Direct Services Billing

Not necessarily. Historically, many School Medicaid programs focused primarily on services included in a student’s Individualized Education Program (IEP). Some states still require certain reimbursable services to be included in an IEP, while others allow reimbursement for services documented through other plans, such as a 504 Plan, Individualized Health Plan or behavioral plan. The requirements depend on the state’s Medicaid program.

Yes. For direct service billing, the student generally must be enrolled in Medicaid or another Medicaid funded coverage program recognized by the state. The school must also meet the other requirements of the state program, including requirements involving the service provided, the provider delivering it and supporting documentation. Medicaid eligibility alone does not make every school health service reimbursable.

Eligible provider types vary by state. Depending on the state program, participating providers may include school nurses, speech language pathologists, physical therapists, occupational therapists, audiologists, behavioral health professionals and other qualified school health personnel. States establish the professional qualifications, licenses, certifications and other requirements that providers must meet before their services can qualify for Medicaid reimbursement.

Documentation requirements vary by state, but schools generally need records that support the student’s eligibility, authorization for the service, the provider’s qualifications and the service actually delivered. Clinical documentation should describe what occurred during the encounter, why the activities were performed and how the student responded. Documentation should also be consistent with the type, duration and purpose of the service being billed.

No. A service is not reimbursable simply because it is medically related or provided by a health professional. Each state identifies the school based services and provider types covered by its Medicaid program. The student, service, provider, documentation and other applicable requirements must all satisfy the state’s rules before the service can qualify for reimbursement.

Parental consent requirements depend on the circumstances under which services are provided and the laws and program requirements that apply. Services provided under IDEA have specific parental consent and notification requirements, while states may establish requirements for Medicaid covered services provided outside of IDEA. Schools should understand which consent rules apply to their program and maintain documentation demonstrating that applicable requirements have been met.

The reimbursement process depends on the state. In a typical direct service billing model, an eligible provider delivers and documents a covered service to a Medicaid eligible student. Information about that encounter is then used to generate a Medicaid claim. Claims are submitted through the state’s Medicaid claiming process, adjudicated, and eligible reimbursement is returned to the participating school or education agency. Some states use other reimbursement methodologies, so the exact process can differ.

Medicaid is a federal and state partnership. Federal requirements establish the overall Medicaid framework, but states design their own Medicaid programs within that framework. States therefore make important decisions about covered school health services, eligible providers, documentation, claiming procedures and reimbursement methodologies. A service or provider that qualifies for reimbursement in one state may be treated differently in another, which is why understanding the specific requirements of the state program is essential.