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Medical Expense Initiative

National and State-level Medicaid Rules

Medicaid content will be included in the editing tools currently used by WellCare.  Medicaid experts continually monitor CMS for quarterly and special regulatory updates to national rules; updates are delivered on a quarterly basis to the editing tool.

This content will include both National and State specific editing guidelines.

National Medicaid rules

National Medicaid editing rules are based on CMS guidelines and are applicable to all
Medicaid claims.

Examples of these national rules include:
• Medicaid National Correct Coding Initiative (NCCI)
• Medically Unlikely Edits (MUE)
• National Physician Fee Schedule
• Medicaid national policies and guidelines issued by CMS
• Validation edits

State-level Medicaid rules

State Medicaid editing rules are based on guidelines published by each state or territory (jurisdiction). Each state defines how guidelines are organized, communicated and published.

State-level Medicaid rules are based on:
• State-specific policies and guidelines
• State-specific fee schedule
• State-specific code sets

Edit examples may include:
• Immunizations
• Family Planning
• Laboratory services
• Durable Medical Equipment Edits
• Prescription referrals
• Validation Edits
• Modifier requirements

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Last Updated On: 12/3/2020