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General Billing Tips
Missed Appointments – According to the Centers for Medicare and Medicaid Services (CMS), providers are not allowed to bill recipients for missed appointments. A missed appointment is not a distinct reimbursable Medicaid service but a part of the provider's overall cost of doing business.
Appeals of denied or paid claims must be submitted within 365 days from the original denial or paid dates.
Verifying Eligibility – Verify recipient eligibility for Medicaid benefits and services at the beginning of each month or at each visit. Recipients may be enrolled in programs with restricted services. Certain services require prior approval for reimbursement. Please refer to the fee schedule to confirm if a PA is required. This information may be obtained from the Interactive Voice Response (IVR) system by calling (202) 906-8319 (in District) or (866) 752-9231(outside DC metro area). The IVR will prompt you to enter your provider number. This is the nine-digit number assigned to you through the Medicaid program. The system will then prompt you to enter the recipient number. This eight-digit code is listed on the patient’s Medical Assistance Card.
Registered web portal users may also use the online eligibility verification tool located under <Inquiry Options > Eligibility Inquiry.
Providers are encouraged to maintain eligibility verification documentation, such as the confirmation number obtained from the IVR or a copy of the eligibility results statement if using the Web Portal.
Timely Filing TCN – Claims for covered services must be filed within 365 days from the date of service. Timely filing guidelines for Medicare/Medicaid Crossover and third party claims are 180 days from the Medicare or third party payer's payment date.
Claims filed within 365 days of the date of service that were denied for any reason other than timely filing may be resubmitted with a copy of the Remittance Advice (RA) indicating the original date of denial.
Adjustments may be submitted within 365 days of the paid date. Voids may be submitted at any time.
Crossover Claims – Crossover claim forms submitted without a separate attachment for each claim will be returned to the provider. All paper crossover claims billed for an inpatient hospital deductible must be billed with a Bill Type 111 (Hospital Inpatient Admit through Discharge Claim). Data submitted on the crossover claim must exactly match what was reported to and from Medicare.
Remember to utilize the Interactive Voice Response (IVR) system or the Web Portal for eligibility inquiries.
Medicare Denials – When billing for services denied by Medicare for recipients who are eligible for Medicare and Medicaid, you must attach the EOMB statement of Medicare denial to the hardcopy or upload with online submitted claim.
TPL Denials - When the third-party payment source denies payment, you must attach the EOB statement of denial to the hardcopy claim or upload with the online submitted claim.
Patient Control Number Claim Field – On the UB04 claim form, the Medical Record Number field (3a), is for the provider's internal use. This is a 20-character field in which the provider may report an internal patient ID number, medical record number, etc. The number entered in this field is printed on the provider's Remittance Advice.
Retroactive Eligibility – When a recipient receives retroactive eligibility, include an attachment indicating the recipient's retroactive eligibility.
Place of Service Codes – Place of Service codes are two (2) digit nationally recognized codes. Refer to the billing manuals for a complete list of the codes.
When submitting an Adjustment or Void, indicate the Transaction Control Number (TCN) from the most recent paid claim.
