About 78% of Medicaid beneficiaries are enrolled in comprehensive managed care organizations, so most Medicaid claims are adjudicated by a commercial insurer with its own rules — not by the state. Practices that bill "Medicaid" as one payer are billing a dozen.
Medicaid claims go to the right payer, in the right order, inside the right window.
At a glance
Step 1
Bill the plan that actually adjudicates rather than the program on the card
Step 2
Track filing windows per plan, which are frequently shorter than commercial
Step 3
Verify eligibility every visit, because Medicaid coverage churns monthly
Step 4
Sequence Medicaid last, since it is the payer of last resort and enforces that
What we actually do
- Bill the plan that actually adjudicates rather than the program on the card
- Track filing windows per plan, which are frequently shorter than commercial
- Verify eligibility every visit, because Medicaid coverage churns monthly
- Sequence Medicaid last, since it is the payer of last resort and enforces that
What this fixes
- One internal Medicaid rule applied to plans that each set their own
- Claims denied for sequencing rather than for coverage
- Filing deadlines missed because the commercial window was assumed
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Review
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Scope
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Report
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Medicaid Billing — Frequently Asked Questions
Why is Medicaid billing treated separately?
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Because it is not one payer. The program name, the managed care structure, and the filing window all change at the state line, and often within a state.
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