Medicaid Billing and Claims Management Medicaid billing for school-based providers is not designed with LEAs in mind, leading to claim denials, administrative inefficiencies, and lost reimbursement opportunities. Medicaid claims are often denied due to missing documentation, parental consent issues, or incorrect service coding. Automating these compliance steps ensures timely and successful reimbursement. The selected system shall: Automate claim submission to DHCFP, with built-in validation checks to reduce errors before submission. Ensure compliance with Medicaid billing and coding standards, including: ICD-10 for diagnostic coding. CPT for medical services, procedures, and tests. SNOMED CT for standardized clinical terminology. LOINC for laboratory and health measurements. National Drug Code (NDC) for medications administered in a school setting (e.g., vaccines, asthma medications). Validate claims across multiple compliance checkpoints, including: Active IEP/health services plan within allowable dates. Tracking of parental consent to treat (annual or in the event of changes in plan of care). Tracking of parental approval for release of information to Medicaid for billing (one time). Verification of provider credentials and service scope to ensure rendering provider is working within current scope of practice and licensure/certification; LEA shall continue to be listed as both furnishing and billing provider on billing claim form. Enable batch processing and bulk claim submission to maximize efficiency. Ensure all Medicaid-covered services are documented in an audit-ready format. Allow for real-time claims tracking features, including status monitoring and proactive resolution mechanisms. Enable integration with the Medicaid Management Information System (MMIS) for seamless data exchange and reporting (DDI Phase).
