Payer claims basics: Medicaid, waiver and insurance

The path, at a high level

1. Enrollment or contract

   You must be enrolled with, or contracted by, a payer before you can bill it. For Medicaid and waiver programs, becomemedicaidprovider.com, also published by Home Care Agency Blueprint, covers enrollment.

2. Eligibility

   Check the client’s coverage with the payer before services, when the payer offers a way to check.

3. Authorization, when the payer uses one

   Some payers approve specific services and units in advance. Keep the authorization on file and serve within it.

4. Documented service

   Each visit recorded the way the payer and your state require, including EVV where your state Medicaid program requires it.

5. Claim

   Built and submitted the way the payer’s contract and provider manual say, using the codes and units the payer names.

6. Remittance or denial

   The payer pays, pays part, or denies or returns the claim with a reason. Record the result and correct and resubmit where the payer allows.

Our own planning, from the CMS list of standard transactions below. Each payer sets its own steps.

Electronic claims and HIPAA transactions

CMS describes a transaction as an electronic exchange of information between two parties to carry out financial or administrative activities related to health care, such as a provider sending a claim to a health plan to request payment. Under HIPAA, HHS adopted standard transactions, including claims, claim status, eligibility, referrals and authorizations, and payment and remittance advice. HIPAA covered entities that conduct these transactions electronically must use an adopted standard.

Clearinghouses and billing vendors

HHS lists health care clearinghouses as one kind of HIPAA covered entity: entities that process nonstandard health information they receive from another entity into a standard format, or the reverse. Whether you need one depends on how each payer accepts claims; ask the payer. HHS also says billing and claims processing done on behalf of a covered entity are examples of business associate activities, which call for a business associate agreement. Decide with counsel whether HIPAA applies to your agency.

Medicaid and waiver programs

Medicaid and waiver billing runs through your state’s program and any managed care plans it uses. Enrollment comes first; becomemedicaidprovider.com, also published by Home Care Agency Blueprint, covers becoming a Medicaid provider. Your state Medicaid agency and its provider manuals set the claim rules, and EVV may apply.

Insurance and other payers

For long-term care insurance, managed care and other plans, the plan’s contract and manuals control. Check with the payer what it covers, what it needs on a claim and how it pays.

What this page does not cover

We do not teach procedure or billing codes, publish rates, or predict whether a claim will be paid. Use the codes and units in your payer’s manual or contract. Skilled, Medicare-certified home health has separate federal billing rules; starthomehealthagency.com, also published by Home Care Agency Blueprint, covers that path.