A SUMMARY OF MEDICAID REQUIREMENTS AND RELATED COA STANDARDS This tool is intended to provide a broad overview of common Medicaid (MA) requirements in relation to COA s Standards. While there are specific federal and state requirements for every Medicaid service not comprehensively addressed here, this document helps to demonstrate how implementation of COA s Standards provides the framework for establishing applicable systems within your organization and how accreditation can serve as a roadmap for meeting those requirements. Please note that all programs that contract with Medicaid should review the federal regulatory requirements governing the provision of Medicaid-reimbursable services such as Outpatient Behavioral Health Services, Case Management Services, Psychiatric Residential Treatment Centers, Home and Community-Based Services, etc., as well as federallyapproved State Medicaid Plans for additional, state-specific requirements. Federal Regulations and each State s Medicaid Plan set the expectations for the program, including: Conditions of Participation (COPs): Basic requirements regarding quality, governance, accreditation, staff credentials, initial and on-going training, supervision, etc. Service Codes: Service-specific rules including the codes and modifiers. These describe each Medicaid service and answer the questions of who, what, where, when and sometimes how often. Treatment Planning and Documentation requirements For all Medicaid-reimbursed services, keep in mind that: The client must be able to participate The client must be able to benefit from the service The client must be a voluntary participant All services must be provided to the exclusive benefit of the client All Services are Authorized and Re-Approved Based upon the Following Key Components: Medical Necessity Any medical or remedial service provided in a home, facility or other settings recommended by a physician or an LIP with the scope of their practice under state law for the maximum reduction of physical or mental disability and restoration of the individual to the best possible functional level. It is a service or supply necessary for the diagnosis, care or treatment of a 1
physical or mental condition and widely accepted professionally in the US as effective, appropriate and essential, based upon recognized standards of the health care specialty involved. Medical Appropriateness Demonstration that the client is at the appropriate Level of Care (LOC) and willing and capable to participate in his/her care. Services may be evaluated as not being Medically Appropriate if the client refuses to participate, demonstrates high-risk behavior, or the assessed needs may be met at a lower level of care. Active Treatment Implementation of a professionally developed and supervised individual plan of care that involves such activities as: Multidisciplinary observation Assessment and evaluation Interdisciplinary treatment planning Evaluation of client progress and appropriate revisions in the treatment plan Identification of discharge criteria and discharge planning Aftercare needs assessment COA also encourages organizations to visit the Office of Inspector General (OIG) website for additional information regarding recent OIG review activities and the results of recent surveys, located at http://oig.hhs.gov/. 2
SUMMARY OF MEDICAID WORKFLOW SERVICE STEPS Inquiry Inquiry is received by phone, email or other means Document reason for seeking services at the requested level of care COA STANDARDS EXAMPLES CM 1 The organization works with community partners and resources to minimize barriers that prevent individuals and families from accessing services. RPM 7.02 Case records comply with all legal requirements and contain information necessary to provide services, including: a. demographic and contact information; b. the reason for requesting or being referred for services; c. SPECIAL NOTES & CONSIDERATIONS Agency must be contracted with Medicaid to deliver services Agency must develop a Program Plan that describes the services provided, eligibility, and certification requirements (if required in State MA Plan) and other state-specific requirements Admission/Enrollment Medicaid eligibility is verified If required in the State MA Plan, recipient is certified as requiring the service Presenting clinical issues screened against admission criteria to make an initial determination of medical appropriateness CM 2 The organization screens applicants promptly and responsively to identify urgency of need and direct individuals to appropriate services. See also RTX 1 and MH 1 CM 2.01 The names, positions and credentials of individuals involved in making the admission decision are documented In many State MA Plans, at least one home visit is required during the admission/assessment 3
