CurrentHighmark DelawarePolicy N/A

Medicaid provider payment and recipient billing criteria

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.

Policy Summary

PayerHighmark Delaware

PolicyMedicaid provider payment and recipient billing criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must accept State Medicaid payment as payment in full (plus any required deductible, coinsurance, or copayment).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

prohibitionPayment to factors is prohibited

accept payment in fullProviders must accept State payment as payment in full (plus required cost sharing)

up to 3xPayment reduction penalty up to three times the over-collected amount

third-party ruleProviders limited in collecting from individuals when third-party liability exists

direct payments allowed

Policy Summary

PayerHighmark Delaware

PolicyMedicaid provider payment and recipient billing criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must accept State Medicaid payment as payment in full (plus any required deductible, coinsurance, or copayment).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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.

Operational note: Providers must comply with the State plan provisions above; prohibited payment practices (payment to factors or over-collection) expose providers to payment reductions and other sanctions as authorized by the Medicaid agency.

Enforcement may include reduction of payments up to three times the over-collected amount.

Coding and penalty summary

Not code-specificmixed

No codes listed

inv-03: Penalty multiplier

Penalty multiplierMedicaid agency may reduce payments to the provider and impose a reduction up to three times the amount the provider sought to collect in violation of §447.20(a).

Scope of penaltyApplies when a provider seeks to collect from an individual (or any financially responsible relative or representative) an amount exceeding the limits in §447.20(a).

Agency discretionReduction is in addition to any other sanction available to the Medicaid agency under §447.21(a).

Provider billing and collection restrictions

Billing Rule

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

inv-05: Definition — factor

TermFactor

DefinitionAn entity through which provider payments are made; payments for services furnished to a recipient may not be made to or through a factor, either directly or by power of attorney.

Prohibition citationSee prohibition of payment to factors in §447. (source language: payment may not be made to or through a factor).

inv-06: Definition — payment in full

TermPayment in full

DefinitionProviders must accept, as payment in full, the amounts paid by the Medicaid agency plus any deductible, coinsurance, or copayment required by the plan.