School Based Claiming Program
The School Based Claiming program is a federal program that offers reimbursement for both the provision of covered medically necessary school-based services (Direct Service Claiming) and the costs of administrative activities (Medicaid Administrative Claiming), such as outreach, which supports the Medicaid school-based program. The Centers for Medicare and Medicaid Services (CMS) is the regulatory agency that funds and oversees these school-based programs at the federal level.
Arizona Medicaid School-Based Claiming Program
Arizona participates in two Medicaid reimbursement programs for school-based services which serves Arizona Medicaid enrolled students. In State Fiscal year 2020, approximately 43,000 students received Medicaid eligible services as prescribed in their Individualized Education Program (IEP). AHCCCS predicts a twenty 20 percent growth in the Medicaid School-Based Claiming (MSBC) Program in SFY 2022 with the open care transformation that will cover all Medicaid enrolled children. These school-based programs assist charter schools, the Arizona School for the Deaf and Blind (ASDB), and participating school districts, referred to as Local Education Agencies (LEAs), by reimbursing them for their costs to provide Medicaid covered services to enrolled students.
The purpose of the Direct Service Claiming (DSC) Program is to allow LEAs to receive reimbursement for the cost to provide Medicaid covered medical services to Title XIX eligible students. Only Title XIX members are eligible for the DSC Program. The purpose of the Medicaid Administrative Claiming (MAC) program is to allow LEAs to receive reimbursement for Medicaid administrative outreach activities that occur routinely within the school setting. The MAC program is one of the two federally funded programs endorsed by the Arizona Department of Education (ADE) and AHCCCS.
Role of AHCCCS
AHCCCS is Arizona’s Medicaid Program that was developed as a result of Title XIX of the Social Security Act. The DSC and the MAC programs in Arizona are two of the programs that are overseen by AHCCCS, Arizona's Medicaid agency. AHCCCS develops the policies and contracts with a Third-Party Administrator (TPA), Public Consulting Group (PCG), to administer both the DSC and MAC programs in Arizona. PCG administers the program in collaboration with ADE.
Contracting with Public Consulting Group (PCG)
In order to become contracted with PCG, a LEA must:
- Be an Arizona public school district or an Arizona charter school,
- Have students enrolled with AHCCCS,
- Provide one or more of the Medicaid covered services on site, and
- Sign an agreement with PCG
The agreement details the responsibilities and rights of both PCG and the participating LEA and the services to be provided to the LEA. The completed contract allows the LEA to participate in the MSBC Program administered by PCG. Upon receipt of the signed contract, PCG will work with the LEA to implement the Medicaid claiming processes.
For more information, visit Public Consulting Group’s website, at: https://web.pcgus.com/
Medicaid School Based Claiming FAQs
Medicaid School-Based Billing Fact Sheet