Service is preauthorized as indicated (medical necessity and medical appropriateness is documented) Additional information is collected as appropriate to make referral decision Additional input is sought if appropriateness of referral (lack of perceived Medical Necessity, etc.) is questioned Referral meets stated admission Criteria If required, state-mandated co-pay established MA set as payor of last resort Referral is assigned to appropriately qualified service provider (Physician, Therapist, CM, etc.) At intake, individuals and families are screened and informed about: a. how well the request matches the organization's services; and b. what services will be available and when. See also RTX 1.03 and MH 1.01 CM 2.02 Prompt, responsive screening practices: a. include screening for level or intensity of service; b. ensure equitable treatment; c. give priority to urgent needs and emergency situations; d. support timely initiation of services; and e. provide for placement on a waiting list, if desired. See also MH 1.02 process The 2009 Office of Inspector General (OIG) Report of a PA PRT cited that this provider violated their own Admission Criteria by accepting a large number of juvenile corrections clients within a short time frame. In their view, this created an unsafe environment, led to an increase in restrictive interventions, and created major disruptions in the therapeutic environment. These findings resulted in a major recoupment of MA funding from this provider. CM 2.03 Individuals and families who cannot be served, or cannot be served promptly, are referred or connected to appropriate resources. See also MH 1.03 Acceptance or Referral Referral acceptance CM 2.02 Outcome of the admission 4
documented in client record Deny Wait List Offer other treatment options if agency is unable to provide service based on insurance provider limitations or ability to pay Prompt, responsive screening practices: a. include screening for level or intensity of service; b. ensure equitable treatment; c. give priority to urgent needs and emergency situations; d. support timely initiation of services; and e. provide for placement on a waiting list, if desired. See also MH 1.02 CM 2.03 Individuals and families who cannot be served, or cannot be served promptly, are referred or connected to appropriate resources. See also MH 1.03 RPM 7.02 Case records comply with all legal requirements and contain information necessary to provide services, including: a. b. the reason for requesting or being referred for services; c. a description of services review process is documented 5
provided directly or by referral; d. routine documentation of ongoing services; e. Evaluation Intake scheduled Client or legal guardian completes required documentation: Consent to Treat Patient Demographic Forms HIPPA Acknowledgement State-required preadmission documents CR 1.04 Clients are informed of their responsibility to provide relevant information as a basis for receiving services and participating in service decisions. CR 1.07 Clients participate in all service decisions and have the right to: a. b. refuse any service, treatment, or medication, unless mandated by law or court order; c. RPM 7.02 Case records comply with all legal requirements and contain information necessary to provide services, including: a. demographic and contact information; b. the reason for requesting 6
Assessment Baseline client assessment is conducted in accordance with the following criteria: thorough and timely completion by appropriately qualified individuals; legible clinician signatures, credentials, and job title; an assessment summary that contains a complete and chronological description of the reasons why the individual (and their family, in the case of a minor child) is seeking treatment or being referred for services; c. up-to-date assessments; d. the service plan, including mutually developed goals and objectives; e. copies of all signed consent forms; f. CM 3 Individuals and families participate in a comprehensive, individualized, strengths-based, culturally responsive assessment. See also RTX 3 and MH 2 CM 3.01 Personnel who conduct assessments are qualified by training, skill, and experience and can recognize individuals and families with special needs. See also RTX 3.03 and MH 11.01 CM 3.02 The information gathered for assessments is comprehensive, directed at concerns identified in the initial screening, and limited to material that is pertinent for Most State MA Plans require that the client s need for services be re-assessed on an annual basis. 7
results that clearly outline the focus areas of treatment; a diagnosis Common required elements in most State MA Plan include: Presenting problem(s) and history, including the client s, legal representative s and family s assessment of the situation; Psychiatric and medical history Recipient s current and potential strengths Resources that are available to the client through his or her natural support system Client s school placement, adjustment and progress, as applicable Client s relationship with his or her family and significant other Identification and effectiveness of services currently being provided meeting service requests and objectives. See also MH 2.01 CM 3.03 Assessments are conducted inperson in a place of the individual s or family's choice, when possible, and include assessment of natural supports and helping networks. See also RTX 3.04 and MH 2.03 CM 3.04 The organization promptly provides or makes arrangements for specialized assessments, as needed. See also RTX 3.05, RTX 3.06, MH 2.03 CM 5.02 Every individual participates in a formal re-assessment annually, or more frequently when indicated. CM 5.03 An event-based re-assessment is conducted: a. within five working days of a precipitating event; 8
b. when there is a change in the individual or family s status or circumstances, or a new issue arises; and c. within 48 hours of notification that hospital or institutional discharge is imminent. Interpretation: An organization that, due to contractual requirements, is unable to conduct event-based reassessments according to these timeframes can modify them to meet the needs and goals of the population served. RPM 7.02 Case records comply with all legal requirements and contain information necessary to provide services, including: a. demographic and contact information; b. the reason for requesting or being referred for services; c. up-to-date assessments; d. the service plan, including mutually developed goals and objectives; 9
