Medicaid pays last, so bill every other plan first

For clients with Medicaid, most traditional Medicare claims cross over to Medicaid automatically. Medicare Advantage balances need a claim from you.

Nate Peereboom
Co-founder, JotPsych

Your client carries Medicaid and an employer plan, and Medicaid sent your claim back unpaid. Medicaid pays only after the other plan pays or denies the claim.

1. Enter each of your client's plans in payment order. Medicaid goes last. The federal Medicaid handbook on coordination of benefits calls Medicaid the payer of last resort: it pays only when no other plan owes for the service.
2. Send the claim to the other plan first. Medicaid rejects your claim when another plan is likely to owe, and names that plan for you, the handbook says. Medicaid calls the rule cost avoidance.
3. Wait for the other plan to pay or deny, then bill Medicaid the balance. Send the other plan's payment information with your claim. Medicaid pays you up to its own rate. After a denial, bill Medicaid only when the other plan denied for a reason other than a filing error, such as a late claim.
4. Check Medicare's remittance before you send a Medicaid claim. For a client with traditional Medicare and Medicaid, most claims cross over to Medicaid after Medicare pays. Medicare's remittance then marks each claim that crossed over, per Medicare's claims manual. Medicare Advantage claims don't cross over. Send those balances to Medicaid yourself, with the Medicare Advantage plan's payment information.

Balances to check before you bill Medicaid

• Out-of-network denials, under Medicaid managed care. Medicaid managed care won't pay the balance when a commercial plan denies your claim only because you're outside its network, the handbook says. Confirm your network status before the first visit.
• Crossover claims past Medicare's 12-month filing limit. Medicaid has to pay a crossover claim only when Medicare got the claim within 12 months of the visit.