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Reporting claims

Updated on April 26, 2021

Reporting claims contain detailed information about individual healthcare-related services provided by a managed care organization (MCO) or other state-designated managed care providers. Reporting claims are similar to standard Medicaid claims. The exception is that the MCO or provider submits the data to provide service delivery information to the state and is not eligible for reimbursement. States use the data for many purposes, including setting MCO rates, evaluating MCO performance, and providing detailed reports to governors, state budget agencies, legislatures, and the public about Medicaid services provided through MCOs and their costs.

A reporting claim, submitted by the provider, records services rendered by the provider. A reporting claim shows a service was paid by a contracted, pre-determined means. Reporting claims are used to validate a completed payment as well as help justify that a review for a request for higher reimbursement. Reporting claims are also loaded within the system to keep track of the benefits used (accumulators) as a whole.

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