e. copies of all signed consent forms; f. a description of services provided directly or by referral; g. routine documentation of ongoing services; h. documentation of routine supervisory review; i. discharge or aftercare plan; j. recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and k. a closing summary entered within 30 days of termination of service. RPM 7.03 The case record contains essential legal and medical information, including, as applicable: a. psychological, medical, toxicological, diagnostic, or other evaluations; b. copies of all written orders for medications or special treatment procedures; and c. court reports, documents 10
Service/Treatment Planning A Preliminary Treatment Plan is completed to guide treatment until the completion of the Master Treatment Plan An Individual Plan of Care is developed in accordance with state-required timelines and includes the following elements: of guardianship or legal custody, birth or marriage certificates, and any legal directives related to the service being provided. RPM 7.04 Case record entries are made by authorized personnel only, and are: a. specific, factual, relevant, and legible; b. kept up to date from intake through case closing; c. completed, signed, and dated by the person who provided the service; and d. signed and dated by supervisors, where appropriate. CM 4 Each individual or family participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support. See also RTX 4 and MH 3 CM 4.01 OIG reviews have focused heavily on the timeliness of all Treatment Planning documentation. Any days outside of the required date ranges have resulted in recoupment of funds from MA-approved service lines. Each State s MA Plan indicates the number of days 11
Date range including current date appropriate signatures (e.g., therapist, consumer, guardian) documentation of interdisciplinary focus type of provider implementing each intervention individualized and measurable goals & objectives that are linked to the assessment and diagnosis and relevant to the reason for admission criteria for transition or discontinuation of services intensity, frequency and rate of services that are to be provided (e.g., number of units or sessions per day/week/month and the length of each therapeutic intervention) documented evidence of clear progress toward the achievement of goals, objectives & discharge criteria All individuals and families receive: a. a service plan; b. direct provision of, or referral for services, as necessary; and c. individual case coordination and monitoring of services. CM 4.02 A service plan is developed in a timely manner with the full participation of the individual or family, and an expedited service planning process is available when crisis or urgent need has been identified. See also MH 3.01 and RTX 4.02 CM 4.03 The service plan is based on the assessment, and includes: a. agreed upon goals, desired outcomes, and timeframes for achieving them; b. services and supports to be provided, and by whom; and c. the individual s or guardian s signature, as appropriate. See also RTX 4.01 and MH 3.02 CM 4.04 from admission for completion of the treatment plan. This timeframe differs from state to state. 12
revision to the objectives and/or interventions when progress is not demonstrated documentation of the team that developed the plan During the service planning process the organization explains: a. available options; b. how the organization can support the achievement of desired outcomes; and c. the benefits, alternatives, and risk or consequences of planned services. See also MH 3.03 and RTX 4.01 CM 4.05 The service plan addresses, as appropriate: a. unmet service and support needs; b. possibilities for maintaining and strengthening family relationships; and c. the need for support of the individual s or family's informal social network. See also RTX 4.01 and MH 3.04 CM 5.04 The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess: a. service plan implementation; b. the service recipient's 13
Service Delivery Services are delivered as defined in the treatment plan All services delivered are documented in per contact progress notes A progress note is present for each service claimed and: is original (i.e., there are no cloned notes or cut and pastes) is legible, completed, and dated the day the service was delivered includes the consumer s legal name progress toward achieving goals and desired outcomes; and c. the continuing appropriateness of agreed upon service goals. See also RTX 4.04 and MH 3.05 CM 5.05 The worker and family regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans. See also MH 3.06 and RTX 4.04 CM 4 Each individual or family participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support. See also RTX 4 and MH 3 CM 4.06 Case management services: a. directly provide, refer, contract, or otherwise arrange for individuals and families to receive needed or Some state MA Plans specify a set number of active treatment hours to be provided per week. This is particularly important in residential treatment services. Documentation of the intensity, frequency and rate of services is then evidenced by the provision of at least X hours of active treatment (e.g., number of units or sessions per day/week/month and the length of each therapeutic 14
