MEDICAID

In 1965 Congress passed Title 19 of the Social Security Act, establishing a federally mandated, state-administered medical assistance program for individuals with incomes below the federal poverty level. The federal name for this program is Medicaid; several states assign local designations (e.g., California uses MediCal; Massachusetts uses MassHealth; Tennessee uses TennCare).Unlike Medicare, which is a nationwide entitlement program, the federal government mandated national requirements for Medicaid and gave states the flexibility to develop eligibility rules and additional benefits if they assumed responsibility for the programs support.

Medicaid provides medical and health-related services to certain individuals and families with low incomes and limited resources (the medically indigent). It is jointly funded by the federal and state governments to assist states in providing adequate medical care to qualified individuals. Within broad federal guidelines, each state:Establishes its own eligibility standards.Determines the type, amount, duration, and scope of services.Sets rates of payment for services.Administers its own program.

Medicaid policies for eligibility are complex and vary considerably, even among states of similar size and geographic proximity. a person who is eligible for Medicaid in one state may not be eligible in another stateservices provided by one state may differ considerably in amount, duration, or scope as compared with services provided in a similar or neighboring state. state legislatures may change Medicaid eligibility requirements during the year.Medicaid does not provide medical assistance for all poor persons, and it is important to realize that low income is only one test for Medicaid eligibility; an individuals resources are also compared to limits established by each state in accordance with federal guidelines.

To be eligible for federal funds, states are required to provide Medicaid coverage for certain individuals who receive federally assisted income-maintenance payments and for related groups that do not receive cash payments. state-only programs to provide medical assistance for specified poor persons who do not qualify for Medicaid.The federal government provides matching funds to state Medicaid programs when certain healthcare services are provided to eligible individuals (e.g., children, disabled, seniors). Each state administers its own Medicaid program, and CMS monitors the programs and establishes requirements for the delivery, funding, and quality of services as well as eligibility criteria

Medicaid eligibility is limited to individuals who can be classified into three eligibility groups:Categorically needyMedically needySpecial groups

Categorically Needy GroupsState Medicaid programs must be available to the following mandatory Medicaid eligibility groups (or mandatory populations) because the federal government provides matching funds:Families who meet states Temporary assistance for Needy Families (TaNF) eligibility requirements in effect on July 16, 1996.Pregnant women and children under age 6 whose family income is at or below 133% of the federal poverty level (annual income guidelines established by the federal government).Caretakers (relatives or legal guardians who take care of children under age 18,or age 19 if still in high school)Supplemental security Income (SSI) recipients (or, in certain states, aged, blind, and disabled people who meet more restrictive requirements than those of the SSI program).Individuals and couples living in medical institutions who have a monthly income up to 300% of the SSI income.

Medically Needy ProgramStates that establish a medically needy Medicaid program expand eligibility to additional qualified persons who may have too much income to qualify under the categorically needy group. This option allows:Individuals to spend down to Medicaid eligibility by incurring medical and/orremedial care expenses to offset their excess income. Thus, their income isreduced to a level below the maximum allowed by their states Medicaid plan.Families to establish eligibility as medically needy by paying monthly premiumsin an amount equal to the difference between family income (reduced by unpaidexpenses, if any, incurred for medical care in previous months) and the incomeeligibility standard.

Medically Needy ProgramStates that implement a medically needy Medicaid program are required to include pregnant women through a 60-day postpartum period, children underage 18, certain newborns for one year, and certain protected blind persons. States may also choose to provide coverage to other medically needy persons, including aged, blind, and/or disabled persons; caretaker relatives or legal guardians who live with and take care of children and other eligible children up to age 21 who are full-time students.

