Checking a Medicaid Recipient's Eligibility

Approximately 225,000 Medicaid claims deny each month because the Medicaid recipient is not eligible. Providers should check eligibility by:

Reasons to check eligibility are:

  1. To determine the person's name as it appears on the enrollment file. The claim must be filed with the person's current file name.
  2. To check to see if the person is eligible on the date of service.
  3. The determine the person's medical eligibility (ME) code. Codes 55, 58, 59 and 80 have limited benefits. Codes 74, 75, 76 and 79 require a co-payment.
  4. To see if a person is Medicare eligible. The claim must be filed to Medicare first.
  5. The see if the person has commercial insurance in addition to Medicaid. The claim must be filed to commercial insurance first.
  6. To see if the person is enrolled in a MC+ managed health care plan. If so the claims must be submitted to the appropriate MC+ managed health care plan.
  7. To determine if the person is locked in to another provider(s). If so the person must receive services from that provider unless a lock-in referral (PI - 118) is submitted from the lock - in provider.