includes identification of the service delivered documents the start & end time of the service includes the location of the service identifies the problem addressed (as listed in the treatment plan) provides a behavioral description of the client during the session includes a statement about progress describes the targeted next steps in services and activities includes the writer s signature, credentials and job title requested services as identified in the service plan; and b. maintain a comprehensive, up-to-date list of community programs and services, and information on how to access them. RPM 7.04 Case record entries are made by authorized personnel only, and are: a. specific, factual, relevant, and legible; b. kept up to date from intake through case closing; c. completed, signed, and dated by the person who provided the service; and d. signed and dated by supervisors, where appropriate. RPM 7.05 Progress notes comply with legal requirements and are entered: a. at least quarterly; or b. monthly, or as required by law or regulation for individuals receiving intervention). 15
Plan Review Assigned utilization management (UM)staff is notified and begins to track the MA-required continued stay review dates and required documentation including the following: MA eligibility verified at pre-admission External Review Organization (ERO) informed of the client s actual admission within the required time-lines, as required client s clinical data was completed on the mandated form and/or entered into the ERO s electronic information system, as required service was preauthorized as indicated (i.e., medical necessity and medical appropriateness is documented) protective services, out-ofhome care, day treatment, or frequent or intensive counseling or treatment. PQI 4.03 Quarterly reviews of case records: a. evaluate the presence, clarity, quality and continuity of required documents using a uniform tool to ensure consistency; and b. include a random sample of both open and closed cases. Interpretation: The organization develops a plan and method to review case records objectively, avoiding conflict of interest and including a case record review form that defines and tracks vital documents and elements. Documents included in the case record review may include: a. assessments; b. service plans; c. appropriate consents; d. progress or case notes or summaries; Following are frequently cited errors that result in recoupment: missing or Illegible documentation; missing or Illegible signature and/or credentials; invalid assessment (i.e., outdated or incomplete); invalid service plan (i.e., outdated or incomplete); services are billed for administrative activities, transportation or other activities excluded in the State MA Plan; insufficient documentation for services provided; lapse in Medicaid eligibility; billing dates are outside of current certification dates; billing was submitted for nonapproved pass days; billing was submitted for dates client was in acute psychiatric care, hospitalized for medical treatment or in 16
State-mandated co-pay established MA set as the payor of last resort Treatment plan and progress notes are reviewed for active treatment, medical necessity, and medical appropriateness including the following: Updated assessments and/or additional assessments are ordered to facilitate the planning process clear progress toward the achievement of goals, objectives & discharge criteria revisions to objectives and/or to promote client progress, as necessary indication of the identified services being provided e. evidence of quarterly case supervision; f. relevant signatures; g. service outcomes; or h. discharge or aftercare plans. COA recommends reviewing one or two quality issues that assess appropriateness, need for, and effectiveness of services. Criteria for assessing quality issues such as appropriateness, need for, and effectiveness of services can include: a. services needed and provided or obtained; b. length of service; c. changes in status or level of service; d. need for continued service; e. compliance with mandated review indicators; and f. timeframes. CM 5.01 Service monitoring includes: a. confirmation, usually within one or two working days, that a service has been initiated as scheduled; b. verification, usually within 15 juvenile corrections setting; incorrect diagnosis code; incorrect service code; incorrect dates of service 17
working days, that the service is appropriate and satisfactory; c. follow-up every three months; and d. immediate response to any complaints or problems that develop in the delivery of service or with the person receiving services. CM 5.04 The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess: a. service plan implementation; b. the service recipient's progress toward achieving goals and desired outcomes; and c. the continuing appropriateness of agreed upon service goals. RTX 4.04 and MH 3.05 CM 5.05 The worker and family regularly review progress toward achievement of agreed upon goals and sign revisions to service 18
goals and plans. See also MH 3.06 Discharge & Aftercare Client is discharged upon completion of treatment objectives and attainment of discharge criteria Discharge planning begins at admission and includes: recommendations for services/supports to meet the client s individualized goals involvement of the client, or parent or legal guardian, in the development of the plan anticipated discharge date recommendations for linkages with natural supports in the community instructions that are provided to client outlining specific supports for continued treatment plan A Discharge Summary is completed that reflects the treatment plan and the RPM 7.02 Case records comply with all legal requirements and contain information necessary to provide services, including: a. demographic and contact information; b. the reason for requesting or being referred for services; c. up-to-date assessments; d. the service plan, including mutually developed goals and objectives; e. copies of all signed consent forms; f. a description of services provided directly or by referral; g. routine documentation of ongoing services; h. documentation of routine supervisory review; i. discharge or aftercare plan; j. recommendations for ongoing and/or future service needs and assignment of aftercare or 19