Special GroupsStates are required to assist the following special groups:Qualified Medicare beneficiaries (QMB) (states pay Medicare premiums, deductibles and coinsurance amounts for individuals whose income is at or below100 percent of the federal poverty level and whose resources are at or below twice the standard allowed under SSI)

Special GroupsStates are required to assist the following special groups:Qualified working disabled individuals (QWDI) (states pay Medicare Part a premiums for certain disabled individuals who lose Medicare coverage because of work; these individuals have incomes below 200 percent of the federal poverty level and resources that are no more than twice the standard allowed under SSI)

Special GroupsStates are required to assist the following special groups:Qualifying individual (QI) (states pay Medicare Part B premiums for individuals with incomes between 120 percent and 175 percent of the federal poverty level)Specified low-income Medicare beneficiary (SLMB) (states pay Medicare Part B premiums for individuals with incomes between 100 percent and 120 percent of the federal poverty level)

Special GroupsStates may also improve access to employment, training, and placement of people with disabilities who want to work by providing expanded Medicaid eligibility to:Working disabled people between ages 16 and 65 who have income and resources greater than that allowed under the SSI program.Working individuals who become ineligible for the group described above because their medical conditions improve. (states may require these individuals to share in the cost of their medical care.)

Special GroupsTwo additional eligibility groups are related to specific medical conditions, and states may provide coverage under their Medicaid plans:Time-limited eligibility for women who have breast or cervical cancerIndividuals diagnosed with tuberculosis (TB) who are uninsured.Women with breast or cervical cancer receive all Medicaid plan services. TB patients receive only services related to the treatment of TB.

State Childrens Health Insurance ProgramImplemented in accordance with the Balanced Budget Act (BBA), which allows states to create or expand existing insurance programs, providing more federal funds to states for the purpose of expanding Medicaid eligibility to include a greater number of currently uninsured children. With certain exceptions, these include low-income children who would not otherwise qualify for Medicaid. SCHIP may also be used to provide medical assistance to children during a presumptive eligibility period for Medicaid.

State Childrens Health Insurance ProgramMedicaid coverage can begin as early as the third month prior to application if the person would have been eligible for Medicaid had he or she applied during that time. Medicaid coverage is usually discontinued at the end of the month in which a person no longer meets the criteria for any Medicaid eligibility group. The BBA allows states to provide 12 months of continuous Medicaid coverage (without reevaluation) for eligible children under the age of 19.

Programs of All-Inclusive Care for the Elderly (PACE)Capitated payment system to provide a comprehensive package of community-based services as an alternative to institutional care for persons age 55 or older who require a nursing facility level of care. PACE is part of the Medicare program, but is an optional service for state Medicaid plans. PACE programs operate only in states that have selected to include this option. PACE programs enter into contracts with various types of providers, physicians, and other entities to furnish care to participants.

Programs of All-Inclusive Care for the Elderly (PACE)This PACE team offers and manages all health, medical, and social services and mobilizes other services as needed to provide preventive, rehabilitative, curative, and supportive care. The care is provided in day health centers, homes, hospitals, and nursing facilities, and its purpose is to help the person maintain independence, dignity, and quality of life.

Programs of All-Inclusive Care for the Elderly (PACE)PACE providers receive payment only through the PACE agreement and must make available all items and services covered under both Medicaid and Medicare, without amount, duration, or scope limitations and without application of any deductibles, copayments, or other cost-sharing. The individuals enrolled in PACE receive benefits solely through the PACE program.

Spousal Impoverishment ProtectionThe Medicare Catastrophic Coverage Act of 1988 (MCCA) implemented Spousal Impoverishment Protection Legislation in 1989 to prevent married couples from being required to spend down income and other liquid assets (cash and property) before one of the partners could be declared eligible for Medicaid coverage for nursing facility care.The spouse residing at home is called the community spouseBefore monthly income is used to pay nursing facility costs, a minimum monthly maintenance needs allowance (MMMNA) is deducted.

Spousal Impoverishment ProtectionTo determine whether the spouse residing in a facility meets the states resource standard for Medicaid, a protected resource amount (PRA) is subtracted from the couples combined resources. The PRA is the greatest of the:Spousal share, up to a maximum of $109,560 in 2011.State spousal resource standard, which a state could set at any amount between $21,912 and 109,560 in 2011.

