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. 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, Chapter 12, Section 30.6.7

Medicaid claim resubmissions

Prior to Jan. 7, 2019, Providers were allowed to resubmit claims subject to a third-party liability (TPL) investigation only after Priority Health had received no response from the patient for 180 days. This was called the "180-day rule." On or after the 180th day after the claim denial, the Provider could resubmit the Medicaid patient claim or verbally request that the claim be reprocessed for payment. The 180-day rule didn't apply to claims denied due to TPL for the situations listed below:

  • Coordination of Benefits
  • Motor vehicle accidents
  • Workers Comp
  • School-related injuries

As of Jan. 7, 2019, Priority Health made changes to eliminate the 180 day rule. When Providers 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.

Any open claims previously denied by Priority Health for the Medicaid "180-day rule" may be resubmitted at your convenience for payment consideration.

1450 - Facility claims

  • Submit a corrected claim with the appropriate bill type, changing the frequency (third digit of the bill type) to reflect the change.
  • Priority Health will adjust the original claim, denying all service lines as charges billed in error.
  • Priority Health will then process the new claim for payment.

1500 - Professional claims

  • Submit a corrected claim with the appropriate billing code.
  • Priority Health will adjust the original claim, denying all service lines as charges billed in error.
  • Priority Health will then process the new claim for payment.

Effective January 1, 2018

All providers furnishing services to Michigan Medicaid beneficiaries, including providers participating in a managed care organization’s provider network, are required to be screened and obtain active enrollment in the Michigan Medicaid program. The purpose of this requirement is to strengthen the Medicaid program integrity by preventing provider fraud. 

Enrollment is completed through Community Health Automated Medicaid Processing System (CHAMPS)—the state’s web-based Medicaid enrollment and billing system. 

For more information about the provider enrollment requirement, view the MDHHS Medical Services Administration Provider Bulletin 17-48.

For information about the Provider Enrollment process, visit the MDHHS Medicaid Provider Enrollment page. Providers who have questions about the enrollment process or require assistance, may contact the MDHHS Provider Enrollment Help Desk at 800.292.2550.

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: