When billing for a Medicaid member, please remember to check the Medicaid website of the state where the member resides for information on Medicaid billing requirements.

Providers should always include their National Provider Identifier (NPI) on Medicaid claims, unless the provider is considered atypical. Providers should also bill using National Drug Codes (NDC) on applicable claims. These data elements and other data elements that are important to submit, when applicable, on Medicaid claims are included below.

Applicable Medicaid claims submitted without these data elements will be denied

  • National Drug Code
  • Billing Provider Identifier (NPI)
  • Rendering Provider Identifier (NPI)

Applicable Medicaid claims submitted without these data elements may be pended or denied until the required information is received

  • Billing Provider (Second) Address Line
  • Billing Provider Middle Name or Initial
  • (Billing) Provider Taxonomy Code
  • (Rendering) Provider Taxonomy Code
  • (Service) Laboratory or Facility Postal Zone or Zip Code
  • (Ambulance) Transport Distance
  • (Service) Laboratory Facility Name
  • (Service) Laboratory or Facility State or Province Code
  • Value Code Amount
  • Value Code
  • Condition Code
  • Occurrence Codes and Date
  • Occurrence Span Codes and Dates
  • Referring Provider Identifier and Identification Code Qualifier
  • Ordering Provider Identifier and Identification Code Qualifier
  • Attending Provider NPI
  • Operating Physician NPI
  • Claim or Line Note Text
  • Certification Condition Applies Indicator and Condition Indicator (Early and Periodic screening diagnosis and treatment (EPSDT))
  • Service Facility Name and Location Information
  • Ambulance Transport Information
  • Patient Weight
  • Ambulance Transport Reason Code
  • Round Trip Purpose Description
  • Stretcher Purpose Description

 

Medicaid encounter data reporting

The data elements mentioned above need to be included on Medicaid claims, so that Blue Plans can comply with encounter data reporting requirements applicable in their respective state.