Spousal Impoverishment ProtectionTo determine whether the spouse residing in a facility meets the states resource standard for Medicaid, a protected resource amount (PRA) is subtracted from the couples combined resources. The PRA is the greatest of the:Amount transferred to the community spouse for her or his support as directed by a court order.Amount designated by a state officer to raise the community spouses protected resources up to the minimum monthly maintenance needs standard.

Confirming Medicaid EligibilityAny time patients state that they receive Medicaid, they must present a valid Medicaid identification card.Eligibility, in many cases, will depend on the patients monthly income. Confirmation of eligibility should be obtained for each visit; failure to do so may result in a denial of payment. Some states have a point-of-service device similar to those used by credit card companies.

Confirming Medicaid EligibilityBeneficiaries carry plastic cards containing encoded data strips. Retroactive eligibility is sometimes granted to patients whose income has fallen below the state-set eligibility level and who had high medical expenses prior to filing for Medicaid. When patients notify the practice that they have become retroactively eligible for Medicaid benefits, confirm this information before proceeding. A refund of any payments made by the patient during the retroactive period must be made and Medicaid billed for these services.

Medicaid allows considerable flexibility within state plans, but some federal requirements are mandatory if federal matching funds are to be received. A states Medicaid program must offer medical assistance for certain basic services to eligible groups.

Mandatory ServicesTo receive federal matching funds, states must offer the following services:Services for Categorically Needy Eligibility GroupsServices for Medically Needy Eligibility GroupsPreauthorized Services

Services for Categorically Needy Eligibility GroupsMedicaid eligibility groups classified as categorically needy are entitled tot he following services unless waived under the Medicaid lawInpatient hospital (excluding inpatient services in institutions for mental disease).Outpatient hospital including Federally Qualified Health Centers (FQHCs) and ifpermitted under state law, rural health clinic (RHC) and other ambulatory servicesprovided by a rural health clinic that are otherwise included under states plans.Other laboratory and x-ray.Certified pediatric and family nurse practitioners (when licensed to practice understate law).

Services for Categorically Needy Eligibility GroupsMedicaid eligibility groups classified as categorically needy are entitled tot he following services unless waived under the Medicaid lawNursing facility services for beneficiaries age 21 and older.Early and periodic screening, diagnosis, and treatment (EPSDT) for children underage 21.Family planning services and supplies.Physicians services.Medical and surgical services of a dentist.Home health services for beneficiaries entitled to nursing facility services under the states Medicaid plan.

Services for Categorically Needy Eligibility GroupsMedicaid eligibility groups classified as categorically needy are entitled tot he following services unless waived under the Medicaid lawIntermittent or part-time nursing services provided by home health agency or by a registered nurse when there is no home health agency in the area.Home health aides.Medical supplies and appliances for use in the home.Nurse mid-wife services.Pregnancy-related services and service for other conditions that might complicate pregnancy.Sixty (60) days postpartum pregnancy-related services.

Services for Medically Needy Eligibility GroupsStates must provide at least the following services when the medically needy are included under the Medicaid plans:Prenatal and delivery servicesPost-partum pregnancy-related services for beneficiaries who are under age 18 and are entitled to institutional and ambulatory services defined in a states planHome health services to beneficiaries entitled to receive nursing facility services under the states Medicaid plan

Services for Medically Needy Eligibility GroupsStates may provide different services to different groups of medically needy individualsSpecified services (if included as medically needy)Beneficiaries under age 21 and/or over age 65 in institutions for mental disease (IMDs)Intermediate care facilities for the mentally retarded (ICF/MRs)The services provided to a particular group must also be available to everyone within that group (unless the state has obtained a waiver).

