission
Emergency inpatient admission
More than one preoperative day
(document reason[s] surgery cannot be
performed within 24 hours of indication
for surgery and specify number of
additional preoperative day[s]
requested)

Preauthorized Services
Preauthorization guidelines include:
Outpatient procedure(s) to be performed in an
inpatient setting (submit CPT code and description of
surgical procedure along with medical necessity
justification for performing surgery on an inpatient
basis)
Days exceeding state hospital stay limitation due to
complication(s) (submit diagnosis stated on original
preauthorization request, beginning and ending dates
originally preauthorized, statement describing the
complication[s], date complication[s] presented,
principal diagnosis, and complication[s] diagnosis)
Extension of inpatient days (document medical
necessity justification for the extension and specify
number of additional days requested)

Medicaid operates as a vendor-payment program,


which means that states pay healthcare providers on a
fee-for-service basis or states pay for Medicaid
services
using prepayment arrangements
When Medicaid makes payment directly to
providers, those participating in Medicaid must
accept the reimbursement as payment in full.
States determine their own reimbursement
methodology and payment rates for services, with
three exceptions
for institutional services - payment may not exceed
amounts that would be paid under Medicare payment
rates
for disproportionate share hospitals (DSHs) - hospitals
that treat a disproportionate number of Medicaid
patients, different limits apply
for hospice care services - rates cannot be lower than

States can require nominal deductibles,


coinsurance, or copayments for certain services
performed for some Medicaid recipients.
Emergency services and family planning services
are exempt from copayments.
Certain Medicaid recipients are also excluded
from this cost-sharing
Pregnant women
Children under age 18
Hospital or nursing home patients who are expected to
contribute most of their income to institutional care.

Federal Medical Assistance Percentage (FMAP)


portion of the Medicaid program paid by the federal
government
Determined annually for each state using a formula that
compares the states average per capita income level with
the national average.
Wealthier states receive a smaller share of reimbursed
costs, and the federal government shares in administration
expenses

The federal government


reimburses states for 100 percent of the cost of services
provided through facilities of the Indian Health Service
provides financial help to the 12 states that furnish the
highest number of emergency services to undocumented
aliens
shares in each states expenditures for the administration of
the Medicaid program.

Most administrative costs are matched at 50


percent, although higher percentages are paid for
certain activities and functions, such as
development of mechanized claims processing
systems.

Medicare-Medicaid Relationship
Medicare beneficiaries with low
incomes and limited resources may
also receive help from the Medicaid
program
For those eligible for full Medicaid
coverage, Medicare coverage is
supplemented by services available
under a states Medicaid program.
Additional services may include
Nursing facility care beyond the 100day limit covered by Medicare
Prescription drugs
Eyeglasses
Hearing aids.

Dual Eligibles (Medi-Medi)


Medicare beneficiaries with low incomes and limited
resources may receive help with out-of-pocket medical
expenses from state Medicaid programs.

Various benefits are available to dual eligibles,


individuals entitled to Medicare and eligible for some
type of Medicaid benefit
Individuals eligible for full Medicaid coverage receive
program supplements to their Medicare coverage via
services and supplies available from the states
Medicaid program.

Dual Eligibles (Medi-Medi)


Services covered by both programs are paid
first by Medicare and the difference by
Medicaid, up to the states payment limit.
Medicaid also covers the following additional
services:
Nursing facility care beyond the 100-day
limit covered by Medicare
Prescription drugs
Eyeglasses
Hearing aids

Medicaid as a Secondary Payer


Medicaid is always the payer of last resort.
If the patient is covered by another medical or
liability policy, including Medicare, TRICARE
(formerly CHAMPUS), CHAMPVA, or Indian
Health Services (IHS), this coverage must be
billed first.
Medicaid is billed only if the other coverage
denies responsibility for payment, pays less
than the Medicaid fee schedule, or if Medicaid
covers procedures not covered by the other
policy.

Participating Providers
Any provider who accepts a Medicaid patient
must accept the Medicaid determined payment
as payment in full.
Providers are forbidden by law to bill patients
for Medicaid-covered benefits.
A patient may be billed for any service that is
not a covered benefit; however, some states
have historically required providers to sign
formal participating Medicaid contracts.
Other states do not require contracts.

