December 2005

What are the necessary requirements for obtaining Medicaid reimbursement?

There are three basic requirements for obtaining reimbursement from Medicaid for services provided to people who are covered by Medicaid, whether they are adults or children. These same basic requirements also apply to Medicare and private sector health insurance.

• The individual to whom the services are being directed must be Medicaid eligible/enrolled.
• The provider/practitioner must meet educational and licensure requirements set by the state in which the service is provided. In addition to licensure, the provider/practitioner must obtain a Medicaid provider number for billing purposes.
• The services must be covered under the Medicaid State Plan or be provided under the Early Periodic Screening, Diagnosis and Treatment (EPSDT) services program of Medicaid.

Provider/practitioners can include physicians, nurse practitioners, psychologists, acute care hospitals, long term care/nursing facilities, home health agencies, care management organizations as long as they meet the State’s licensure requirements. It is important to become knowledgeable about those requirements at the state level.

EPSDT allows for the provision of services, and therefore, payment of these services regardless of whether an individual Medicaid State Plan covers the services. However, the services must be recognized as potentially reimbursable but are optional under the Federal Medicaid regulations and guidelines. For example, physician service and inpatient hospital services are mandated and must be provided by every state. On the other hand, the rehabilitation option, “rehab option” is not required by the Federal statute but states may provide these services if they wish.