individual s response to the course of treatment follow-up responsibility, if needed; and k. a closing summary entered within 30 days of termination of service. CM 8.01 Planning for case closing: a. is a clearly defined process that includes assignment of staff responsibility; b. begins at intake; and c. involves the worker, the individual, a parent or legal guardian, and others, as appropriate. See also RTX 18.01 and MH 9.01 CM 9 When the need for aftercare has been identified, the organization and service recipient work together to develop an aftercare plan, and follow-up occurs when possible and appropriate. Interpretation: While the decision to develop an aftercare plan is based on the wishes of the service recipient, unless aftercare is mandated, the organization is 20
Provider Qualifications Provider qualifications are reasonably related to the population being served and the services delivered Provider requirements and credentials are verified and expected to be proactive with respect to aftercare planning. See also RTX 18.05, RTX 18.08, and MH 10 CM 9.01 An aftercare plan is developed sufficiently in advance of case closing to ensure an orderly transition. See also RTX 18.05 and MH 10.01 CM 9.02 An aftercare plan identifies services needed or desired and specifies steps for obtaining these services. See also RTX 18.06 and MH 10.02 CM 9.03 The organization takes the initiative to explore suitable resources and make contact with service providers. See also RTX 18.07 and MH 10.03 CM 10 Case management personnel are qualified by professional training and experience to access and coordinate services for the populations served. Additional provider requirements may be set forth in the State MA Plan. These qualifications may include minimum age requirements, education, 21
current, including: license/certification FACIS Screening Fingerprint Clearance Required initial training have been completed and documented Annual required trainings have been completed within required timelines See also MH 11 and RTX 19 HR 3.02 Recruitment and selection procedures include: a. notifying personnel of available positions; b. verifying references and credentials of personnel and independent contractors; c. providing applicants with a written job description; d. giving final candidates the opportunity to speak with currently-employed personnel; e. retaining hiring records in accordance with legal requirements; and f. using standard interview questions that comply with employment and labor laws. HR 3.03 Screening procedures include appropriate, legally permissible, and mandated reviews of state criminal history records and civil child abuse and neglect registries work experience, training, credentialing, supervision and licensing requirements. The lack of appropriate credentials and initial and ongoing training has been a key focus of CMS and OIG reviews. Services provided by a staff member who is not appropriately qualified or who has not completed the initial and on-going training requirements within the required time-lines has resulted in denials of the entire length of stay of all clients that were treated by that individual. 22
for new employees, consultants, independent contractors, volunteers, and student interns who will: a. work in residential programs; b. provide direct services to, or be alone with, children, the elderly, or other persons determined by the organization to be vulnerable or at risk; or c. work with sensitive or confidential information such as personnel files and case records. HR 7.01 Personnel records are updated regularly, and contain: a. identifying information and emergency contacts; b. application for employment, hiring documents including job postings and interview notes, and reference verification; c. job description; d. compensation 23
documentation, as appropriate; e. pre-service and inservice training records; and f. performance reviews and all documentation relating to performance, including disciplinary actions and termination summaries, if applicable. TS 1 The organization's training and development program provides personnel with the information necessary to competently provide services. TS 1.03 The personnel training and development program: a. b. outlines specific expectations regarding training required of personnel in different positions and categories; c. TS 2 Personnel throughout the agency 24
are trained to fulfill their job responsibilities. Restrictive Interventions Record includes written acknowledgement from parent/legal guardian that he/she has been informed of the facility policy on the use of restraint or seclusion The Treatment Plan documents: Use of restraint or seclusion Success of previous interventions Any contraindications to restraint or seclusion Individualized hierarchy of less intensive interventions to be attempted prior to the implementation of restrictive interventions Orders for restraint or seclusion are written for specific occurrences of danger TS 3 The organization has a system of supervision that promotes effective use of organizational resources and positive outcomes. BSM 2.01 The organization: a. provides an explanation for and offers a copy of its written behavior support and management philosophy and procedures to service recipients or their parents or legal guardians at admission; b. informs service recipients or parents or legal guardians of strategies used to maintain a safe environment and prevent the need for restrictive behavior management interventions; c. has procedures that address harassment and violence towards other service recipients, personnel, and, as 25
