Medicaid billing

Medicaid participation

If you are not currently contracted with the Priority Health Medicaid product, Priority Health will reimburse you at the Michigan Medicaid fee schedule for covered services. Prior authorization may be required. Visit our authorizations page for instructions on how to request in-network and out of network authorizations. You may not balance-bill the member.

Go to the Michigan Medicaid fee schedule on the State of Michigan website.

New vs. established patients:

See the Medicare Claims Processing Manual,

Medicaid claim requirements

Medicaid is always the payer of last resort. When a Medicaid member is also covered by another payer, the Michigan Department of Health and Human Services (MDHHS) requires other payers be:

  • Billed first
  • Identified properly on the claim (see details below)

How to ensure your claims get paid

  1. Ensure that ALL applicable Other Insurances are listed on the claim. You can find this information in CHAMPS.
  2. Ensure that all required data elements are present for each Other Insurance listed on the claim.

Below in bold are the required data elements by loop. Elements identified with an * are situational and only required in certain circumstances.

Loop ID - 2320 - Other Subscriber Information

  • SBR - Other Subscriber Information*
  • CAS - Claim Level Adjustments*
  • AMT - Coordination of Benefits (COB) Payer Paid Amount*
  • AMT - Remaining Patient Liability*
  • AMT - Coordination of Benefits (COB) Total Non-Covered Amount*
  • OI - Other Insurance Coverage Information
    Claim Filing Indicator Code
    Yes/No Condition or Response Code
    Release of Information Code
  • MIA - Inpatient Adjudication Information*
  • MOA - Outpatient Adjudication Information*

Loop ID - 2330A - Other Subscriber Name

  • NM1 - Other Subscriber Name
  • N3 - Other Subscriber Address*
  • N4 - Other Subscriber City, State, ZIP Code
  • REF - Other Subscriber Secondary Identification*

Loop ID - 2330B - Other Payer Name

  • NM1 - Other Payer Name
    Entity Identifier Code
    Entity Type Qualifier
    Name Last or Organization Name
    Identification Code Qualifier
    Identification Code
  • N3 - Other Payer Address*
  • N4 - Other Payer City, State, ZIP Code
  • DTP - Claim Check or Remittance Date*
  • REF - Other Payer Secondary Identifier*
  • REF - Other Payer Prior Authorization Number*
  • REF - Other Payer Referral Number*
  • REF - Other Payer Claim Adjustment Indicator*
  • REF - Other Payer Claim Control Number*

There may be certain circumstances where Other Insurance may not be applicable but should still be listed. We're constantly reviewing our procedures and code lists and conferring with MDHHS about discrepancies. However, we must still require providers to list Other Insurance in these circumstances until further notice.

Medicaid edit 21007

In January 2021, MDHHS implemented Medicaid edit 21007 which rejects claims that don't meet the criteria listed above.

In November 2021, we instituted our own edit 21007 to front-end reject these claims as well. If the edit identifies another payer based on a membership list provided by the State, and that payer isn't identified on the claim with all the information the state needs, it rejects the claim with the following message:

"Beneficiary Has Other Insurance so providers Must Submit Other Insurance Payer Information on the Encounter"

If your claim is rejected due to edit 21007, follow the steps in How to ensure your claims get paid above before resubmitting a corrected claim.

Medicaid edit 5169

Pay close attention to the provider types you enter into the Attending, Referring and Ordering fields for Medicaid claims. Medicaid edit 5169 rejects claims for "non-approved provider types." Below are the allowed provider types per Medicaid policy:

Dates of service before Jan. 1, 2022

For dates of service before Jan. 1, 2022, the provider types below are allowed* in the Attending, Referring and Ordering fields:

  • Physicians (MD/DO)
  • Certain mid-level practitioners (Nurse practitioners, certified nurse midwives, physician assistants)
  • Podiatrists
  • Optometrists
  • Chiropractors
  • Dentists

*For Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs), the Attending field should be limited to Physician (MD/DO), Nurse Practitioner and Physician Assistant.

If you’re experiencing claim rejections for dates of service before Jan. 1, 2022, check the following:

  • All providers in the Attending, Referring and Ordering fields are allowable provider types as described above
  • Type 2 (Facility/Group) NPIs aren’t listed in the Attending, Referring or Ordering fields
  • The taxonomy code assigned to the provider in the National Plan & Provider Enumeration System (NPPES) is up-to-date and corresponds to an acceptable provider type as described above. For example: If the provider still has the specialty “Student” in NPPES, the claim will reject. Additionally, the taxonomy Specialist (174400000X) is not appropriate as it is not clinical.
  • The provider is registered in CHAMPS and has both an active business status and an active specialty

Dates of service on or after Jan. 1, 2022

For dates of service on or after Jan. 1, 2022, the allowable provider types vary by claim type:

