Billing medicaid patients

You may bill recipients only in the following situations:

The recipient's Medicaid eligibility status is pending . If you bill the recipient and they are found eligible for Medicaid with a retroactive date that includes the date of service, you must return the entire amount collected from the recipient and then bill Medicaid. For this reason, it is recommended that you hold claims until after eligibility is determined.

Medicaid does not cover the service and the recipient agrees to pay by completing a written, signed agreement that includes the date, type of service, cost, verification that the provider informed the recipient that Medicaid will not pay for the service, and recipient agreement to accept full responsibility for payment. This agreement must be specific to each incident or arrangement for which the client accepts financial responsibility.

The TPL payment was made directly to the recipient or his/her parent or guardian. You may not bill for more than the TPL paid for services rendered.

The recipient fails to disclose Medicaid eligibility or TPL information. If a recipient does not disclose Medicaid eligibility or TPL information at the time of service or within Medicaid ’ s stale date period, the recipient assumes full responsibility for payment of services.

You may not bill the recipient:


For co-payment indicated on a private insurance card

For the difference between the amount billed and the amount paid by Medicaid or a TPL

When Medicaid denies the claim because the provider failed to follow Medicaid policy

Medicaid is the payor of last resort and must be billed after all other payment sources.

Prohibition on Billing Plan Members - Commercial insurance

Your agreement with the Plan requires providers to accept payment directly from the Plan. Payment from the Plan constitutes payment in full, with the exception of applicable deductibles, co-insurance and any other amounts listed as member responsibility on the Explanation of Payment/Provider Remittance Advice.

Providers may not bill Plan members for:

* The difference between actual charges and the contracted reimbursement amount;

* Services denied because of timely filing requirements;

* Services denied due to failure to follow Plan procedures;

* Covered services for which a claim has been returned and denied for lack of information;

* Remaining or denied charges for those services where a contracted provider fails to notify the plan of a service that required prior authorization; payment for that service will be denied; and

* Covered services that were not medically necessary, in the judgment of the Plan, unless prior to rendering the service, the provider obtains the member’s informed written consent and the member receives information that they would be financially responsible for the specific services.

* Sales tax or GET on services rendered Non-Covered Services

Plan members may be billed for non-covered services like cosmetic procedures and items of convenience (i.e., televisions), services received from unauthorized nonplan providers, in addition to instances when a member self-refers to a specialist or other provider within the network without following Plan procedures (e.g. without obtaining prior authorization) and the Plans denies payment to the provider.

If a provider bills a member for non-covered services or for self-referrals, he or she shall inform the member and obtain prior agreement from the member regarding the cost of the procedure and the payment terms at time of service.

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