|  | Healthcare Industry | Medicaid

Medicaid Provider Requirements

Hospitals, doctors' offices, elderly homes, and other medical care facilities must follow a specific set of rules in order to be reimbursed by the government via the Medicaid program. The federal government subsidizes a large part of Medicaid and the local and state governments cover the rest of the cost. While individual states may have set some additional rules, all the programs must fall within the guidelines of the federal protocols in order to be reimbursed.

  1. Enrolling

    • A provider must enroll in the Medicaid program. The states usually regulate this on an individual level, issuing providers Medicaid numbers to easily identify the organization. In order to obtain the number the provider must show licensure, certification, or accreditation. Providers must apply for an ID for each type of service provided, such as pharmacy services, emergency medical services and sales of durable medical equipment. Most states also require the provider to include W-9 forms in order to verify that staffing requirements are being met.

    Reimbursement

    • For reimbursement, providers need to submit the appropriate claim forms. Different services require more extensive forms, but a majority of the paperwork is available online. In order to save on individual billing costs because the coding rules for Medicaid are quite specific, providers can choose to contract billing out with an agency known as a "clearinghouse." These agencies specialize in Medicaid billing processes in order to ensure the provider receives the maximum amount of payment.

    Service Requirements

    • In order to be a Medicaid provider, clients cannot refuse service due to race, color, age or disability. A provider must advise a patient in advance if the patient is being accepted on a private-pay basis. If a particular need of the patient does not fall under the Medicaid scope of care, the patient can still be treated but will have to cover the bill. Outside services such as labs, imaging centers or pharmacies must accept the patients under the Medicaid provisions. These contracts should be in place before the patient's information is handed over to such providers. All covered services must be billed at the Medicaid rate; a provider cannot pick and choose which services to accept the lower rates for.

Medicaid - Related Articles