MedicaidReimbursementMedium impact
Medicaid claims handling for out-of-state Medicaid members
Blue Cross Blue Shield of Rhode Island·Provider Update
Effective date
Jan 1, 2019
We identified it
Jun 20, 2026
Summary
Out-of-state Medicaid claims must be paid at the Medicaid allowed amount from the member's home state, not the local provider's negotiated rate. Providers are federally prohibited from balance billing Medicaid members for the difference between the allowed amount and charges.
Action Required
Immediately: Billing team must ensure out-of-state Medicaid claims are processed at the member's home state Medicaid rate, not local negotiated rates. Update billing system to prevent balance billing of Medicaid members per 42 CFR 447.15. Train staff to identify member's home state for proper reimbursement calculation.