Billing Medicaid as a provider can seem hard at first! The good news? With the right steps, it soon becomes routine.
This guide from RxCredentialing gives you a clear roadmap for the entire process.
What Is Medicaid?
Medicaid is a health program jointly run by the federal and state governments in the U.S. It now covers more than 80 million people, including:
- Children
- Pregnant women
- People with disabilities
- Low-income adults
- Seniors who also receive Medicare (known as “dual eligibles”)
What’s the Difference Between Medicare and Medicaid?
Medicare
A health insurance program for people age 65 and older, and also for some younger people with disabilities.
- ✓It’s federal, so the rules are the same in every state.
- ✓Most people get it when they retire.
Medicaid
For people with low income, including children, pregnant women, seniors, and people with disabilities.
- ✓It’s run by both the federal and state governments, so the rules can be different in each state.
- ✓You can have Medicaid at any age if you qualify.
Some people get both Medicare and Medicaid at the same time; they are known as “dual eligibles.” You can learn more about these programs on the official CMS website.
Why Should Healthcare Providers Treat Medicaid Patients?
While many providers worry about reimbursement rates, there are three major reasons to consider accepting Medicaid:
- Large patient pool – Medicaid covers a fast-growing segment of the population, especially in underserved areas.
- State-level incentives – Some states offer extra perks like value-based payments or higher rates for specific specialties.
- Community impact – You’re helping some of the most vulnerable people. That service brings lasting value to your community. If you need help managing these new patients, consider our physician billing services.
Here’s How to Bill Medicaid as a Provider:
Billing Medicaid as a provider involves 7 key steps to ensure you get paid without denials.
Enroll as a Medicaid Provider
You can’t send a single reimbursement claim to Medicaid until the program adds you to its roster. Therefore, your first job is getting on that list. Think of it like joining the payroll before payday.
Every state runs its own enrollment portal, and they all live on official .gov pages. A quick search for “[Your State] Medicaid provider enrollment” on Google will land you on the right link. For example: In Texas, you’ll use TMHP (Texas Medicaid & Healthcare Partnership). In California, it’s PAVE (Provider Application and Validation for Enrollment). If the web address doesn’t end in .gov or belong to a well-known state partner, then don’t trust it.
Have these items ready before you start the Medicaid provider enrollment form: NPI number (your unique provider ID), Tax ID (EIN, needed when you bill under a practice name), Medical license and DEA registration (proves you can treat and, if needed, prescribe), Specialty and service sites (tells Medicaid what you do and where you do it), and Bank details (sets up direct deposit for fast pay).
Log in or create an account on your state’s portal. Follow each screen. Upload documents as asked. If a field stumps you, most portals have a help line or live chat—so use it. You can also call the state’s Medicaid provider relations office, as that team’s entire job is guiding newbies like you through enrollment. If you get stuck, consider using an insurance credentialing service to speed up the process.
After you click Submit, the state reviews your file. This “Medicaid credentialing” step checks licenses and other data. Time frame is usually between 30 to 90 days. Faster for solo providers. Slower if you enroll a new group practice. Once approved, you’re ready to send Medicaid claims and get paid as a healthcare provider.
Verify Patient Eligibility Before Each Visit
Eligibility verification simply means you confirm, ahead of time, that Medicaid still covers your patient and the service you plan to provide. A quick check spares you from most “patient not eligible” denials.
State Medicaid portal (get an instant “yes” or “no”), EHR or clearinghouse tool (many systems ping Medicaid in real time), or Medicaid helpline (a phone call helps when the portal is down or the data looks odd).
Confirm active coverage for today. Review service limits. Check for a managed care plan. Look for other insurance (third-party liability).
Confirm That Medicaid Covers the Service
You have your Medicaid ID. You’ve checked the patient’s eligibility. One last check keeps your claim safe: make sure the service itself is on your state’s covered list.
Search for “Your State Medicaid fee schedule 2025.” Look for a PDF or spreadsheet on a .gov site.
The schedule shows whether the code is covered, the dollar amount Medicaid pays, any limits, and whether prior authorization is required.
States post monthly or quarterly alerts. A code that paid last year may need approval today.
A five-minute call beats a denied claim.
Services Medicaid Often Rejects or Restricts:
- ❌ Cosmetic work such as Botox or laser skin treatments, unless medically required.
- ❌ Out-of-network care when you are not enrolled in the patient’s Medicaid HMO or lack a referral.
- ❌ Adult dental or vision extras in many states.
- ❌ Experimental or investigational treatments unless the state grants a special waiver.
Secure Prior Authorization When It Counts
Some services need prior authorization (PA) before you provide them. Getting that green light is the difference between a paid claim and a painful write-off. As a rule of thumb, if a service is pricey, ongoing, or ordered by a specialist, plan on requesting a PA.
