Value of verifying Medicaid eligibility upfront?

Identifying a Medicaid member’s eligibility upfront is critical for both service continuity and financial sustainability. By proactively verifying eligibility and coverage details before providing services, providers can prevent avoidable denials, ensure compliance, and maintain revenue stability.

Preventing Billing Rejections & Revenue Loss

Medicaid operates under strict eligibility and coverage rules, meaning services provided to ineligible members will not be reimbursed. If a provider does not verify eligibility before delivering services, claims may be rejected due to:

Inactive Medicaid status
Lapsed coverage due to member non-renewal
Enrollment in a different Medicaid managed care plan
Coverage limited to certain providers or service types

Since Medicaid rules prevent retroactive claim overrides in many cases, providers may never recover payment for services delivered to an ineligible member.

Steps to Prevent Eligibility Issues

To avoid denials and financial losses, providers should:

Verify eligibility before each service date using Pennsylvania’s Medicaid eligibility portal (EVS) or the member’s Managed Care Organization (MCO).
Check for plan changes—members may switch plans, affecting billing requirements.
Confirm required authorizations—some services require pre-approval.
Ensure provider enrollment with Medicaid and MCOs to avoid credentialing-related denials.

Common Billing Rejections That Cannot Be Overridden in Pennsylvania

Certain claim denials cannot be fixed after services are rendered, leading to permanent revenue loss:

Member is not Medicaid-eligible on the date of service (coverage expired or lapsed).
Member is covered under a different Medicaid managed care plan than the one billed.
Service is not covered under the member’s eligibility category (e.g., a behavioral health service billed under a physical health plan).
Prior authorization required but not obtained before services were rendered.
Provider is not enrolled or credentialed with the member’s Medicaid plan.

Impact of Ineligible Claims on Providers

Failing to verify eligibility leads to:

Lost revenue (Medicaid denials often cannot be appealed).
Higher administrative costs (resubmissions, eligibility corrections).
Disruptions in care (denied services may require reauthorization, delaying treatment).