Medicaid and Managed Care


Medicaid managed care grew rapidly in the 1990s.
In 1991, 2.7 million beneficiaries were enrolled in some
form of managed care.
By 2004 that number had grown to 27 million, an
increase of 900 percent. (60 percent of the Medicaid
population who receive benefits through managed care).
States can make managed care enrollment voluntary, or
they can seek a waiver of the Social Security Act from
CMS to require certain populations to enroll in an MCO.

Medicaid and Managed Care


Medicaid managed care does not always mean a
comprehensive health care plan that requires a monthly
premium and is at financial risk for the cost of care provided
to all enrollees.
Medicaid beneficiaries are also enrolled in primary care case
management (PCCM) plans, which are similar to fee-forservice plans except that each PCCM enrollee has a primary
care provider who authorizes access to specialty care but is
not at risk for the cost of care provided.

Most states that have not placed all

Medicaid beneficiaries into a


prepaid

HMO have some form of prior


approval or

preauthorization for recipients.

Medicaid and Managed Care

Preauthorization guidelines
include:
Elective inpatient admission
Emergency inpatient admission
More than one preoperative
day
Outpatient procedure(s) to be
performed in an inpatient
setting
Days exceeding state hospital
stay limitation due to
complication(s)
Extension of inpatient days

Medicaid Eligibility Verification System


Sometimes called recipient eligibility
verification system or REVS
Allows providers to electronically access the
states eligibility file using the methods listed
below.
Point-of-service device: The patients medical
identification card contains a magnetic strip, and
when the provider swipes the card through a
reader, accurate eligibility information is displayed.
Computer software: When the provider enters a
Medicaid recipients identification number into special
computer software, accurate eligibility information is
displayed.

Medicaid Eligibility Verification System


Allows providers to electronically access the
states eligibility file using the methods listed
below.
Automated voice response: Providers can call the
states Medicaid office to receive eligibility
verification information through an automated voice
response system.

Then, a receipt ticket is generated upon


eligibility verification by MEVS.

Medicaid Remittance Advice


Providers receive reimbursement from Medicaid
on a lump-sum basis, which means they will
receive payment for several claims at once.
A Medicaid remittance advice is sent to the
provider which contains the current status of all
claims.
The provider should compare content on the
remittance advice to claims submitted to
determine whether proper payment was received.
If improper payment was issued, the provider has
the option to appeal the claim.

Medicaid Remittance Advice


An adjusted claim has a payment correction,
resulting in additional payment(s) to the
provider.
A voided claim is one that Medicaid should not
have originally paid, and results in a deduction
from the lump-sum payment made to the
provider.
If a year-to-date negative balance appears on
the Medicaid remittance advice as a result of
voided claims, the provider receives no
payment until the amount of paid claims
exceeds the negative balance amount.

Utilization Review
The federal government requires states
to verify the receipt of Medicaid services.
A sample of Medicaid recipients is sent a
monthly survey letter requesting
verification of services paid the previous
month on their behalf.
Federal regulations also required
Medicaid to establish and maintain a
surveillance and utilization review
subsystem (SURS), which safeguards
against unnecessary or inappropriate use
of Medicaid services or excess payments
and assesses the quality of those
services.

Utilization Review
A post payment review process monitors both the
use of health services by recipients and the delivery
of health services by providers.
Overpayments to providers may be recovered by the
SURS unit, regardless of whether the payment error
was caused by the provider or by the Medicaid
program.
The SURS unit is also responsible for identifying
possible fraud or abuse, and most states organize
the unit under the states Office of Attorney General,
which is certified by the federal government to
detect, investigate, and prosecute fraudulent
practices or abuse against the Medicaid program.

Medical Necessity
Medicaid-covered services are payable only when the
service is determined by the provider to be medically
necessary. Covered services must be:
Consistent with the patients symptoms, diagnosis,
condition, or injury.
Recognized as the prevailing standard and consistent
with generally accepted professional medical standards
of the providers peer group.
Provided in response to a life-threatening condition; to
treat pain, injury, illness, or infection; to treat a
condition that could result in physical or mental
disability; or to achieve a level of physical or mental
function consistent with prevailing community
standards for diagnosis or condition.

Medical Necessity
In addition, medically necessary services are:
Not furnished primarily for the convenience of the
recipient or the provider.
Furnished when there is no other equally effective
course of treatment available or suitable for the
recipient requesting the service that is more
conservative or substantially less costly.

Fiscal Agent
The name of the states Medicaid fiscal agent
will vary from state to state.

Underwriter
Underwriting responsibility is shared between
state and federal governments.
Federal responsibility rests with CMS. The
name of the state agency will vary according
to state preference.

Form Used
The CMS-1500 claim is required.

Timely Filing Deadline


Deadlines vary from state to
state.
It is important to file a Medicaid
fee-for-service claim as soon as
possible.
The only time a claim should be
delayed is when the patient does
not identify Medicaid eligibility or
if the patient has applied for
retroactive Medicaid coverage.
Medicare-Medicaid crossover
claims follow the Medicare, not
Medicaid, deadlines for claims.

Allowable Determination
The state establishes the maximum
reimbursement payable for each non
managed care service.
It is expected that Medicaid programs will
use the new Medicare physician fee
schedule for these services, with each state
establishing its own conversion factor.
Medicaid recipients can be billed for any
noncovered procedure performed. However,
because most Medicaid patients have
incomes below the poverty level, collection
of fees for uncovered services is difficult.

Accept Assignment
Accept assignment must be selected on the CMS-1500
claim, or reimbursement may be denied.
It is illegal to attempt collection of the difference
between the Medicaid payment and the fee the
provider charged, even if the patient did not reveal
Medicaid status at the time services were rendered.

Deductibles
A deductible may be required. In such cases, eligibility
cards usually are not issued until after the stated
deductible has been met.

Copayments
Copayments are required for some Medicaid recipients.

Inpatient Benefits
All nonemergency hospitalizations must be
preauthorized.
If the patients condition warrants an extension of
the authorized inpatient days, the hospital must
seek an authorization for additional inpatient days.

Major Medical/Accidental Injury Coverage


There is no special treatment for major medical or
accidental injury categories.
Medicaid will conditionally subrogate claims when
there is liability insurance to cover a persons
injuries.
Subrogation is the assumption of an obligation for
which another party is primarily liable.

Major Medical/Accidental Injury Coverage


Because Medicaid eligibility is determined by
income, patients can be eligible one month and not
the next.
Check eligibility status on each visit.
New work requirements may change this, as
beneficiaries may continue coverage for a specific
time even if their income exceeds the state
eligibility levels.
Prior authorization is required for many procedures
and most nonemergency hospitalizations.
Consult the current Medicaid handbook for a listing
of the procedures that must have prior
authorization.

Major Medical/Accidental Injury


Coverage
Cards may be issued for the
Unborn child of . . .
These cards are good only for
services that promote the life and
good health of the unborn child.
Because other health and liability
programs are primary to Medicaid,
the remittance advice from the
primary coverage must be attached
to the Medicaid claim.
A combined Medicare-Medicaid
(Medi-Medi) claim should be filed by
the Medicaid deadline on the CMS1500 claim.

BLOCK
1

INSTRUCTIONS
Enter an X in the Medicaid box.

1a

Enter the Medicare identification number as it appears


on the patients Medicaid card. Do not enter hyphens or
spaces in the number.

Enter the patients last name, first name, and middle


initial (separated by commas) (e.g., DOE, JOHN, J).

Enter the patients birth date as MM DD YYYY (with


spaces). Enter an X in the appropriate box to indicate
the patients gender. If the patients gender is unknown,
leave blank.

4
5

Leave blank.
Enter the patients mailing address and telephone
number. Enter the street address on line 1, enter the city
and state on line 2, and enter the 5- or 9-digit zip code
and phone number on line 3.

BLOCK
INSTRUCTIONS
6-8
Leave blank.
99d

Leave blank. Blocks 9 and 9a9d are


completed if the patient has additional
insurance coverage, such as commercial
insurance

10ac

Enter an X in the NO boxes. (If an X is


entered in the YES box for auto accident,
enter the 2-character state abbreviation of
the patients residence.)

10d

Leave blank. For Medicaid managed care


programs, enter an E for emergency care
or U for urgency care (if instructed to do
so by the administrative contractor.)

BLOCK

INSTRUCTIONS

17

Enter the first name, middle initial (if known), last


name, and credentials of the professional who
referred or ordered healthcare service(s) or
supply(s) reported on the claim. Do not enter any
punctuation. Otherwise, leave blank.

17a

Leave blank.

17b

Enter the 10-digit national provider identifier (NPI)


of the professional in Block 17. Otherwise, leave
blank.

18

Enter the admission date and discharge date as


MM DD YYYY (with spaces) if the patient received
inpatient services (e.g., hospital, skilled nursing
facility). Otherwise, leave blank. If the patient has
not been discharged at the time the claim is
completed, leave the discharge date blank.

