Just like when you bill to the private third-party payer, billers must send claims to Medicare and Medicaid. These claims are very similar to the claims you’d send to a private third-party payer, with a few notable exceptions.

When you claim for Medicare and Medicaid, there is no need to go through a clearinghouse for these claims, and it also means that 100% “clean” claims submission. Make sure you’re familiar with the Medicare contractor’s claim submission preference and submit claims accordingly because Medicare is not going to adapt to provider needs; the provider does all of the adapting!

Medical Billing Guidelines for Medicare and Medicaid


Note that, Medicare strictly adheres to the established National Correct Coding Initiative (NCCI) edits, along with procedure/medical necessity protocol. In addition, its claims processing system is highly refined. Any claim that is submitted with errors or without the correct information does not process.

Centers for Medicare & Medicaid Services CMS, Through Medicare, sets the rules for the country, but Medicare claims processing happens in regional areas. CMS contracts with private companies, called Medicare Administrative Contractors (MACs), to process Medicare claims.

A provider who furnishes a service that Medicare probably won’t cover can ask the patient to sign an advanced beneficiary notice (ABN). By signing an ABN, the patient agrees to be financially responsible for the service if Medicare denies payment. If the provider doesn’t offer the ABN or the patient doesn’t sign the notice before services are rendered, the patient doesn’t have to pay for that service.

When billing for traditional Medicare (Parts A and B), billers will follow the same protocol as for private, third-party payers, and input patient information, NPI numbers, procedure codes, diagnosis codes, price, and Place of Service codes. We can get almost all of this information from the superbill, which comes from the medical coder.

Claims related to Parts C and D of Medicare are relayed through a private insurer and should never be filed through Medicare. You won’t file Medicare claims with Parts C and D because private health plan carriers have agreements with Medicare to receive a certain amount per member every month. Part D of Medicare coverage may change depending on the person receiving care because coverage depends on the drugs involved. Some drugs aren’t covered by Part D at all. Thus claims filed through Parts C and D of Medicare should be treated like any other claim handled through a private health plan carrier.

Only those providers who are licensed to bill for Part D may bill Medicare for vaccines or prescription drugs provided under Part D. If the provider is not a licensed Part D provider, the biller must assign that total directly to the patient (or the patient’s secondary insurance, if they have it, and if it covers that procedure or prescription).

If a biller has to use manual forms to bill Medicare, a few complications can arise. For instance, billing for Part A requires a UB-04 form (which is also known as a CMS-1450). Part B, on the other hand, requires a CMS-1500. For the most part, however, billers will enter the proper information into a software program and then use that program to transfer the claim to Medicare directly.


Medicaid programs differ from state to state medical billing for Medicaid is much more complicated than Medicare. Some citizens eligible for care in one state may not be eligible for care in another state, or they may receive more or fewer benefits depending on the state in which they receive care. Billing codes claim submission protocols, reimbursement rates, and other billing information will vary by state.

You will start the medical billing process for Medicaid by filling out a state claim form for the services and procedures covered. Most state Medicaid claim forms will be divided into main two parts: information regarding the patient and/or the insured person and information regarding the healthcare provider.

Be aware when billing for Medicaid that many Medicaid programs cover a larger number of medical services than Medicare, which means that the program has fewer exceptions. Medicaid is the last payer to be billed for a service. That is, if a payer has an insurance plan, that plan should be billed before Medicaid.


  1. Department of Health and Hospital, State of Louisiana. Retrieved from
  2. Medicare Secondary Payer (MSP) Manual Chapter 3 – MSP Provider, Physician, and Other Supplier Billing Requirements. Retrieved from
  3. Earl Dirk Hoffman, Jr., Barbara S. Klees, Catherine A. Curtis. Overview of the Medicare and Medicaid Programs. Retrieved from