Glossary of Medicaid Doula Terms Every Provider Should Know

The Medicaid system has its own language — and understanding it is part of being an effective provider. Here’s a plain-language glossary of the terms you’ll encounter most as a Medicaid doula.

CredentialingThe process by which an MCO verifies your qualifications, training, and background before adding you to their provider network. Each MCO credentials separately. Timeline: approximately 45 days.

CMS (Centers for Medicare & Medicaid Services)The federal agency that administers Medicare and oversees Medicaid in partnership with states. CMS sets national standards; states implement them with some variation.

CPT Code (Current Procedural Terminology)A standardized code that identifies a specific medical or clinical service for billing purposes. Doulas use CPT codes when submitting claims to Medicaid and MCOs.

EIN (Employer Identification Number)A federal tax identification number assigned to businesses by the IRS. Used in place of your SSN on business enrollment applications. Free to obtain through the IRS website.

EOB (Explanation of Benefits)A document sent by an MCO or Medicaid explaining how a claim was processed — what was paid, what was denied, and why.

Fee-for-Service (FFS)The traditional Medicaid payment model in which the state pays providers directly for each covered service. Doulas must enroll in FFS before joining MCOs.

HIPAA (Health Insurance Portability and Accountability Act)Federal law governing the privacy and security of protected health information. As a Medicaid provider, doulas are required to maintain HIPAA compliance.

ICD-10 CodeA diagnostic code used to describe the reason for a service. Used alongside CPT codes in claim submissions.

MCO (Managed Care Organization)A health insurance plan that contracts with the state to provide Medicaid benefits to enrollees. Examples in New York include Healthfirst, Fidelis Care, Anthem, and Molina Healthcare. Most Medicaid recipients receive their benefits through an MCO.

NPI (National Provider Identifier)A unique 10-digit number issued by CMS that identifies a healthcare provider. Required for Medicaid enrollment. Apply for free at NPPES.

PA (Prior Authorization)Approval from an MCO required before certain services are covered. Know which visit types require prior authorization for each plan you’re contracted with.

Provider AgreementThe contract between you and an MCO that outlines reimbursement rates, billing requirements, covered services, and your obligations as a network provider.

Provider ManualA document published by each Medicaid agency or MCO that describes covered services, billing requirements, and provider obligations. Read this before you apply.

Remittance AdviceA document from Medicaid or an MCO that lists all claims processed in a payment cycle, including what was paid and what was adjusted or denied.

Timely Filing LimitThe deadline for submitting a claim after the date of service. Missing this window typically results in a permanent denial. Know this limit for every plan you bill.

W-9 FormAn IRS tax form providing your taxpayer identification information. Required by most MCOs and Medicaid agencies during enrollment.