Choose the right portal (every state runs its own PA system) and fill in the nuts and bolts (CPT or HCPCS code, ICD-10 code, provider info, target date).
Your clinical notes, past imaging, lab results, or a referring specialist’s letter strengthen the request.
Most plans give a decision within a few business days. Log the submission date and reference number.
If approved, schedule the service. If denied, read the reason and fix it on appeal. If they need more info, provide it and resubmit.
Tips that keep the process painless:
- Train your front-desk staff.
- Watch the clock (PAs often expire).
- Keep a PA cheat sheet.
- Flag urgent cases.
Submit Your Medicaid Claim
Use CMS-1500 or UB-04 forms. Include accurate ICD-10, CPT, POS codes, NPI numbers, and send via EHR, clearinghouse, or portal. For help with this step, explore our physician billing services.
- Forms: CMS-1500 (professional) or UB-04 (facility).
- Codes: ICD-10 (why) and CPT/HCPCS (what you did).
- POS Code: Check this code twice. A wrong POS is a top reason claims bounce back.
- NPIs: Rendering provider NPI must match the person who gave the care.
- Method: Through your EHR, a clearinghouse, or direct upload to the state portal.
Track Each Claim and Match Every Payment
Submitting the claim is only halftime. To get paid in full, you still need to watch the claim move through the system and confirm the deposit hits your account. A little follow-through here prevents big revenue leaks later. If you are struggling with a high number of denials that pop up most, consider a professional service.
Use the State Medicaid portal, a clearinghouse dashboard, or review your Remittance Advice (RA) or EOB.
Bad patient data, coverage gaps, NPI/Tax ID mismatches, or missing prior authorization.
Match every deposit to the specific claim. Flag under-payments at once. If you need to appeal, move fast; many Medicaid programs close the window after 90 days.
Fix and Resubmit Denied Claims
A denial is normal. It just means something on the claim needs a quick edit. Most states let you correct and resend—as long as you do it within their time limit (often 90–180 days).
Look for the short code (CO-16, PR-49, etc.) that tells you what went wrong.
Correct any typos, add the right modifier, swap in the correct code, or include the PA number.
Use the same route you used before. Mark it as a corrected claim if your state asks for that.
Send the fix before the timely-filing window closes.
Write down each denial to prevent the same mistake next time. You can also explore our healthcare denial management services.
Frequently Asked Questions
Medicaid provider enrollment timelines can vary significantly by state, but it typically takes between 30 to 90 days. The process can be faster for individual providers and may take longer for new group practices or when the application is incomplete.
A Medicaid managed care plan is a type of health plan where the state contracts with private managed care organizations (MCOs) to provide health services to Medicaid beneficiaries. If a patient is enrolled in an MCO, you must be credentialed with that specific plan to receive reimbursement.
In most cases, no. Medicaid rules typically prohibit providers from billing a patient for a covered service, even if the claim is denied. This is a crucial rule to prevent beneficiaries from being financially responsible for services that should be covered. Exceptions may apply for non-covered services if the patient signed a waiver beforehand.
The CMS-1500 form is used by professional providers (e.g., physicians, therapists) for outpatient services. The UB-04 form is used by facilities (e.g., hospitals, ambulatory surgery centers) for inpatient and outpatient services.
The timely-filing limit for Medicaid claims varies by state. It is typically between 90 and 180 days from the date of service, but some states may have different rules. It's essential to check your specific state's Medicaid provider manual for the exact deadline.
Prior authorization (PA) is a process where a provider must get approval from the payer before performing a specific service or procedure. It is often required for high-cost services, non-routine procedures, or certain medications to ensure medical necessity.
You can find your state's fee schedule on the official state Medicaid website or its designated contractor's portal. A simple search for "[Your State] Medicaid fee schedule" will typically lead you to a downloadable PDF or a searchable database.
First, carefully read the denial code and reason on your Remittance Advice (RA) or Explanation of Benefits (EOB). Correct any simple errors (e.g., typos, wrong codes) and resubmit the claim. For more complex issues, you may need to file a formal appeal with supporting documentation.
Verifying patient eligibility before each visit is crucial because a patient's Medicaid coverage status can change frequently. A quick check prevents you from providing services to an ineligible patient and later having your claim denied, leading to a financial loss for your practice.
Yes, while some concepts are similar, Medicaid billing is handled by individual states with their own specific rules, forms, and regulations. Medicare is a federal program with more uniform rules across the country. It is important for providers to understand the differences to avoid denials.
Let Us Turn Your Medicaid Claims Into Quick Payouts
Hand your Medicaid claims to RxCredentialing, a medical billing services company. We spot the tiny coding slips that trigger denials, talk to the payer for you, and stay on the case until you see “Paid” in your portal.
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