Preauthorized ServicesMost states that have not placed all Medicaid beneficiaries into a prepaid HMO have some form of prior approval or preauthorization for recipients. Preauthorization guidelines include:Elective inpatient admissionEmergency inpatient admissionMore than one preoperative day (document reason[s] surgery cannot be performed within 24 hours of indication for surgery and specify number of additional preoperative day[s] requested)

Preauthorized ServicesPreauthorization guidelines include:Outpatient procedure(s) to be performed in an inpatient setting (submit CPT code and description of surgical procedure along with medical necessity justification for performing surgery on an inpatient basis)Days exceeding state hospital stay limitation due to complication(s) (submit diagnosis stated on original preauthorization request, beginning and ending dates originally preauthorized, statement describing the complication[s], date complication[s] presented, principal diagnosis, and complication[s] diagnosis)Extension of inpatient days (document medical necessity justification for the extension and specify number of additional days requested)

Medicaid operates as a vendor-payment program, which means that states pay healthcare providers on afee-for-service basis or states pay for Medicaid services using prepayment arrangementsWhen Medicaid makes payment directly to providers, those participating in Medicaid must accept the reimbursement as payment in full. States determine their own reimbursement methodology and payment rates for services, with three exceptionsfor institutional services - payment may not exceed amounts that would be paid under Medicare payment ratesfor disproportionate share hospitals (DSHs) - hospitals that treat a disproportionate number of Medicaid patients, different limits applyfor hospice care services - rates cannot be lower than Medicare rates.

States can require nominal deductibles, coinsurance, or copayments for certain services performed for some Medicaid recipients. Emergency services and family planning services are exempt from copayments. Certain Medicaid recipients are also excluded from this cost-sharingPregnant womenChildren under age 18Hospital or nursing home patients who are expected to contribute most of their income to institutional care.

Federal Medical Assistance Percentage (FMAP) portion of the Medicaid program paid by the federal government Determined annually for each state using a formula that compares the states average per capita income level with the national average. Wealthier states receive a smaller share of reimbursed costs, and the federal government shares in administration expensesThe federal government reimburses states for 100 percent of the cost of services provided through facilities of the Indian Health Serviceprovides financial help to the 12 states that furnish the highest number of emergency services to undocumented aliensshares in each states expenditures for the administration of the Medicaid program.

Most administrative costs are matched at 50 percent, although higher percentages are paid for certain activities and functions, such as development of mechanized claims processing systems.

Medicare-Medicaid RelationshipMedicare beneficiaries with low incomes and limited resources may also receive help from the Medicaid programFor those eligible for full Medicaid coverage, Medicare coverage is supplemented by services available under a states Medicaid program. Additional services may includeNursing facility care beyond the 100-day limit covered by MedicarePrescription drugsEyeglassesHearing aids.

Dual Eligibles (Medi-Medi)Medicare beneficiaries with low incomes and limited resources may receive help with out-of-pocket medical expenses from state Medicaid programs.

Various benefits are available to dual eligibles, individuals entitled to Medicare and eligible for some type of Medicaid benefitIndividuals eligible for full Medicaid coverage receive program supplements to their Medicare coverage via services and supplies available from the states Medicaid program.

Dual Eligibles (Medi-Medi)Services covered by both programs are paid first by Medicare and the difference by Medicaid, up to the states payment limit. Medicaid also covers the following additional services:Nursing facility care beyond the 100-day limit covered by MedicarePrescription drugsEyeglassesHearing aids

Medicaid as a Secondary PayerMedicaid is always the payer of last resort. If the patient is covered by another medical or liability policy, including Medicare, TRICARE (formerly CHAMPUS), CHAMPVA, or Indian Health Services (IHS), this coverage must be billed first.Medicaid is billed only if the other coverage denies responsibility for payment, pays less than the Medicaid fee schedule, or if Medicaid covers procedures not covered by the other policy.

Participating ProvidersAny provider who accepts a Medicaid patient must accept the Medicaid determined payment as payment in full. Providers are forbidden by law to bill patients for Medicaid-covered benefits. A patient may be billed for any service that is not a covered benefit; however, some states have historically required providers to sign formal participating Medicaid contracts. Other states do not require contracts.

Medicaid and Managed CareMedicaid managed care grew rapidly in the 1990s. In 1991, 2.7 million beneficiaries were enrolled in some form of managed care. By 2004 that number had grown to 27 million, an increase of 900 percent. (60 percent of the Medicaid population who receive benefits through managed care). States can make managed care enrollment voluntary, or they can seek a waiver of the Social Security Act from CMS to require certain populations to enroll in an MCO.