to self or others, not as a standing order or an as needed (PRN) basis Orders are signed by the ordering Physician/licensed practitioner as soon as possible, and include: Name of the person ordering the intervention Date and Time of the order The specific restraint or seclusion ordered Maximum amount of time that the consumer may be secluded or restrained A physician or other licensed practitioner permitted by the state evaluates the consumer s well being immediately after the restraint or seclusion is completed A face-to-face assessment is completed within 1 hour of initiation of the intervention and includes documentation of: applicable, foster parents; d. obtains the service recipient s or parent s or legal guardian s consent when restrictive behavior management interventions are part of the treatment modality; and e. when the service recipient is a minor, notifies the parents or legal guardians promptly when manual restraint, mechanical restraint, or locked seclusion were used. BSM 2.05 Service recipients identified as being in need of restrictive behavior management interventions are assessed for: a. antecedents to harassing, violent, or out-of-control behavior; b. the effectiveness of previous uses of behavioral interventions; c. psychological and social factors that can influence use of such interventions; and 26
physical and psychological status behavior appropriateness of the intervention any complications resulting from the intervention A debriefing is completed within 24 hours of an intervention that includes the client, parent/legal guardian, and all involved staff Documentation is completed by the end of the shift in which the intervention occurs and includes: less restrictive interventions attempted prior to the implementation of seclusion, restraint or other restrictive interventions start and end time of the intervention time and results of 1 hour face-to-face assessment the emergency safety situation that required the intervention d. medical conditions or factors that could put the person at risk. BSM 2.06 A behavior support and management plan is based on assessment results and: a. identifies strategies that will help the person deescalate their behavior and prevent harassing, violent, or out-of-control behavior; b. specifies interventions that may or may not be used; c. is modified as necessary; and d. is developed and signed by the person, his/her parent or legal guardian, and the foster parent or personnel, as appropriate. BSM 5 Restrictive behavior management interventions are used in a manner that protects the safety and well-being of service recipients and personnel in emergency or crisis situations when less-restrictive measures 27
outcome of the intervention, including any injuries alternative techniques that might have prevented the use of the intervention procedures to prevent recurrence recommended changes to the treatment plan the name of staff involved in the intervention the date and time of parent/legal guardian notification, including the name of the staff person who completed the notification have proven ineffective. BSM 5.01 Qualified personnel authorize each restrictive behavior management intervention, in accordance with any applicable federal or state requirements. BSM 5.02 Service recipients are monitored continuously, face-to-face, and assessed at least every 15 minutes for any harmful health or psychological reactions. BSM 6.01 The use of restrictive behavior management interventions is documented, including: a. the justification, use, circumstances, and length of application in the individual s case record; and b. names of the service recipient and personnel involved, reasons for the intervention, length of intervention, and verification of continuous 28
visual observation in a log. BSM 6.02 Debriefing occurs in a safe, confidential setting within 24 hours of the incident and includes the service recipient, appropriate personnel, the foster parents, and parents or legal guardian to: a. evaluate physical and emotional well-being; b. identify the need for counseling, medical care, or other services related to the incident; c. identify antecedent behaviors and modify the service plan as appropriate; and d. facilitate the person s reentry into routine activities. Financial Compliance No service is billed before the initial assessment is completed No service is billed prior to the assignment of a diagnosis No service is billed without a current treatment plan Date of service on bill is FIN 7.10 The organization that provides services as a vendor establishes safeguards against over- and under-billing that include: a. an accurate account of units of service provided; b. timely submission of invoices 29
correct There are no duplicate bills Diagnosis on bill matches current diagnosis in clinical record and required documents; and c. compliance with applicable regulations. Note: Organizations should review state Medicaid plans or other third party reimbursement claims processing requirements to avoid administrative denials for payment. Payment can be denied for many reasons, including, but not limited to: failure to submit the claim within the appropriate timeframe, incomplete or missing documentation or forms; and codes or services being inconsistent with authorizations. 30