MedicaidReimbursementMedium impact
Medicaid claims handling for out-of-state Medicaid members
Blue Cross Blue Shield of Rhode Island·Provider Update
Effective date
Feb 1, 2019
We identified it
Jun 20, 2026
Summary
Out-of-state Medicaid claims must be reimbursed at the member's home state Medicaid rate, not the provider's local rate. Providers are strictly prohibited from balance billing Medicaid members for any difference between charges and the allowed amount.
Action Required
Immediately: Billing team must verify patient's home state for all out-of-state Medicaid members and expect reimbursement at that state's Medicaid rate. Update billing procedures to ensure NO balance billing of Medicaid patients for amounts above the allowed rate. Train staff on federal prohibition against balance billing per 42 CFR 447.15.