Mississippi Medicaid Provider Billing Handbook

Overview

The Mississippi Medicaid Provider Billing Handbook is the official guidance document for all healthcare providers who submit claims to the Mississippi Division of Medicaid. The handbook outlines the policies, procedures, and technical requirements needed to ensure accurate and timely reimbursement.

Key objectives of the handbook include:

• Standardizing claim preparation across all provider types.
• Ensuring compliance with federal and state regulations.
• Reducing claim denials and delays.
• Providing clear instructions for electronic and paper submissions.

Provider Eligibility & Enrollment

Before billing, a provider must be enrolled and approved by Mississippi Medicaid. The enrollment process involves:

1. Completing the Provider Enrollment Application (PEA).
2. Submitting required documentation (e.g., licenses, tax identification number, NPI).
3. Passing a background check and, when applicable, a site visit.

Eligibility is maintained by:

• Timely renewal of licensure.
• Maintaining a valid National Provider Identifier (NPI).
• Adhering to any specialtyspecific requirements (e.g., prior authorization for certain services).

Coding & Documentation Standards

Accurate coding is essential for claim acceptance. The handbook requires:

ICD10CM Diagnosis Codes

Use the most specific diagnosis code available. Unspecified codes increase the risk of denial.

CPT/HCPCS Procedure Codes

Report services with CPT codes and supplement with HCPCS modifiers when needed (e.g., modifier 25 for a significant, separate evaluation).

PlaceOfService (POS) Codes

POS must reflect the actual location of service (e.g., 11 for office, 21 for inpatient hospital).

All documentation must substantiate the codes reported, including:

• Patient identifiers and date of service.
• Chief complaint and history of present illness.
• Physical exam findings.
• Assessment, plan, and any ordered tests.

Claim Submission Process

Mississippi Medicaid requires electronic submission through the MI Medicaid Provider Portal (MIPortal) or a certified clearinghouse. Paper claims are accepted only in exceptional circumstances.

Electronic Data Interchange (EDI)

Use the HIPAAmandated 837P (professional) or 837I (institutional) transaction set. Required fields include:

• Subscriber ID and Medicaid ID.
• Provider NPI.
• Claim control number.
• Diagnosis and procedure codes.

Submission Timing

• Claims must be submitted within 90 days of the date of service.
• Retroactive claims older than 90 days are subject to a late filing review and may be denied.

Denial Management

If a claim is denied, the provider should:

1. Review the denial code and accompanying explanation.
2. Correct any errors (e.g., missing NPI, invalid code).
3. Resubmit within the 30day appeal window.

Payments & Reimbursements

Reimbursements are issued on a monthly cycle, typically on the 15th of the following month. Payments are made via electronic funds transfer (EFT) to the providers designated bank account.

Fee Schedules

Medicaid fee schedules are based on the Medicare physician fee schedule with statespecific adjustments. The handbook provides a downloadable PDF of the current schedule.

Cost Reports

Institutional providers must file an annual cost report using the CMS Form 116. Accuracy of the cost report influences prospective payment rates.

Coordination of Benefits (COB)

If the patient has secondary insurance, Medicaid will be the payer of last resort. Providers must submit the secondary claim after Medicaid processing.

Audit & Compliance

Mississippi Medicaid conducts regular audits to ensure compliance with billing rules.

Types of Audits

• Prepayment review Realtime edits during claim submission.
• Postpayment audit Random selection of paid claims for verification.
• Special investigations Triggered by irregular patterns or whistleblower reports.

Common Findings

• Unbundling of services.
• Upcoding using higherpaid codes without clinical justification.
• Missing signatures or inadequate documentation.

To avoid penalties:

• Implement a robust internal audit program.
• Train staff regularly on coding updates.
• Maintain complete and legible records for at least five years.