Medicaid and Managed CareMedicaid managed care does not always mean a comprehensive health care plan that requires a monthly premium and is at financial risk for the cost of care provided to all enrollees. Medicaid beneficiaries are also enrolled in primary care case management (PCCM) plans, which are similar to fee-for-service plans except that each PCCM enrollee has a primary care provider who authorizes access to specialty care but is not at risk for the cost of care provided. Most states that have not placed all Medicaid beneficiaries into a prepaid HMO have some form of prior approval or preauthorization for recipients.

Medicaid and Managed CarePreauthorization guidelines include:Elective inpatient admissionEmergency inpatient admissionMore than one preoperative dayOutpatient procedure(s) to be performed in an inpatient settingDays exceeding state hospital stay limitation due to complication(s)Extension of inpatient days

Medicaid Eligibility Verification SystemSometimes called recipient eligibility verification system or REVSAllows providers to electronically access the states eligibility file using the methods listed below. Point-of-service device: The patients medical identification card contains a magnetic strip, and when the provider swipes the card through a reader, accurate eligibility information is displayed. Computer software: When the provider enters a Medicaid recipients identification number into special computer software, accurate eligibility information is displayed.

Medicaid Eligibility Verification SystemAllows providers to electronically access the states eligibility file using the methods listed below. Automated voice response: Providers can call the states Medicaid office to receive eligibility verification information through an automated voice response system.Then, a receipt ticket is generated upon eligibility verification by MEVS.

Medicaid Remittance AdviceProviders receive reimbursement from Medicaid on a lump-sum basis, which means they will receive payment for several claims at once. A Medicaid remittance advice is sent to the provider which contains the current status of all claims. The provider should compare content on the remittance advice to claims submitted to determine whether proper payment was received.If improper payment was issued, the provider has the option to appeal the claim.

Medicaid Remittance AdviceAn adjusted claim has a payment correction, resulting in additional payment(s) to the provider. A voided claim is one that Medicaid should not have originally paid, and results in a deduction from the lump-sum payment made to the provider. If a year-to-date negative balance appears on the Medicaid remittance advice as a result of voided claims, the provider receives no payment until the amount of paid claims exceeds the negative balance amount.

Utilization ReviewThe federal government requires states to verify the receipt of Medicaid services. A sample of Medicaid recipients is sent a monthly survey letter requesting verification of services paid the previous month on their behalf.Federal regulations also required Medicaid to establish and maintain a surveillance and utilization review subsystem (SURS), which safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services.

Utilization ReviewA post payment review process monitors both the use of health services by recipients and the delivery of health services by providers. Overpayments to providers may be recovered by the SURS unit, regardless of whether the payment error was caused by the provider or by the Medicaid program.The SURS unit is also responsible for identifying possible fraud or abuse, and most states organize the unit under the states Office of Attorney General, which is certified by the federal government to detect, investigate, and prosecute fraudulent practices or abuse against the Medicaid program.

Medical NecessityMedicaid-covered services are payable only when the service is determined by the provider to be medically necessary. Covered services must be:Consistent with the patients symptoms, diagnosis, condition, or injury.Recognized as the prevailing standard and consistent with generally accepted professional medical standards of the providers peer group.Provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition.

Medical NecessityIn addition, medically necessary services are:Not furnished primarily for the convenience of the recipient or the provider.Furnished when there is no other equally effective course of treatment available or suitable for the recipient requesting the service that is more conservative or substantially less costly.

Fiscal AgentThe name of the states Medicaid fiscal agent will vary from state to state.

UnderwriterUnderwriting responsibility is shared between state and federal governments.Federal responsibility rests with CMS. The name of the state agency will vary according to state preference.Form UsedThe CMS-1500 claim is required.

Timely Filing DeadlineDeadlines vary from state to state. It is important to file a Medicaid fee-for-service claim as soon as possible.The only time a claim should be delayed is when the patient does not identify Medicaid eligibility or if the patient has applied for retroactive Medicaid coverage.Medicare-Medicaid crossover claims follow the Medicare, not Medicaid, deadlines for claims.

