What Is Medicaid Billing?
Medicaid billing submits claims either to a state Medicaid agency through its MMIS portal or to the Medicaid managed care plan the patient is enrolled in — and managed care is now the larger share: CMS reports that 84.8% of Medicaid enrollees were in some form of managed care as of 1 July 2024. Compliance turns on the state's own filing deadline, prior-authorization rules set per plan, EVV for personal care and home health services that require an in-home visit, and HCPCS T-code adoption that varies state by state.
- Every state, DC and the U.S. territories run a separate program — own MMIS, own fee schedule, own filing deadline
- 84.8% of Medicaid enrollees were in some form of managed care as of 1 July 2024 (CMS)
- EVV required for personal care and home health services that need an in-home visit (Cures Act section 12006(a))
- HCPCS T-codes (T1015, T1019, T2025) and state plan codes drive billing Medicare does not recognize
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Medicaid is not one payer. Every state, the District of Columbia and the U.S. territories run their own program under Title XIX of the Social Security Act, each with its own Medicaid Management Information System (MMIS), its own fee schedule, its own filing deadline and its own panel of contracted Managed Care Organizations (MCOs). The deadlines are the part that costs money first: Texas Medicaid requires the claim at TMHP within 95 days of the date of service for in-state providers, while Medi-Cal runs a six-month billing limit from the month of service — so a practice applying one filing calendar across state lines writes off claims that were payable. Managed care is now the default rather than the exception: CMS reported that as of 1 July 2024, of approximately 87 million people enrolled in Medicaid, over 73 million (84.8%) received some or all of their care through a managed care plan, with 67.9 million in comprehensive MCOs. Electronic Visit Verification (EVV) is federally required for Medicaid personal care and home health services that need an in-home visit, and each state's HCPCS T-code adoption (T1015 encounter rate, T1019 personal care, T2025 waiver service) creates code-set differences that cause clean-claim drift the moment a practice crosses a state line. This page covers how Medicaid billing actually plays out across MMIS submission, MCO contracting, EVV compliance, prior-authorization gates, and the prompt-pay rules state Departments of Insurance enforce against MCO carriers.
Medicaid at a Glance
People enrolled in Medicaid (2024)
~87 million
Source: CMS 2024 Medicaid Managed Care Enrollment Report, verified 2026-10-02
Enrollees in any managed care (7/1/2024)
over 73 million (84.8%)
Source: CMS 2024 Medicaid Managed Care Enrollment Report, verified 2026-10-02
Enrollees in comprehensive MCOs (7/1/2024)
67.9 million
Source: CMS 2024 Medicaid Managed Care Enrollment Report, verified 2026-10-02
Dual eligibles in comprehensive MCOs (7/1/2024)
4.3 million (39.8% of duals)
Source: CMS 2024 Medicaid Managed Care Enrollment Report, verified 2026-10-02
EVV required for personal care services
January 1, 2020
Source: Medicaid.gov EVV guidance, Cures Act §12006(a), verified 2026-09-17
EVV required for home health services
January 1, 2023
Source: Medicaid.gov EVV guidance, Cures Act §12006(a), verified 2026-09-17
Billing Challenges Specific to Medicaid
State-by-state MMIS submission and timely-filing variation
Every state runs its own Medicaid Management Information System with distinct EDI specifications, claim-form requirements and filing deadlines, and federal law sets only the outer limit: 42 CFR 447.45(d)(1) requires the state agency to make providers file within 12 months of the date of service, which leaves states free to be far stricter. Texas Medicaid requires the claim at TMHP within 95 days of each date of service for in-state providers, and hospital inpatient claims within 95 days of the discharge date. Medi-Cal runs a six-month billing limit from the month of service, with defined late-billing exceptions and a hard denial past the twelfth month. A practice that applies one filing calendar to every state misses the tightest one and writes off claims that were payable. Deadlines verified against TMHP and the Medi-Cal provider bulletins on 17 September 2026; every other state has to be checked in its own manual, not inferred from these.
Medicaid Managed Care Organization (MCO) fragmentation
CMS reported 84.8% of Medicaid enrollees in some form of managed care as of 1 July 2024, and 67.9 million in comprehensive MCOs — plans contracted and capitated by the state Medicaid agency. A patient with Medicaid coverage may actually be assigned to Centene/Sunshine Health, Humana Healthy Horizons, Molina Healthcare, UnitedHealthcare Community Plan, or Anthem Healthy Blue depending on the state and county — each with its own provider portal, prior-authorization policy, fee schedule, and claim-submission rules. The MCO's contract with the state sets the prompt-pay standard, but day-to-day claim adjudication runs through the MCO's payer system, not the state MMIS.
