SD Medicaid Billing
For organizations with a billing department and personnel, connect early with the billing department to ensure that billing is set up and ready to go once the CHW/CHR program begins seeing patients/clients.
Billing a Recipient
South Dakota Medicaid Provides guidance for Billing a Recipient. Per the South Dakota Medicaid Billing and Policy Manual for Billing and Recipient, SD Medicaid recipients are exempt from cost sharing when receiving CHW services and do not have to pay a co-pay to receive services. This is noted under the section of the manual, “Recipients Exempt from Cost Sharing” as noted in the third bullet point – “individuals residing in a long-term care facility or receiving home and community-based services”.
CHW Agencies will utilize the CMS 1500 Claim to submit CHW claims (either electronically, through the Medicaid portal, or through paper claims). The CMS 1500 Claim Instructions Manual from SD Medicaid provides a basic overview to assist in further understanding the CMS 1500 Claims. The general claim guidance manual provides an overview of South Dakota Medicaid claims requirements.
In addition to Z-Codes for chronic diseases, pregnancy, substance use disorder, and many other Z-codes related to qualifying conditions for CHW services, SD Medicaid also allows for Social Determinants of Health (SDoH) Z-Codes to be utilized on CMS 1500 Claims. The SD Medicaid Billing and Policy Manual for Community Health Worker Services lists all possible SDoH Z-Codes that can be included on a CMS 1500 Claim for CHW services, as the Z-Code relates to the primary care provider’s referral related to a qualifying condition and/or qualifying barrier. See Attachment A of the CHW Billing and Policy Manual for a complete list of the codes.
CMS 1500 Sample
Click below to view a sample CMS 1500 billing form. This will be helpful to understand as you review the Medicaid Claims instructions.