HealthCare News

Medicaid Claims Handling for Medicaid Members

Issue: #387 MAR2016

Topic: Coding/Billing


Blue Cross and Blue Shield plans currently administer Medicaid programs in California, Delaware, Hawaii, Illinois, Indiana, Kentucky, Michigan, Minnesota, New Jersey, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and Wisconsin as a Managed Care Organization (MCO), providing comprehensive Medicaid benefits to the eligible population. Because Medicaid is a state-run program, requirements vary for each state, and thus each BCBS plan. Medicaid members have limited out-of-state benefits, generally covering only emergency situations. In some cases, such as continuity of care, children attending college out-of-state, or a lack of specialists in the member’s home state, a Medicaid member may receive care in another state, and generally the care requires prior authorization.

Identifying Medicaid members to determine eligibility and benefits

BCBS plan ID cards do not always indicate that a member has a Medicaid product. BCBS plan ID cards for Medicaid members do not include the suitcase logo that you may have seen on most BCBS ID cards, but they do include a disclaimer on the back of the ID card providing information on benefit limitations. For members with such ID cards, you should obtain eligibility and benefit information and prior authorization for services using the same tools as you would for other BCBS members.

  • Submit an eligibility inquiry by calling the BlueCard Eligibility Line at 1-800-676-BLUE
  • Submit an eligibility inquiry using BlueExchange
  • Obtain pre-service review using the Electronic Provider Access (EPA) tool

Medicaid reimbursement and billing

Claims for all BCBS Medicaid members should be submitted to your local BCBS Plan. If you are contracted with your local BCBS plan for Medicaid, your local Medicaid rates will only apply for BCBSND members; they do not apply to out-of-state Medicaid members.

When you see a Medicaid member from another state and submit the claim, you must accept the Medicaid fee schedule that applies in the member’s home state. Please remember that billing out-of-state Medicaid members for the amount between the Medicaid-allowed amount and charges for Medicaid-covered services is specifically prohibited by Federal regulations (42 CFR 447.15).

If you provide services that are not covered by Medicaid to a Medicaid member, you will not be reimbursed. You may only bill a Medicaid member for services not covered by Medicaid if you have obtained written approval from the member in advance of the services being rendered.

In some circumstances, a state Medicaid program will have an applicable copayment, deductible or coinsurance applied to the member’s plan. You may collect this amount from the member as applicable. Note that the coinsurance amount is based on the Medicaid fee schedule for that service.

Medicaid billing data requirements

When billing for a Medicaid member, please remember to check the Medicaid website of the state where the member resides for information on Medicaid billing requirements.

Providers should always include their National Provider Identifier (NPI) on Medicaid claims, unless the provider is considered atypical. Providers should also bill using National Drug Codes (NDC) on applicable claims. These data elements and other data elements that are important to submit, when applicable, on Medicaid claims are included below.

Effective March 2016, applicable Medicaid claims submitted without these data elements will be denied. Prior to March 2016, applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received:

  • National Drug Code
  • Rendering Provider Identifier (NPI)
  • Billing Provider Identifier (NPI)

Applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received:

  • Billing Provider (Second) Address Line
  • Billing Provider Middle Name or Initial
  • (Billing) Provider Taxonomy Code
  • (Rendering) Provider Taxonomy Code
  • (Service) Laboratory or Facility Postal Zone or Zip Code
  • (Ambulance) Transport Distance
  • (Service) Laboratory Facility Name
  • (Service) Laboratory or Facility State or Province Code
  • Value Code Amount
  • Value Code
  • Condition Code
  • Occurrence Codes and Date
  • Occurrence Span Codes and Dates
  • Referring Provider Identifier and Identification ode Qualifier
  • Ordering Provider Identifier and Identification Code Qualifier
  • Attending Provider NPI
  • Operating Physician NPI
  • Claim or Line Note Text
  • Certification Condition Applies Indicator and Condition Indicator (Early and Periodic Screening Diagnosis and Treatment, or EPSDT)
  • Service Facility Name and Location Information
  • Ambulance Transport Information
  • Patient Weight
  • Ambulance Transport Reason Code
  • Round Trip Purpose Description
  • Stretcher Purpose Description