Documentation for Medicaid

Medicaid Toolkit

States require documentation for all Medicaid services provided; however, documentation requirements may vary depending on the state and the setting (e.g., school, clinic, or hospital) where the service is provided. State-specific documentation requirements, rules, and guidance can be found in the state's Medicaid plan and/or Medicaid agency guidance documents (e.g., the state provider handbook). One example of a state provider handbook can be found on the Alaska Medicaid website. State associations of audiology and speech-language pathology may meet with local Medicaid agencies and offer to collaborate on manuals and make suggestions for documentation processes that ensure timely reimbursement and limited denials.



Providers faced with cumbersome paperwork and duplicative data entry may choose to advocate changes in documentation requirements. Many professionals are not aware that the majority of concerns can be addressed at the state level or within the work setting. Some states have published Medicaid provider manuals that list specific requirements for documentation, which can be used to advocate for workplace changes. For example, Virginia offers provider manuals for a variety of settings, including local education agencies, nursing facilities, and early intervention. Other related topics for advocacy include demonstration of medical necessity, sufficiency of IEP, and physician referral.


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