  • Inpatient Attending: Physicians (MD/DO), Dentist, Certified Midwives and Podiatrists only
  • Outpatient Attending: Many different provider types are allowed. See the full list here.
  • Home Health, Hospice, Nursing Facility Attending: Physicians (MD/DO) only
  • FQHC, RHC, THC Attending: Refer to MSA 21-47 for a list of allowable provider types
  • DME Referring/Ordering: Physicians (MD/DO), Nurse Practitioners, Certified Nurse Midwives, Physician Assistants and Podiatrists only

If you’re experiencing claim rejections for dates of service on or after Jan. 1, 2022, check the following:

  • Type 2 (Facility/Group) NPIs aren’t listed in the Attending, Referring or Ordering fields
  • The taxonomy code assigned to the provider in the National Plan & Provider Enumeration System (NPPES) is up-to-date and corresponds to an acceptable provider type as described above. For example: If the provider still has the specialty “Student” in NPPES, the claim will reject. Additionally, the taxonomy Specialist (174400000X) is not appropriate as it is not clinical.
  • The provider is registered in CHAMPS and has both an active business status and an active specialty
  • For FQHC / RHC / THC, Limited Liability Social Workers aren’t allowed in the Attending field. Check the provider’s registration in CHAMPS to see if it needs to be updated.
  • Only Local Health Departments may list Physical Therapists, Occupational Therapists and behavioral health professionals in the Referring or Ordering fields on their claims. 

Medicaid 180-day rule

As of Jan. 7, 2019, the 180 day rule, which allowed providers to resubmit claims subject to third party liability (TPL) investigation, is no longer in effect. When you submit a Medicaid claim that requires TPL review, the claim will be pended, reviewed and paid if no other liable parties are identified. Claims will continue to deny if our review determines there's another primary payer, including motor vehicle, worker's compensation or school-related injuries.

Medicaid short stays

Effective Jan. 1, 2018, the Michigan Department of Health and Human Services (MDHHS) established a Short Hospital Stay reimbursement rate of $1,608 for certain outpatient and inpatient hospital stays.

The qualification criteria, as outlined by MDHHS, are listed below. If a stay doesn’t qualify for the Short Hospital Stay rate, we’ll reimburse it at the normal Medicaid rate. 

Outpatient hospital claims

An outpatient hospital claim will qualify if all the following criteria are met:

  • The primary diagnosis code billed on the outpatient claim is listed in the diagnosis table
  • The claim does not include a surgical revenue code (36x) billed on any line of the outpatient claim
  • The claim does not include cardiac catheterization lab revenue code 481
  • The claim includes observation revenue code 762
  • The claim must include discharge status codes 01, 06, 09, 21, 30, 50 or 51

Inpatient hospital claims

An inpatient hospital claim will qualify if all the following criteria are met:

  • The primary diagnosis code billed on the inpatient claim is listed in the diagnosis table
  • The claim does not include a surgical revenue code (36x) billed on any line of the inpatient claim
  • The claim has a date of discharge equal to or one day greater than the date of admission
  • The claim does not include cardiac catheterization lab revenue code 481
  • The claim must include discharge status codes 01, 06, 09, 21, 30, 50 or 51

Exclusions

Claims with the following conditions will not qualify:

  • Claims where Medicaid is the secondary payer. MDHHS will follow the rules of the primary payer, and MDHHS will be responsible for payment up to co-insurance and/or deductible
  • Claims for patients who leave the hospital Against Medical Advice
  • Claims for deceased patients
  • Claims that include primary diagnoses not listed in the diagnosis table, including claims for births and deliveries, for example

Diagnoses

To qualify, a claim must include one of the primary diagnosis codes listed here: 

Medicaid fee schedules vs Priority Health policy

Priority Health is a Medicaid Health Plan (MHP).

Per the Medicaid Provider Manual, MHPs must consistently comply with and apply all applicable published Medicaid coverage guidelines and limitation policies for claims processing. MHPs have the option to provide benefits for services over and above the defined criteria within the Medicaid Provider Manual and MDHHS. The Medicaid fee schedule is one of the factors utilized to determine if CPT and HCPCS codes are payable services.

  • If the CPT or HCPCS code isn’t on the Medicaid fee schedule, this service isn’t a payable service unless detailed within the Priority Health provider manual.
  • If the CPT or HCPCS code is listed within the Medicaid fee schedule, these services are payable if any medical criteria defined for these services is met.

A CPT or HCPCS code being listed in the Medicaid fee schedule doesn’t automatically deem the service payable. MHPs can govern medical criteria for coverage of services through utilization management activities. This means that MHPs can define prior authorization requirements, utilization management and review criteria that determine if service is payable for CPT and HCPCS codes on the Medicaid fee schedule.

Priority Health defines these criteria in our medical policies and/or payment policy details throughout this Provider Manual.

Appealing claim denials by indicating the CPT or HCPCS is on the Medicaid fee schedule is insufficient to overturn appeals. As noted above, coverage criteria may exist that affects the claim processing as a payable service.