Medicaid

Timely Filing Limits

Timely filing limits vary by state — typically 90 to 365 days from the date of service. Check your specific state Medicaid program and any MCO deadlines, which may differ from the state fee-for-service limit.

Appeal Time Limits

State Fair Hearing deadlines vary — typically 90 to 120 days from the denial notice. MCO-level appeals typically have shorter deadlines (30-60 days). Always check the denial notice for the exact deadline and appeal instructions for your state.

Corrected Claim Process

Corrected claim submission varies by state. Most states accept Frequency Code 7 on the CMS-1500 or 837 transaction. Some states require paper submission with a corrected claim form. Check your state Medicaid manual for specific instructions.

Prior Authorization

Prior authorization requirements vary significantly by state and MCO. Common services requiring prior auth include: durable medical equipment, imaging (MRI/CT/PET), behavioral health services, specialty therapies, and certain prescription medications. Check the specific state Medicaid fee schedule and MCO policy.

Referral Requirements

Many Medicaid programs require referrals for specialist visits, especially under managed care. Check the specific state and MCO requirements.

Eligibility Verification

Verify Medicaid eligibility through your state's Medicaid portal, the 270/271 eligibility transaction, or the state's IVR system. Eligibility can change monthly, so verify before each visit. Check for MCO assignment and any spend-down or share-of-cost requirements.

Claim Status Resources

Check claim status through your state Medicaid portal or MCO portal. Most states provide online claim status lookup and also accept 277 claim status transactions.

Coordination of Benefits

Medicaid is always the payer of last resort. If the patient has any other coverage (Medicare, commercial, TRICARE), that coverage must be billed first. Report other insurance on the claim and include Explanation of Benefits (EOB) from the primary payer when billing Medicaid.

Modifier Policies

Medicaid modifier policies follow NCCI with state-specific additions. Common Medicaid-specific considerations: TH (pregnancy), U1-U5 (informal codes for specific state programs), and state-specific modifiers for family planning and other services. Check your state Medicaid manual.

Telehealth Policies

Medicaid telehealth coverage varies by state. Many states expanded telehealth coverage during and after the COVID-19 PHE. Check your state's current telehealth policy for covered services, originating site requirements, and modifier requirements.

Medical Necessity Resources

Medical necessity is determined by each state. Check the state Medicaid manual, fee schedule, and any MCO medical necessity criteria. Documentation must support the service provided and its medical necessity per state guidelines.

NDC Billing Requirements

NDC requirements vary by state. Many state Medicaid programs require NDCs for physician-administered drugs. Check your state Medicaid pharmacy manual for formatting requirements and covered drug codes.

Common Denial Reasons

• CO-24 (charges covered under capitation/managed care plan)
• CO-27 (expenses incurred after coverage terminated)
• CO-31 (patient not identified as member)
• CO-50 (not medically necessary)
• CO-109 (claim not covered by this payer — check COB)
• CO-197 (authorization/notification absent).

Common Rejection Reasons

• Eligibility not active on date of service
• missing MCO referral
• missing prior authorization number
• invalid provider enrollment
• invalid NPI
• member ID format errors.

Documentation Requirements

Documentation requirements vary by state but generally include: medical necessity, date of service, provider signature, treatment provided, and patient response to treatment. Check your state Medicaid provider manual for specific requirements.

Electronic Claim Submission

Submit claims electronically via the 837 transaction to your state Medicaid program or MCO. Most states accept direct electronic submission or clearinghouse submission. Use the 837P for professional and 837I for institutional claims.

Provider Portal

Each state maintains its own Medicaid provider portal. Common vendors include DXC Technology, Gainwell Technologies, Molina Medicaid Solutions, and Conduent. MCO portals are separate from the state fee-for-service portal.

Provider Manual

Each state publishes a Medicaid provider manual. Check your state's Medicaid agency website. CMS also publishes the Medicaid program general guidance. The State Medicaid Manual (SMM) is available on CMS.gov.

Contact Information

Contact your state Medicaid agency or MCO provider relations department. State contact information is available on the state Medicaid website. CMS Medicaid contact information is on medicaid.gov.

Educational Notes

Medicaid is the most varied payer — always verify the specific state and MCO requirements. State Medicaid policies change frequently, especially regarding covered services, telehealth, and prior authorization. Bookmark your state's Medicaid provider manual and check for updates regularly.

Related Academy Courses

• Government Payer Mastery
• Denial Codes Decoded
• Prior Authorization & Medical Necessity Mastery
• Insurance Verification & Eligibility Mastery.

Related Knowledge Center Articles

• Medicaid Eligibility Verification
• Coordination of Benefits: Medicaid as Payer of Last Resort
• Prior Authorization Resource Center
• State Medicaid Programs Directory
• Telehealth Policy Updates.

Related AI Investigation Topics

CO-197 authorization/notification investigations, CO-24 benefit plan coverage disputes, CO-27 coverage termination disputes, CO-31 member identification investigations, Medicaid prior authorization denials with state-specific requirements.