Allowable DeterminationThe state establishes the maximum reimbursement payable for each non managed care service. It is expected that Medicaid programs will use the new Medicare physician fee schedule for these services, with each state establishing its own conversion factor. Medicaid recipients can be billed for any noncovered procedure performed. However, because most Medicaid patients have incomes below the poverty level, collection of fees for uncovered services is difficult.

Accept AssignmentAccept assignment must be selected on the CMS-1500 claim, or reimbursement may be denied. It is illegal to attempt collection of the difference between the Medicaid payment and the fee the provider charged, even if the patient did not reveal Medicaid status at the time services were rendered.

DeductiblesA deductible may be required. In such cases, eligibility cards usually are not issued until after the stated deductible has been met.

CopaymentsCopayments are required for some Medicaid recipients.

Inpatient BenefitsAll nonemergency hospitalizations must be preauthorized. If the patients condition warrants an extension of the authorized inpatient days, the hospital must seek an authorization for additional inpatient days.

Major Medical/Accidental Injury CoverageThere is no special treatment for major medical or accidental injury categories.Medicaid will conditionally subrogate claims when there is liability insurance to cover a persons injuries. Subrogation is the assumption of an obligation for which another party is primarily liable.

Major Medical/Accidental Injury CoverageBecause Medicaid eligibility is determined by income, patients can be eligible one month and not the next. Check eligibility status on each visit. New work requirements may change this, as beneficiaries may continue coverage for a specific time even if their income exceeds the state eligibility levels. Prior authorization is required for many procedures and most nonemergency hospitalizations.Consult the current Medicaid handbook for a listing of the procedures that must have prior authorization.

Major Medical/Accidental Injury CoverageCards may be issued for the Unborn child of . . . These cards are good only for services that promote the life and good health of the unborn child.Because other health and liability programs are primary to Medicaid, the remittance advice from the primary coverage must be attached to the Medicaid claim.A combined Medicare-Medicaid (Medi-Medi) claim should be filed by the Medicaid deadline on the CMS-1500 claim.

BLOCKINSTRUCTIONS1Enter an X in the Medicaid box.1aEnter the Medicare identification number as it appears on the patients Medicaid card. Do not enter hyphens or spaces in the number.2Enter the patients last name, first name, and middle initial (separated by commas) (e.g., DOE, JOHN, J).3Enter the patients birth date as MM DD YYYY (with spaces). Enter an X in the appropriate box to indicate the patients gender. If the patients gender is unknown, leave blank.4Leave blank. 5Enter the patients mailing address and telephone number. Enter the street address on line 1, enter the city and state on line 2, and enter the 5- or 9-digit zip code and phone number on line 3.

BLOCKINSTRUCTIONS6-8Leave blank.99dLeave blank. Blocks 9 and 9a9d are completed if the patient has additional insurance coverage, such as commercial insurance10acEnter an X in the NO boxes. (If an X is entered in the YES box for auto accident, enter the 2-character state abbreviation of the patients residence.)10dLeave blank. For Medicaid managed care programs, enter an E for emergency care or U for urgency care (if instructed to do so by the administrative contractor.)11-16Leave blank.

BLOCKINSTRUCTIONS17Enter the first name, middle initial (if known), last name, and credentials of the professional who referred or ordered healthcare service(s) or supply(s) reported on the claim. Do not enter any punctuation. Otherwise, leave blank.17aLeave blank.17bEnter the 10-digit national provider identifier (NPI) of the professional in Block 17. Otherwise, leave blank.18Enter the admission date and discharge date as MM DD YYYY (with spaces) if the patient received inpatient services (e.g., hospital, skilled nursing facility). Otherwise, leave blank. If the patient has not been discharged at the time the claim is completed, leave the discharge date blank.

