Processing Claims for Medicare and Medicaid

Know how to handle claims through these government healthcare programs.

Medicare claims

As a medical billing specialist, Medicare claims you file on behalf of the provider are sent directly to nearby MACs for processing. MACs typically take around 30 days to process each claim they receive.

Part A claims: Medicare pays the provider directly. Any deductibles, co-pays, or other fees that apply after Medicare pays the provider must be satisfied by the patient.

Part B claims: Medicare pays either the provider or the patient for care covered by the plan, which depends on who accepts assignment of the claim. If the provider accepts assignment of the claim, Medicare will pay them for 80% of the approved amount. The remaining 20% will be paid to the provider by the patient. If the provider does not accept assignment of the claim Medicare will pay the patient the approved amount for care received, and they will then pay the provider.

Medicaid claims

Processing billing for Medicaid claims can be trickier than those filed under Medicare because Medicaid claims must adhere to both federal and state guidelines. Providers who participate in Medicaid must meet these guidelines, and as a medical billing specialist you should be aware of any discrepancies between federal and state guidelines as you process claims. For example, a provider must adjust the remaining balance once meeting any applicable charges for a co-payment or deductible and after Medicaid has paid what they are allowed to pay under the Medicaid fee schedule.

Note also that Medicaid is officially the payer of last resource for a claim, meaning that if a person has any other health coverage for services rendered, those institutions should be billed before Medicaid.