Medicaid provider payment and recipient billing criteria
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Governs limits on provider billing and payment acceptance under a State Medicaid plan, including prohibition on factoring payments, acceptance of agency payment as payment in full, provider restrictions when third-party liability exists, penalties for over-collection, and rules for direct payments to recipients for physician/dentist services. Affects Medicaid agencies, providers, and recipients.
No material clinical or coverage changes in this revision.
State plan provider payment and recipient billing criteria
State plan provider payment and recipient billing rules
Covered when the State plan includes the following provisions governing provider payment acceptance and recipient billing:
ALL of the following
ALL of the following
- Payment for any service furnished to a recipient by a provider may not be made to or through a factor, either directly or by power of attorney.
ALL of the following
- Providers must accept, as payment in full, the amounts paid by the Medicaid agency plus any deductible, coinsurance or copayment required by the plan.
- Providers may not deny services to an eligible individual because of the individual's inability to pay the required cost sharing, though inability to pay does not eliminate the individual's liability for the cost sharing charge.
ALL of the following
- If the total established liability of third parties for the service is equal to or greater than the amount payable under the State plan (including applicable cost sharing), the provider may not seek to collect any payment from the individual or any financially responsible relative or representative.
- If established third-party liability is less than the amount payable under the State plan (including applicable cost sharing), the provider may collect only the lesser of: (i) any cost-sharing amount imposed on the individual; or (ii) the difference between the amount payable under the State plan and the total established third-party liability.
- A provider may not refuse to furnish services to an eligible individual on account of a third party's potential liability for the services.
ALL of the following
- If a provider seeks to collect from an individual an amount that exceeds the amounts permitted under the third-party liability rules, the Medicaid agency may reduce any payment otherwise due to the provider in addition to any other sanction.
- The reduction may be equal to up to three times the amount that the provider sought to collect in violation.up to 3x
ALL of the following
- States may make direct payments to recipients for physicians' or dentists' services; if a State does so, the State plan must provide for direct payments and specify the conditions under which payments are made.
Enforcement may include reduction of payments up to three times the over-collected amount.
Coding and penalty summary
| No codes listed |
Provider billing and collection restrictions
Provider billing: accept State payment as payment in full; do not bill through factors
Providers must accept amounts paid by the Medicaid agency plus any deductible, coinsurance, or copayment required by the plan as payment in full; they may not seek payment through a factor. When a third party is liable, providers may not collect from the individual any amount if the third-party liability equals or exceeds the State payment, and if third-party liability is less than the State payment, providers may collect only the lesser of applicable cost-sharing or the difference between State payment and third-party liability. If a provider collects more than permitted, the Medicaid agency may reduce payments to the provider and impose a reduction up to three times the over-collected amount.
- Providers must accept State payment as payment in full (plus any deductible, coinsurance or copayment).
- Payment for services may not be made to or through a factor (directly or by power of attorney).
- If established third-party liability >= State payment, providers may not collect from the individual; if third-party liability < State payment, providers may collect only the lesser of cost-sharing or the difference between State payment and third-party liability.
- If a provider seeks to collect more than permitted, the agency may reduce payments and impose a reduction up to three times the amount sought to be collected in violation.
Key definitions
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