State medical billing rules for all 50 states and DC

Why do billing rules change from state to state?

Four clocks and rules change at the state line: which Medicare Administrative Contractor (MAC) pays your Medicare claims, how long the state Medicaid program gives you to file, how fast insurers must pay a clean claim, and whether a state law or federal IDR sets the price of an out-of-network bill. The state pages below answer each one with the agency, the rule and the source.

Medicare is the one clock that does not move. Under 42 CFR 424.44(a)(1), a Medicare claim for services furnished on or after January 1, 2010 must be filed no later than the close of the period ending 1 calendar year after the date of service. That 12-month limit applies in every state, and only the contractor you send the claim to changes.

The table and groups on this page cover the 50 states and the District of Columbia. We group them by the four regions the U.S. Census Bureau uses (Northeast, Midwest, South and West), and DC sits in the South region on that map.

Which Medicare contractor handles claims in my state?

Each state belongs to one A/B MAC jurisdiction, with one exception noted below. CMS lists the contractor for each jurisdiction on its Medicare Administrative Contractors by state chart, and every state page repeats the contractor for that state.

The exception is Virginia. The CMS chart puts Part B claims for Arlington and Fairfax counties and the city of Alexandria under Novitas in JL, and the rest of Virginia under Palmetto GBA in JM. Home health and hospice claims go to separate contractors in several states, and the state pages name them where they differ.

Which states have their own surprise billing law?

Going by what each state page says, 24 jurisdictions have a state law or program that applies to state-regulated plans, 27 have none that sets the out-of-network payment, and 3 are marked not confirmed because no official source for them is cited. The comparison table below lists the name for each one.

A state law only decides the price when it applies to the plan and the service. Under 45 CFR 149.30, a specified State law is one that provides a method for determining the total amount payable for an item or service from a nonparticipating provider or emergency facility. Where one applies, the rate comes from that law. Where none does, the federal process applies.

The plan type usually decides the route. Several state pages say fully insured plans follow the state law while self-funded employer plans follow the federal No Surprises Act, unless the state lets them opt in. Our state surprise billing laws guide compares the approaches.

When the federal route applies, the dates are short. Under 45 CFR 149.510, either party may start a 30-business-day open negotiation period beginning on the day the provider receives an initial payment or notice of denial. The notice of IDR initiation goes out during the 4-business-day period beginning on the first business day after open negotiation ends.

Read No as: the state page found no state law that sets the out-of-network payment amount, so federal IDR applies to insured plans. Not confirmed means no official source for the state is cited, so read the statute before you rely on either answer. Several of the No entries rest on 2021 CMS letters to the states, and each state page dates the statement.

How long do I have to file a Medicaid claim?

It depends on the state, and several give you far less than Medicare. The federal rule at 42 CFR 447.45(d)(1) requires the Medicaid agency to make providers submit all claims no later than 12 months from the date of service, and a state may set a shorter limit.

Many state pages list 12 months or 365 days. The shorter limits on the state pages include 90 days in Massachusetts and New Mexico, 90 days with delay exceptions in New York, and 95 days in Texas. California, Georgia, Oklahoma and South Dakota give six months, and Arizona allows six months for an initial claim and 12 for a clean one. Illinois, Indiana, Nevada, North Dakota, Pennsylvania and Vermont use 180 days.

Counting rules matter as much as the number. Georgia and South Dakota count six months after the month of service, Alabama requires that the fiscal agent receive the claim within one year, and inpatient limits in North Carolina and South Carolina run from the last date of service or the discharge date. Check the Medicaid payer guide and the state page before you rely on a general rule.

The Nebraska page states no Medicaid limit and neither does the Utah page, so check each state's Medicaid manual. The Colorado and Tennessee pages give only the federal 12-month rule.

How fast must insurers pay a clean claim?

State prompt pay laws set how many days an insurer has to pay or deny a clean claim, and the clocks on the state pages run from 15 days for an electronic claim to 60 days for a paper claim in Connecticut. They apply to plans the state regulates, meaning fully insured plans. Self-funded employer plans follow their plan documents and ERISA claims rules.

• New Hampshire and Hawaii: 15 days for a clean electronic claim (RSA 420-J:8-a and HRS 431:13-108).
• Connecticut and Florida: 20 days for an electronic claim, with Connecticut allowing 60 days for paper and Florida 40.
• Alabama, Arkansas, Idaho and Oklahoma: 30 days electronic.
• Pennsylvania: 45 days, with 10% per annum interest if late.
• Virginia: 40 days to pay a clean claim.

Interest and penalties differ as much as the days. Alabama sets 1.5 percent a month, North Carolina 18% annual interest, and Missouri 1% a month plus a 1% daily penalty after the processing day 45 deadline. Colorado's page could not cite its statute, so it gives no deadline. Keep the clearinghouse acceptance report for each claim, because the insurer's clock starts when it receives a clean claim.

What should I check first on a state page?

Check the plan type before anything else, because it decides which rule applies. A fully insured plan follows the state prompt pay law and any state surprise billing law, a self-funded employer plan follows its plan documents and the federal rules, and Medicare and Medicaid follow their own filing limits.

1. Confirm who paid or denied the claim: Medicare, the state Medicaid program, a Medicaid managed care plan or a commercial plan.
2. Find the filing limit for that payer and note whether it counts from the date of service, the month of service or discharge.
3. For a late commercial payment, compare the insurer's receipt date on the clearinghouse report with the payment date, then check the state prompt pay clock.
4. For an out-of-network underpayment, check whether the state law names the service you billed before you start open negotiation.
5. Mark any state marked Not confirmed and read the statute before you rely on it.

Each state page works through these checks with the agencies, forms and deadlines for that state, so the answer you need sits one click from the card for your state.

How do we handle billing across states?

We set up each account around the state it bills in: the Medicare contractor, the Medicaid filing limit, the prompt pay clock and the surprise billing pathway. Claims are sent within 24 hours of charge entry, and denials are worked within 48 hours.

For out-of-network disputes, we check the plan type and the state law first, then run open negotiation and federal IDR or the state process, whichever applies. Our out-of-network billing and IDR service tracks the deadlines from first notice to final payment, and you can book a call to walk through your states.