3 Understanding Medicaid vs. Medicare Advantage claims While many claims submission requirements are similar, there are key differences between Medicaid and Medicare Advantage (MA) that can affect how claims are processed and paid. Understanding these distinctions can help reduce delays and denials. Medicaid claims Medicaid benefits and coverage are governed by state and federal regulations, which may vary by program. Eligibility: Member eligibility may change month to month and should be verified on the date of service. Authorizations: Many services require prior authorization, and claims must align exactly with the approved services and units. Timely filing: Timely filing limits are strictly enforced and vary by program. Cost share: Most Medicaid members have little to no cost share; co-pays and deductibles are limited by state guidelines. Coordination of benefits: Medicaid is often the payer of last resort, which may require additional documentation. Medicare Advantage claims MA plans follow guidelines from the Centers for Medicare & Medicaid Services (CMS) and plan-specific policies. Eligibility: Eligibility is generally stable, but benefit plans may change annually. Authorizations: Prior authorization requirements are planspecific and must meet CMS coverage rules. Timely filing: Timely filing limits apply and are outlined in the Provider contract and plan policy. Cost share: Members may have co-pays, co-insurance, or deductibles, depending on their benefit plan. Risk adjustment: Accurate diagnosis coding is essential, as MA claims support CMS risk adjustment and member care planning. Tips for both programs ■Verify eligibility and benefits prior to service. ■Ensure that services billed match the authorization (when required). ■Submit clean claims with accurate coding and supporting information. ■Review evidence of benefits statements regularly, and address discrepancies promptly. We’re here to support you Our goal is to partner with you to ensure accurate, timely claims processing for both Medicaid and MA members. For detailed requirements, please refer to the Provider Manual or contact us. Special services for children of traveling farmworkers El Paso Health has special Medicaid services for the children of traveling farmworkers. The services include assistance with scheduling their upcoming Texas Health Steps exams, as well as vision, mental health, and transportation benefits for them. El Paso Health is also assisting members with community resources such as housing, food security, utility assistance, and child care assistance. If you have any questions or would like to receive more information about these services for children of traveling farmworkers or would like the program coordinator to provide an in-service to your staff, please call the Outreach Coordinator at 915-532‑3778, ext. 1075. stay informed
RkJQdWJsaXNoZXIy MjI2MTU5NA==