BLOCKINSTRUCTIONS19Reserved for local use. Some Medicaid programs require entry of the Medicaid providers NPI, and others require entry of a description of unlisted procedure or service codes reported in Block 24E (If description does not fit, enter SEE ATTACHMENT, and attach documentation to the claim describing the unlisted procedures/services provided.)20Enter an X in the NO box if all laboratory procedures reported on the claim were performed in the providers office. Otherwise, enter an X in the YES box, enter the total amount charged by the outside laboratory in $ CHARGES, and enter the outside laboratorys name, mailing address, and NPI in Block 32. (Charges are entered without punctuation. For example, $1,100.00 is entered as 110000 below $ CHARGES.)21Enter the ICD code for up to four diagnoses or conditions treated or medically managed during the encounter. Lines 1, 2, 3, and 4 in Block 21 will relate to CPT/HCPCS service/procedure codes reported in Block 24E.

BLOCKINSTRUCTIONS22Enter the original claim reference number plus Medicaid resubmission code, if applicable to the claim. Otherwise, leave blank.23Enter the Medicaid preauthorization number, which was assigned by the payer, if applicable to the claim. Otherwise, leave blank.24AEnter the date the procedure or service was performed in the FROM column as MMDDYYYY (without spaces). Enter a date in the TO column if the procedure or service was performed on consecutive days during a range of dates. Then, enter the number of consecutive days in Block 24G.24BEnter the appropriate 2-digit Place of Service (POS) code to identify the location where the reported procedure or service was performed. (Refer to Appendix II for POS codes.)

BLOCKINSTRUCTIONS24CEnter E an E if the service was provided for a medical emergency, regardless of where it was provided. Otherwise, leave blank.24DEnter the CPT or HCPCS level II code and applicable required modifier(s) for procedures or services performed. Separate the CPT/HCPCS code and first modifier with one space. Separate additional modifiers with one space each. Up to four modifiers can be entered.24EEnter the diagnosis pointer number from Block 21 that relates to the procedure/service performed on the date of service.24FEnter the fee charged for each reported procedure or service. When multiple procedures or services are reported on the same line, enter the total fee charged. Do not enter commas, periods, or dollar signs. Do not enter negative amounts. Enter 00 in the cents area if the amount is a whole number.

BLOCKINSTRUCTIONS24GEnter the number of days or units for procedures or services reported in Block 24D. If just one procedureor service was reported in Block 24D, enter a 1 in Block 24G.24HEnter an E if the service was provided under the EPSDT program, or enter an F if the service was provided for family planning. Enter a B if the service can be categorized as both EPSDT and family planning. Otherwise, leave blank.24ILeave blank. The NPI abbreviation is preprinted on the CMS-1500 claim.

BLOCKINSTRUCTIONS24JEnter the 10-digit NPI for the: provider who performed the service if the provider is a member of a group practice. (Leave blank if the provider is a solo practitioner.) supervising provider if the service was provided incident to the service of a physician or nonphysician practitioner and the physician or practitioner who ordered the service did not supervise the provider. (Leave blank if the incident to service was performed under the supervision of the physician or nonphysician practitioner.) DMEPOS supplier or outside laboratory if the physician submits the claim for services provided by the DMEPOS supplier or outside laboratory. (Leave blank if the DMEPOS supplier or outside laboratory submits the claim.)

Otherwise, leave blank.

BLOCKINSTRUCTIONS25Enter the providers social security number (SSN) or employer identification number (EIN). Do not enter hyphens or spaces in the number. Enter an X in the appropriate box to indicate which number is reported.26Enter the patients account number as assigned by the provider.27Enter an X in the YES box to indicate that the provider agrees to accept assignment. Otherwise, enter an X in the NO box.28Enter the total charges for services and/or procedures reported in Block 24.29-30Leave blank.

BLOCKINSTRUCTIONS31Enter the providers name and credential (e.g., MARY SMITH MD) and the date the claim was completed as MMDDYYYY (without spaces). Do not enter any punctuation.32Enter the name and address where procedures or services were provided if at a location other than the patients home, such as a hospital, outside laboratory facility, physicians office, skilled nursing facility, or DMEPOS supplier. Otherwise, leave blank. Enter the name on line 1, the address on line 2, and the city, state and 5- or 9-digit zip code on line 3. For a 9-digit zip code, enter the hyphen.32aEnter the 10-digit NPI of the provider entered in Block 32.32bLeave blank.

