Glossary
Medicaid doula billing glossary
Short definitions for the terms doulas see in Medicaid billing guides, payer pages, and claim checks.
Quick path
Start with the step you need.
- 1Find the rule for your stateStart with the state where the client has Medicaid coverage.Choose your state
- 2Check what is missingReview setup, visit notes, codes, and payer steps before billing.Use the checklist
- 3Save the checklistDownload the checklist, then keep client details in your own secure records.Open checklist
Terms
Open a term for the plain definition and related guides.
NPI
An NPI is a national provider number used on healthcare claims and payer enrollment records. Some doula Medicaid programs require an individual NPI, a group NPI, or both.
ProviderOne
ProviderOne is Washington's Medicaid provider and billing system. Washington doulas use it for provider setup and fee-for-service claim entry.
Fee schedule
A fee schedule is a payer table that lists codes, rates, and sometimes modifiers or effective dates. It helps show what a state says it pays before payer review.
Managed care / MCO
Managed care means a Medicaid health plan handles some or all coverage and billing steps for a member. MCO stands for managed care organization.
Fee-for-service
Fee-for-service is a Medicaid payment path where the state Medicaid program pays claims directly instead of routing them through a managed care plan.
837P
An 837P is the professional healthcare claim format used by many billing systems and clearinghouses. Doulas may see it when a biller or software prepares a professional claim.
CPT
CPT codes are medical procedure codes used on claims and fee schedules. Some state doula guides use CPT-style codes or state-specific billing rows.
HCPCS
HCPCS codes are healthcare billing codes often used for Medicaid services, supplies, and state benefit rows. Many doula programs use HCPCS codes such as T1032 or T1033.
Modifier
A modifier is added to a billing code to describe a specific service, setting, or program rule. Examples include state-specific modifiers for doula visit type or delivery support.
Timely filing
Timely filing is the deadline for sending a claim or corrected claim to the payer. The deadline can vary by state, payer, plan, and claim type.
Unit-based billing
Unit-based billing means payment is calculated from billing units, often 15-minute time blocks. The state may set a unit rate and a maximum number of units.
Prior authorization
Prior authorization is payer approval before a service, extra visit, or exception is billed. Some states use a different term, such as prior approval.
Provider enrollment
Provider enrollment is the process of being approved by Medicaid or a Medicaid plan before billing. It can include IDs, attestations, portal setup, and state-specific documents.
Eligibility verification
Eligibility verification means checking that the client has active Medicaid coverage for the relevant date and payer path. It should happen outside public tools.