How to Run Medicaid Eligibility Reports

Overview: Medicaid eligibility verification involves sending requests to NC Tracks to confirm a patient’s eligibility for a specific month. This is crucial for billing since eligibility can change monthly, impacting patient coverage.

Exclusions: Patients excluded from the report include those without a valid Medicaid payer ID on the Referral, missing gender, discharged before the report's start date, or with a canceled/referral status (unless "Include Referred but Not Admitted" is checked).

Pre-Verification Reports: Before creating the eligibility file, verify patient information using Reports 07.01 and 07.02 in Barnestorm Office under Reports > Audit.

Note: From the Transmit to NC Medicaid screen, always wait for the connection to show as established before clicking on anything and then select the Eligibility bullet.

Creating Medicaid Eligibility Verifications

1. Go to: Billing > Other > Create Eligibility Verifications.
2. Eligibility Dates: Default is the current month; adjust as needed. Patients discharged before or admitted after the date range are excluded.
3. Select Payer: Choose a Medicaid payer from the left panel.
4. Make Selections: Configure options on the right panel. Only one NPI can be used at a time.
• Check "Include all payers with..." to include all relevant payers.
• Uncheck “Include all payers with this Receiver Id” and “Include all payers with this Sender Id.”
5. Optional: Check "Include Referred but Not Admitted" or "Select All PCS" for specific patient groups.
6. Create File: Click "Create Eligibility File."
7. Print Report (optional): Print the Patients in Eligibility Batch report.
8. Repeat: Click anywhere on the screen to return to the main screen and repeat the steps for additional NPIs or payers.

Sending the Eligibility Transmission (File Type 270)

1. Go to: Billing > HIPAA Transactions > Transmit to NC Medicaid.
2. Select Files: On the left side, click the “Eligibility” bullet and select the 270 files (marked with a red arrow) to send.
3. Send Files: Click the "Send" button.
4. Wait for Response: It may take several hours to receive a response (see next step.)

Receiving Medicaid’s Response (not the eligibility report)

1. Continue: From Billing > HIPAA Transactions > Transmit to NC Medicaid.
2. Identify Response File: From the right side, look for a small file (e.g., 301) with a time/date stamp after your transmission.
3. Receive File: Select the file and click "Receive."
4. Confirmation: If successful, the 270 file on the left side will show a green checkmark, indicating NC Tracks received it.

Receiving and Printing the Verification Report (File Type271)

1. Go to: Billing > HIPAA Transactions > Transmit to NC Medicaid.
2. Receive Verification Report: Select the larger file from the right panel and click "Receive."
3. Print Report: Go to Billing > Other > Print Eligibility Verifications. Select the file from the right pane and print.

Understanding the Report

Program CAPDA or MCAID with a Status of OK means the patient has direct Medicaid.

Program MQBB with status of MQ means that Medicaid pays the Medicare Part B premium, and that services are not covered by Medicaid. CAP services cannot be billed to Medicaid.

*** NOT NC Medicaid Direct *** means the patient has an active account with the provider listed beside PHP, ex. United HealthCare or Trillium Health Resources.

Example of Medicaid Direct, not PHP/LME

Example of PHP/LME, not Medicaid Direct

** Inactive means that the patient does not have Medicaid for the selected month of the report.

72 Invalid/Missing Subscriber/Insured ID means that the Medicaid HIC# was not found, or the name or birth date does not match the records.

Pvt Insurance will let you know if the patient also has a private insurance policy.  Nothing else needs done unless the patient is being billed for skilled services, which may require a denial from the insurance first. 

For Medicare Missing D9 - NC Only, this report checks for Medicare conditions requiring special billing codes. If the patient has Medicare but is not homebound, then you have to bill Medicaid and use the D9condition code on the claim to indicate that Medicare is not the primary payer for that service.