BLOCK

INSTRUCTIONS

19

Reserved for local use. Some Medicaid programs


require entry of the Medicaid providers NPI, and
others require entry of a description of unlisted
procedure or service codes reported in Block 24E
(If description does not fit, enter SEE ATTACHMENT,
and attach documentation to the claim describing
the unlisted procedures/services provided.)

20

Enter an X in the NO box if all laboratory


procedures reported on the claim were performed
in the providers office. Otherwise, enter an X in
the YES box, enter the total amount charged by
the outside laboratory in $ CHARGES, and enter
the outside laboratorys name, mailing address,
and NPI in Block 32. (Charges are entered without
punctuation. For example, $1,100.00 is entered as
110000 below $ CHARGES.)

21

Enter the ICD code for up to four diagnoses or

BLOCK

INSTRUCTIONS

22

Enter the original claim reference number plus Medicaid


resubmission code, if applicable to the claim. Otherwise,
leave blank.

23

Enter the Medicaid preauthorization number, which was


assigned by the payer, if applicable to the claim.
Otherwise, leave blank.

24A

Enter the date the procedure or service was performed


in the FROM column as MMDDYYYY (without spaces).
Enter a date in the TO column if the procedure or service
was performed on consecutive days during a range of
dates. Then, enter the number of consecutive days in
Block 24G.

24B

Enter the appropriate 2-digit Place of Service (POS) code


to identify the location where the reported procedure or
service was performed. (Refer to Appendix II for POS
codes.)

BLOCK

INSTRUCTIONS

24C

Enter E an E if the service was provided for a medical


emergency, regardless of where it was provided.
Otherwise, leave blank.

24D

Enter the CPT or HCPCS level II code and applicable


required modifier(s) for procedures or services
performed. Separate the CPT/HCPCS code and first
modifier with one space. Separate additional modifiers
with one space each. Up to four modifiers can be
entered.

24E

Enter the diagnosis pointer number from Block 21 that


relates to the procedure/service performed on the date
of service.

24F

Enter the fee charged for each reported procedure or


service. When multiple procedures or services are
reported on the same line, enter the total fee charged.
Do not enter commas, periods, or dollar signs. Do not
enter negative amounts. Enter 00 in the cents area if the
amount is a whole number.

BLOCK

INSTRUCTIONS

24G

Enter the number of days or units for procedures or


services reported in Block 24D. If just one procedure
or service was reported in Block 24D, enter a 1 in Block
24G.

24H

Enter an E if the service was provided under the EPSDT


program, or enter an F if the service was provided for
family planning. Enter a B if the service can be
categorized as both EPSDT and family planning.
Otherwise, leave blank.

24I

Leave blank. The NPI abbreviation is preprinted on the


CMS-1500 claim.

BLOCK
24J

INSTRUCTIONS
Enter the 10-digit NPI for the:
provider who performed the service if the provider is a
member of a group practice. (Leave blank if the provider
is a solo practitioner.)
supervising provider if the service was provided
incident to the service of a physician or nonphysician
practitioner and the physician or practitioner who
ordered the service did not supervise the provider.
(Leave blank if the incident to service was performed
under the supervision of the physician or nonphysician
practitioner.)
DMEPOS supplier or outside laboratory if the physician
submits the claim for services provided by the DMEPOS
supplier or outside laboratory. (Leave blank if the
DMEPOS supplier or outside laboratory submits the
claim.)
Otherwise, leave blank.

BLOCK

INSTRUCTIONS

25

Enter the providers social security number (SSN)


or employer identification number (EIN). Do not
enter hyphens or spaces in the number. Enter an X
in the appropriate box to indicate which number is
reported.

26

Enter the patients account number as assigned by


the provider.

27

Enter an X in the YES box to indicate that the


provider agrees to accept assignment. Otherwise,
enter an X in the NO box.

28

Enter the total charges for services and/or


procedures reported in Block 24.

29-30

Leave blank.

BLOCK
31

INSTRUCTIONS
Enter the providers name and credential (e.g., MARY
SMITH MD) and the date the claim was completed as
MMDDYYYY (without spaces). Do not enter any
punctuation.

32

Enter the name and address where procedures or


services were provided if at a location other than the
patients home, such as a hospital, outside laboratory
facility, physicians office, skilled nursing facility, or
DMEPOS supplier. Otherwise, leave blank. Enter the
name on line 1, the address on line 2, and the city, state
and 5- or 9-digit zip code on line 3. For a 9-digit zip code,
enter the hyphen.