BLOCKINSTRUCTIONS33Enter the providers billing name, address, and telephone number. Enter the phone number in the area next to the Block title. Do not enter parentheses for the area code. Enter the name on line 1, enter the address on line 2, and enter the city, state, and 5- or 9-digit zip code on line 3. For a 9-digit zip code, enter the hyphen.33aEnter the 10-digit NPI of the billing provider (e.g., solo practitioner) or group practice (e.g., clinic).33bLeave blank.

BLOCKINSTRUCTIONS4Enter the primary policyholders last name, first name, and middle initial (separated by commas).6Enter an X in the appropriate box to indicate the patients relationship to the primary policyholder. If the patient is an unmarried domestic partner, enter an X in the Other box.7Enter the primary policyholders mailing address and telephone number. Enter the street address on line 1, enter the city and state on line 2, and enter the 5- or 9-digit zip code and phone number on line 3.9Enter the primary policyholders last name, first name, and middle initial (if known) (separated by commas). If the primary policyholder is the patient, enter SAME.9aEnter the primary policyholders policy or group number. Do not enter hyphens or spaces in the number.

BLOCKINSTRUCTIONS9bEnter the primary policyholders birth date as MM DD YYYY (with spaces). Enter an X in the appropriate box to indicate the secondary or supplemental policyholders gender. If the primary policyholder is the patient, leave blank.9dEnter the name of the primary policyholders health insurance plan (e.g., commercial health insurance plan name or government program).10a-cEnter an X in the appropriate box.10dLeave blank.11Enter the rejection code provided by the payer if the patient has other third-party payer coverage and the submitted claim was rejected by that payer. Otherwise, leave blank.11dEnter an X in the YES box.

BLOCKINSTRUCTIONS28Enter the total charges for services and/or procedures reported in Block 24.29Enter the amount paid by the other payer. If the other payer denied the claim, enter 0 00.30Enter the total amount due (by subtracting the amount entered in Block 29 from the amount entered in Block 28). Do not report negative amounts or a credit due to the patient.

The infant of a Medicaid recipient is automatically eligible for Medicaid for the entire first year of life. Individual state Medicaid programs determine reimbursement procedures for services provided to newborns. When claims are submitted under the mothers Medicaid identification number, coverage is usually limited to the babys first 10 days of life Medicaid usually covers babies through the end of the month of their first birthday (e.g., baby born January 5 this year, is covered until January 31 next year). The baby must continuously live with its mother to be eligible for the full year, and the baby remains eligible for Medicaid even if changes in family size or income occur and the mother is no longer eligible for Medicaid.A mother/baby claim is submitted for services provided to a baby under the mothers Medicaid identification number.

BLOCKINSTRUCTIONS1aEnter the mothers Medicaid ID number as it appears on the patients Medicaid card. Do not enter hyphens or spaces in the number.2Enter the mothers last name followed by the word NEWBORN (separated by commas).EXAMPLE: VANDERMARK, NEWBORN3Enter the infants birth date as MM DD YYYY (with spaces). Enter an X to indicate the infants gender.4Enter the mothers name (separated by commas), followed by (MOM), as the responsible party.EXAMPLE: VANDERMARK, JOYCE (MOM)21Enter ICD secondary diagnosis codes in fields 2, 3, and/or 4, if applicable.

Each state selects a payer that administers its State Childrens Health InsuranceProgram (SCHIP) program, and the payer develops its own CMS-1500 claimsinstructions

BLOCKINSTRUCTIONS1Enter an X in the Other box.1aEnter the SCHIP identification number (assigned by the Health Plan) of the subscriber (person who holds the policy).19Leave blank. 22Leave blank. 29Enter the total amount the patient (or another payer) paid toward covered services only. If no payment was made, leave blank.30Enter the total amount due (by subtracting the amount entered in Block 29 from the amount entered inBlock 28). Do not report negative amounts or a credit due to the patient.

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