Medicaid Claim Lifecycle

A Medicaid claim goes through many stages before you get paid. Understanding this lifecycle helps you identify where problems occur and how to fix them. Here's the complete journey.

Stage 1: Service Delivery

Everything starts with providing the service:

• Service must be authorized (prior authorization if required)
• Participant must be Medicaid eligible on date of service
• Service must be documented properly
• For EVV services, visit must be electronically verified

What can go wrong: Service provided without authorization, participant eligibility lapsed, inadequate documentation.

Stage 2: Claim Generation

Turning documented services into claims:

• Services are coded with appropriate procedure codes
• Units/hours calculated from documentation
• Diagnosis codes attached if required
• Provider and member information added
• Dates of service and place of service coded

What can go wrong: Wrong procedure code, incorrect units, missing required fields, member ID errors.

Stage 3: Claim Scrubbing

Checking claims before submission:

• Verify all required fields are complete
• Check for duplicate claims
• Validate codes are active and appropriate
• Confirm member eligibility
• Check against authorization limits

What can go wrong: Errors missed, leading to denials after submission.

Stage 4: Claim Submission

Sending claims to the payer:

• Claims formatted per payer requirements (837P, 837I)
• Transmitted electronically to Medicaid or clearinghouse
• Receive acknowledgment of receipt
• Claims enter payer's adjudication queue

What can go wrong: Transmission failures, file format errors, rejected at front-end edits.

Stage 5: Adjudication

Payer processes and decides on claims:

• Payer verifies member eligibility
• Checks provider enrollment and authorization
• Applies coverage rules and edits
• Calculates payment based on fee schedule
• Generates decision: pay, deny, or pend

What can go wrong: Claim denied for eligibility, authorization, or medical necessity. Claim pended for additional information.

Stage 6: Remittance (ERA/EOB)

Receiving payment information:

• 835 ERA (Electronic Remittance Advice) received
• Shows payment amount for each claim
• Includes adjustment/denial reason codes
• Payment deposited (if EFT) or check mailed

What can go wrong: ERA not received, can't match ERA to claims, payment less than expected.

Stage 7: Payment Posting

Recording payments in your system:

• Match payments to original claims
• Post payment amounts
• Record adjustments and denials
• Update accounts receivable
• Flag denials for follow-up

What can go wrong: Payments posted to wrong claims, adjustments not recorded, denials not worked.

Stage 8: Denial Management

Working denied claims:

• Review denial reason codes
• Determine if claim can be corrected and resubmitted
• Appeal if denial is incorrect
• Write off if truly not payable
• Track denial patterns for prevention

What can go wrong: Missing appeal deadlines, not working denials, same errors recurring.

Key Metrics to Track

• Days in A/R: How long from service to payment
• Clean claim rate: % of claims paid on first submission
• Denial rate: % of claims denied
• Collection rate: % of billed amount actually collected