Electronic Visit Verification (EVV) compliance for personal care and home health
Section 12006(a) of the 21st Century Cures Act requires states to implement EVV for Medicaid personal care services and home health services that require an in-home visit by a provider — by January 1, 2020 for personal care and January 1, 2023 for home health. EVV captures six data elements at the point of service: type of service performed, individual receiving the service, date of service, location of service, individual providing the service, and the time the service begins and ends. The federal lever is financial and falls on the state, not the claim: a state that has not implemented EVV faces incremental FMAP reductions of up to 1% unless it has both made a good-faith effort and hit unavoidable delays. The claim-level consequence is set by the state — some run a state-mandated aggregator, others allow an open-vendor model — so whether an unmatched visit pends, denies or simply fails to post depends on the state's own edits, and that is the rule to read before the first claim goes out. Dates and scope read from the Medicaid.gov EVV guidance on 17 September 2026.
Prior authorization and the Medicaid 'soft denial' problem
State Medicaid agencies and MCOs maintain prior-authorization lists for most non-emergent procedures, durable medical equipment, behavioral health units beyond an annual cap, and any out-of-network referral. Unlike commercial denials that hit on a hard EX/CO code, Medicaid PA failures often produce pended or denied-for-additional-information statuses that require provider follow-through to convert to payment, and the federal prompt-pay standard does not help while a claim sits there. Under 42 CFR 447.45(d)(2) and (d)(3) the state Medicaid agency must pay 90% of clean claims from practitioners in individual or group practice, or in shared health facilities, within 30 days of receipt and 99% within 90 days. The definition does the work: a claim that cannot be processed without more information from the provider or a third party is not a clean claim at all under 447.45(b), so a pended claim never enters the 30-day count. That is why aged Medicaid A/R balloons in practices without a dedicated pend-resolution queue.
Dual-eligible (Medicare-Medicaid) coordination and crossover
Dual-eligible patients carry both Medicare and Medicaid; CMS counted 4.3 million of them enrolled in comprehensive Medicaid MCOs as of 1 July 2024, which it put at 39.8% of all dually eligible individuals. Many are Qualified Medicare Beneficiaries (QMBs) for whom state Medicaid pays Medicare cost-sharing. Federal law prohibits balance-billing QMB patients (§1902(n)(3)(B) of the Social Security Act). Medicare automatically crosses these claims to state Medicaid through the COBA process, but Medicaid will only pay up to the lesser of the Medicaid fee schedule or the remaining cost-share — meaning crossovers frequently pay zero because Medicare already exceeded the Medicaid allowable. Practices must identify QMB status at eligibility (the 271 response carries the indicator) and route the patient correctly through the Medicaid secondary workflow without billing the patient.
What We Handle for Medicaid
Multi-state MMIS submission with per-state timely-filing tracking
Direct submission to state MMIS portals (TMHP, eMedNY, Medi-Cal, AHCA and others) with a per-state filing calendar built into the workflow — each state's deadline taken from that state's current manual rather than assumed from a neighbor, and claims worked against the tightest clock that applies to them.
Medicaid MCO contracting and per-plan claim routing
Roster maintenance for Centene, Molina, UnitedHealthcare Community Plan, Humana Healthy Horizons, Anthem Healthy Blue, and regional MCOs. Each MCO's portal credentials, fee schedule, and PA policy maintained so claims route correctly on the patient's effective coverage as of date of service.
EVV compliance for personal care and home health
EVV system integration (Sandata, HHAeXchange, CareBridge, Tellus, or state-mandated aggregators) with visit-to-claim reconciliation so every billed unit has a matching verified visit. EDI 837P submission with EVV transaction ID reference to prevent the rejected-no-EVV-match denial.
Prior authorization and pend-resolution workflows
PA submission through MCO portals, response tracking, and dedicated pend-resolution queues that work pended Medicaid claims before they age past the prompt-pay threshold. Prior-auth requests filed with the clinical documentation and ICD-10 specificity each MCO's medical-policy library requires.
Dual-eligible crossover and QMB management
QMB status verification at intake, COBA crossover monitoring from Medicare to state Medicaid, and balance-billing prevention on dual-eligible accounts. Manual Medicaid secondary billing when COBA fails to auto-crossover within the expected window.
State-specific T-code and waiver-program billing
T1015 encounter-rate billing for FQHCs and RHCs, T1019 personal care, T2025 waiver service, T1017 case management, and the state-plan code variants each Medicaid program publishes. Waiver-program billing under 1915(c) HCBS waivers with the program-specific modifier and unit-rate logic.
Codes Frequently Billed to Medicaid
| Code | Description |
|---|---|
| T1015 | Clinic visit/encounter, all-inclusive (FQHC/RHC encounter rate) |
| T1019 | Personal care services, per 15 minutes (Medicaid HCBS) |
| T1017 | Targeted case management, each 15 minutes |
| T2025 | Waiver service, not otherwise specified |
| T1023 | Program intake assessment |
| H0031 | Mental health assessment by non-physician |
| H0036 | Community psychiatric supportive treatment, face-to-face |
| H2014 | Skills training and development, per 15 minutes |
| S5125 | Attendant care services, per 15 minutes |
| 99381 | Initial preventive visit, infant under 1 year (EPSDT/Medicaid covered) |
Last updated: 2026-10-02
Common Questions
Common questions about medicaid billing services.
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Request ReviewHow does Medicaid timely filing work across states?
