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Feb 1, 2019

Medicaid claims handling for out-of-state Medicaid members

Some providers expect to be reimbursed at the locally negotiated Blue rate or Medicaid rate they are accustomed to receiving in the state in which they practice. Medicaid claims are paid at the Medicaid allowed amount applicable in the member's home state. Providers are specifically prohibited by federal regulations from balance billing members. Please remember that billing out-of-state Medicaid members for the amount between the Medicaid-allowed amount and charges for Medicaid-covered services is specifically prohibited by Federal regulations (42 CFR 447.15).