Medicaid Billing: It’s Complicated! 10 FAQs

Medicaid Billing: It’s Complicated! 10 FAQs

Medicaid billing can be a big, complicated world, but knowing where to start in your state and getting familiar with some of the billing lingo is a good place to begin. If you’re looking for answers about the basics of Medicaid billing for Home and Community Based Services (HCBS) or electronic Medicaid billing, keep reading to cut through the complexity.

  1. How does a Medicaid provider bill Medicaid electronically?

Every state has a different application process and requirements for Medicaid provider enrollment. Some Home and Community-Based Services (HCBS) providers will register with their state using a state-issued provider ID. Many providers also also register as a Medicaid provider and apply for a National Provider Identifier (NPI). Once registered, providers will also need to register with each state Medicaid program they plan to bill. Do an Internet search for your state and “Medicaid provider enrollment” for more information.
  1. What are the billing options for Medicaid?

Home and Community-Based Services (HCBS) organizations can bill Medicaid in different ways, for example by:
  • Manually submitting all claims on paper.
  • Using a clearinghouse as an intermediary to take paper claims and verify accurate information before submitting to the payer.
  • Billing Medicaid electronically, either by
    • Submitting billing information to a web-based portal provided by the payer or
    • Using an electronic billing software that manages all the billing data automatically and submits complete claims for payment. These claims typically take an 837p or 837i form. These are Electronic Data Interchange (EDI) claims. EDI Autoclaim is an example of an electronic billing software.
  1. What’s the difference in billing for Medicaid vs Medicare?

Medicare is nationally administered by the Centers for Medicare and Medicaid Services (CMS) and therefore has standard billing requirements across the country. Medicaid is administered at the state-level. Home and Community-Based Services (HCBS) agencies must meet all state-specific Medicaid billing requirements for each state they plan to bill in. Home and Community-Based Services agencies operating in multiple states will find that while most states use the same electronic format for submission, there can be distinct differences in the method of claim transmission from state-to-state.
  1. What is EDI?

Electronic Data Interchange (EDI) is the electronic exchange of business information in a standard format. Simply put, EDI is how different entities send and receive large amounts of data efficiently. EDI transfers can occur between a health care provider and Medicaid or between Medicaid and another health care plan. EDI data exchanges contain a set of message types, which are referred to most commonly by number instead of name. The two message types processed by Annkissam's Medicaid Billing software, EDI Autoclaim, are 835 and 837. EDI Autoclaim is also capable of processing 270 and 271 files, which are eligibility requests and responses.
  1. What is an 835 file?

An 835 file is also called a "Health Care Claim Payment and Remittance Advice." It is the Electronic Data Interchange (EDI) version of the paper or PDF remittance advice document. The 835 file meets HIPAA 5010 requirements for electronic transmission of claim and payment information. The 835 contains details such as, if charges were paid or denied and how the payment was made.
  1. What is an 837 file?

The 837 file is the standard format used by healthcare professionals and suppliers to transmit healthcare claims electronically in batch. One 837 file can contain thousands of claims, all submitted to the payer in one transaction. The 837 file meets HIPAA 5010 requirements for electronic transmission of patient data, including patient name, diagnosis code, type of service provided, service date, charges and provider name.
  1. What’s the difference between 837i and 837p in electronic Medicaid billing?

The 837i is the electronic version of the paper form UB-04. 837i files are used to transmit institutional claims. Institutional claims are those submitted by hospitals and skilled nursing facilities. The 837p is the electronic version of the CMS-1500 form. 837p files are used to transmit professional claims. Professional claims are those from physicians, suppliers and other non-institutional providers for either inpatient or outpatient services.
  1. What is the CMS 1500 form?

CMS-1500 is the standard paper claim form used to bill fee-for-service claims when submitting a paper claim is allowed. The CMS-1500 is the manual paper version of an electronic 837p submission. In the past, it was common for states to require denied 837 claims to be submitted on CMS-1500 for reprocessing. That practice is gradually becoming obsolete as more states allow for corrected claims to be submitted via 837.
  1. When should one use the UB 04 vs CMS 1500 claim submission form?

While the CMS-1500 is used for professional claims, the UB-04 is used for institutional claims. Institutional claims are typically submitted by hospitals, inpatient facilities and skilled nursing facilities. The vast majority of Home and Community-Based Services (HCBS), if billed on paper, are billed using CMS-1500. If they are billed electronically, most HCBS claims are billed using the 837 Electronic Data Interchange (EDI). However, in some cases, the UB-04 is required for Medicaid claims.
  1. I can’t seem to find a place to bill Medicaid in my state. Why is that?

Many states develop a state-specific name for their Medicaid programs. For example, in Massachusetts, Medicaid is called MassHealth. Wyoming calls their state Medicaid program Equality Care. Arizona calls their Medicaid program Health Care Cost Containment System. Many states refer to Medicaid as Medical Assistance. Some states that call Medicaid Medical Assistance include Delaware, Florida, Illinois, Iowa, Minnesota, Virginia and Washington, DC.