32a

Enter the 10-digit NPI of the provider entered in Block


32.

32b

Leave blank.

BLOCK
33

INSTRUCTIONS
Enter the providers billing name, address, and
telephone number. Enter the phone number in the area
next to the Block title. Do not enter parentheses for the
area code. Enter the name on line 1, enter the address
on line 2, and enter the city, state, and 5- or 9-digit zip
code on line 3. For a 9-digit zip code, enter the hyphen.

33a

Enter the 10-digit NPI of the billing provider (e.g., solo


practitioner) or group practice (e.g., clinic).

33b

Leave blank.

BLOCK

INSTRUCTIONS

Enter the primary policyholders last name, first name,


and middle initial (separated by commas).

Enter an X in the appropriate box to indicate the


patients relationship to the primary policyholder. If the
patient is an unmarried domestic partner, enter an X in
the Other box.

Enter the primary policyholders mailing address and


telephone number. Enter the street address on line 1,
enter the city and state on line 2, and enter the 5- or 9digit zip code and phone number on line 3.

Enter the primary policyholders last name, first name,


and middle initial (if known) (separated by commas). If
the primary policyholder is the patient, enter SAME.

9a

Enter the primary policyholders policy or group number.


Do not enter hyphens or spaces in the number.

BLOCK

INSTRUCTIONS

9b

Enter the primary policyholders birth date as MM DD


YYYY (with spaces). Enter an X in the appropriate box to
indicate the secondary or supplemental policyholders
gender. If the primary policyholder is the patient, leave
blank.

9d

Enter the name of the primary policyholders health


insurance plan (e.g., commercial health insurance plan
name or government program).

10a-c

Enter an X in the appropriate box.

10d

Leave blank.

11

Enter the rejection code provided by the payer if the


patient has other third-party payer coverage and the
submitted claim was rejected by that payer. Otherwise,
leave blank.

11d

Enter an X in the YES box.

BLOCK

INSTRUCTIONS

28

Enter the total charges for services and/or procedures


reported in Block 24.

29

Enter the amount paid by the other payer. If the other


payer denied the claim, enter 0 00.

30

Enter the total amount due (by subtracting the amount


entered in Block 29 from the amount entered in Block
28). Do not report negative amounts or a credit due to
the patient.

The infant of a Medicaid recipient is automatically


eligible for Medicaid for the entire first year of life.
Individual state Medicaid programs determine
reimbursement procedures for services provided to
newborns.
When claims are submitted under the mothers Medicaid
identification number, coverage is usually limited to the
babys first 10 days of life
Medicaid usually covers babies through the end of the
month of their first birthday (e.g., baby born January 5
this year, is covered until January 31 next year).
The baby must continuously live with its mother to be
eligible for the full year, and the baby remains eligible
for Medicaid even if changes in family size or income
occur and the mother is no longer eligible for Medicaid.
A mother/baby claim is submitted for services provided
to a baby under the mothers Medicaid identification
number.

BLOCK

INSTRUCTIONS

1a

Enter the mothers Medicaid ID number as it appears on


the patients Medicaid card. Do not enter hyphens or
spaces in the number.

Enter the mothers last name followed by the word


NEWBORN (separated by commas).
EXAMPLE: VANDERMARK, NEWBORN

Enter the infants birth date as MM DD YYYY (with


spaces). Enter an X to indicate the infants gender.

Enter the mothers name (separated by commas),


followed by (MOM), as the responsible party.
EXAMPLE: VANDERMARK, JOYCE (MOM)

21

Enter ICD secondary diagnosis codes in fields 2, 3,


and/or 4, if applicable.

Each state selects a payer that


administers its State Childrens
Health InsuranceProgram (SCHIP)
program, and the payer develops its
own CMS-1500 claimsinstructions

BLOCK

INSTRUCTIONS

Enter an X in the Other box.

1a

Enter the SCHIP identification number (assigned by the


Health Plan) of the subscriber (person who holds the
policy).

19

Leave blank.

22

Leave blank.

29

Enter the total amount the patient (or another payer)


paid toward covered services only. If no payment was
made, leave blank.

30

Enter the total amount due (by subtracting the amount


entered in Block 29 from the amount entered in
Block 28). Do not report negative amounts or a credit
due to the patient.

Thank you for listening


and
God bless...

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