Medicaid filing deadlines are set by each state Medicaid agency, not federally, and they vary widely. Texas Medicaid requires the claim at TMHP within 95 days of each date of service for in-state providers (95 days from the discharge date for hospital inpatient claims). Medi-Cal applies a six-month billing limit from the month of service under Welfare and Institutions Code 14115, with defined exceptions for late billing and denial past the twelfth month. The federal rule runs the other way from how it is usually described: 42 CFR 447.45(d)(1) requires the state Medicaid agency to make providers submit claims no later than 12 months from the date of service. That is a ceiling on the state's own window, not a floor under it, which is exactly why a state can — and Texas does — require the claim in 95 days. MCO contracts can narrow the deadline further still, so a managed-care claim may be due before the underlying state Medicaid program would require it. Deadlines read from TMHP and the Medi-Cal provider bulletins, and the regulation from the eCFR, on 17 September 2026.
What is Electronic Visit Verification and who does it apply to?
Electronic Visit Verification is required by section 12006(a) of the 21st Century Cures Act for Medicaid personal care services and home health services that require an in-home visit by a provider — which is the scope line practices miss, because a service delivered outside the home is outside the mandate. It applies to personal care furnished under sections 1905(a)(24), 1915(c), 1915(i), 1915(j), 1915(k) and section 1115, and to home health under 1905(a)(7) or a waiver. EVV captures six data elements: type of service, individual receiving it, date, location, individual providing it, and start and end times. States had to require it by January 1, 2020 for personal care and January 1, 2023 for home health, and a state that does not faces incremental FMAP reductions of up to 1% absent a good-faith effort and unavoidable delays. States run either a state-managed system or an open-vendor model, and each state decides what happens to a visit with no match — so the state's own edit, not the federal rule, tells you whether the claim pends or denies. Scope and dates read at Medicaid.gov on 17 September 2026.
Why are Medicaid Managed Care claims different from straight Medicaid?
CMS reported that 84.8% of Medicaid enrollees were in some form of managed care as of 1 July 2024, with 67.9 million in comprehensive MCOs contracted by their state Medicaid agency. The state pays the MCO a per-member-per-month capitation, and the MCO becomes the financial risk-bearer for that beneficiary's care — including claim adjudication. Practices submit MCO claims to the MCO's payer system (Centene, Molina, UnitedHealthcare Community Plan, Humana, Anthem) rather than the state MMIS, using the MCO's payer ID, fee schedule, prior-authorization rules, and provider portal. The state Medicaid agency only adjudicates claims for fee-for-service Medicaid beneficiaries who are not enrolled in an MCO.
What is the federal prompt-pay rule for Medicaid?
There are two federal rules, and they are not interchangeable. 42 CFR 447.45(d) binds the state Medicaid agency: 90% of clean claims from practitioners in individual or group practice, or in shared health facilities, paid within 30 days of receipt, 99% within 90 days, and all other claims within 12 months. 42 CFR 447.46 carries that 30-day and 90-day standard into MCO contracts under section 1932(f) of the Act — but with an exception the contract can use: an MCO and its providers may agree to an alternative payment schedule, which must then be stipulated in the contract. So the answer to when an MCO owes you payment is in your contract first and the regulation second. A pended claim is outside both counts, because a claim that cannot be processed without more information is not a clean claim under 447.45(b). Many states also layer their own prompt-pay statutes and interest provisions on top. Regulation text read at the eCFR on 17 September 2026.
Why are HCPCS T-codes used so heavily in Medicaid?
HCPCS Level II T-codes exist for state Medicaid programs, and Medicare does not pay them: every T code in the CMS October 2026 Alpha-Numeric HCPCS file carries a Medicare coverage status of not payable or non-covered (checked 17 September 2026). Commercial payers recognize them only where a contract says so. State Medicaid programs use T-codes to bill services that fall outside the standard CPT code set — encounter-rate billing for FQHCs and RHCs (T1015), personal care services (T1019), waiver services (T2025), targeted case management (T1017), and program intake (T1023). State-specific behavioral health programs frequently use H-codes (H0031, H0036, H2014) alongside T-codes. The fee schedule and unit definitions for each T-code are set by the individual state Medicaid plan, so the same T-code can pay differently across state lines.
How do dual-eligible (Medicare and Medicaid) claims work?
Dual-eligible patients have both Medicare and Medicaid coverage; CMS counted 4.3 million of them in comprehensive Medicaid MCOs as of 1 July 2024, 39.8% of all dually eligible individuals. Many are Qualified Medicare Beneficiaries (QMBs) for whom state Medicaid pays the Medicare cost-sharing (deductibles, coinsurance, copays) on the patient's behalf. Medicare adjudicates the claim first, then automatically crosses the claim to state Medicaid through the Coordination of Benefits Agreement (COBA) process. State Medicaid pays the lesser of the remaining Medicare cost-share or the Medicaid fee schedule allowed amount — which is often zero, because Medicare commonly pays above the Medicaid allowable. Federal law prohibits balance-billing QMB patients for any Medicare cost-sharing under §1902(n)(3)(B) of the Social Security Act.
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