For Providers

Medicaid Reimbursement and Billing

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Out-of-State Medicaid Claims for Blue Cross and Blue Shield Association Plans
State Medicaid agencies contract with Blue Cross and/or Blue Shield Plans as Managed Care Organizations (MCOs) to provide comprehensive Medicaid benefits on a risk basis. Both federal and state regulations guide these relationships, but the eligible population, covered benefits and specific rules regarding each state’s Medicaid program may differ from state to state. Many state Medicaid programs require providers to enroll as Medicaid providers with that state’s Medicaid agency before payment can be issued. In other cases, a state Medicaid program will accept a provider’s Medicaid enrollment in the state where the provider practices.

Medicaid Reimbursement and Billing
Claims for all Horizon NJ Health Medicaid members should be submitted to your local BCBS Plan.

If you are contracted with Horizon NJ Health, your Medicaid rates will only apply for services provided to Horizon NJ Health members. These rates do not apply to services provided to out-of-state Medicaid members.

When you provide services to a Medicaid member from another state, you must accept that state’s Medicaid allowance (less any member responsibility such as copayments) as payment in full. Please note that billing out-of-state Medicaid members for any amounts in excess of the Medicaid-allowed amount for Medicaid-covered services is specifically prohibited by federal regulations (42 CFR 447.15).

Medicaid Billing Data Requirements
When billing for a Medicaid member, please remember to check the Medicaid website of the state where the member resides for information on Medicaid billing requirements.

Providers should always include their National Provider Identifier (NPI) on Medicaid claims, unless the provider is considered atypical. Providers should also bill using National Drug Codes (NDC) on applicable claims.

As a reminder, applicable Medicaid claims submitted without these data elements will be denied.

Provider Enrollment Requirements
As indicated above, some states require that out-of-state providers enroll in their state’s Medicaid program in order to be reimbursed. Some of these states may accept a provider’s Medicaid enrollment in the state where they practice to fulfill this requirement.

If you are required to enroll in another state’s Medicaid program, you should receive notification upon submitting an eligibility or benefit inquiry. You should enroll in that state’s Medicaid program before submitting the claim. If you submit a claim without enrolling, your Medicaid claims will be denied and you will receive information from your local BCBS plan regarding the Medicaid provider enrollment requirements. You will be required to enroll before the Medicaid claim can be processed and before you may receive reimbursement. Click here to view the provider enrollment requirements for states where BCBS Plans offer Medicaid products.