Medicaid Reimbursement for Lead-Related Services

When seeking Medicaid reimbursement, remember that reimbursement for services begin at a blood lead level of 5 µg/dL. Reimbursement rates can be verified by contacting the Childhood Lead Poisoning Prevention Program (CLPPP). 

Medicaid provider field representatives (PDF) are available in each region of the state to provide technical assistance.

In February 2022, the CLPPP team presented a webinar on Medicaid reimbursement for lead-related services:


Frequently asked questions

General information

How do I submit a claim for reimbursement of a lead-related service?

Claims can be submitted two ways:

  1. Electronic claims submission
    • ForwardHealth Portal using the online claim submission software
    • Provider Electronic Solutions (PES) claims submission software
      • The Division of Medicaid Services offers electronic billing software at no cost to the provider. To obtain PES software, providers may download it from the ForwardHealth Portal. For assistance installing and using PES software, providers may call the Electronic Data Interchange (EDI) Helpdesk at 866-416-4979.
  2. Paper submission
    • Paper claims must be submitted using the 1500 Health Insurance Claim Form. ForwardHealth does not provide the 1500 Health Insurance Claim Form. The form may be obtained from any federal forms supplier.

How long from the date of service (DOS) can I submit a reimbursement claim?

Claims may be submitted 365 days from the DOS.

What does the child's blood lead level need to be in order to bill Medicaid for services?

In order to bill for a home visit or environmental investigation the child has to have one capillary or venous blood lead level, greater than or equal to 5 µg/dL.

Is there any special documentation required for billing, or are the DHS forms/reports acceptable?

The property investigation or clearance report, that you created as part of your lead investigation, are sufficient as documentation of the environmental services provided, if you have used the DHS-approved templates for these reports. The DHS-provided nursing case management form only captures the initial home visit date. Additional documentation of a subsequent education visit(s) is recommended.

Can a local health department bill for lead investigations and education visits if they have Case Management certification, but not HealthCheck certification?

No, a local health department must enroll as a HealthCheck screening provider in order to bill for lead investigations and education visits.

Do we need to get the HealthCheck Screener with Case Management certification?

Local health departments can enroll as HealthCheck providers to do screens, case management, or both. Local health departments that are enrolled as HealthCheck Screener or HealthCheck Screener/Case Management providers can bill for lead investigations and nurse education visits.

Who is considered the HealthCheck Screener? Is it always a nurse?

The local health department becomes certified as a HealthCheck Screener or HealthCheck Screener/Case Management, which allows the health department to bill for services conducted by staff within the department. However, to bill for the education visit, a registered nurse must perform the visit.

How does a local health department enroll as a HealthCheck Screener?

More information on becoming a HealthCheck Screener is available on the ForwardHealth Portal

We receive general purpose revenue from the state through the Childhood Lead Program Consolidated Contract. Can we still submit claims to the Medicaid Program as long as we do not receive more money than the program costs?

Yes. Medicaid reimburses for the costs of individual services provided: nurse education home visits, initial lead investigations (i.e., lead risk assessments), and follow-up investigations (i.e., clearances). You are then free to use your consolidated contract childhood lead program funds for other lead-related activities covered under your contract with the Division of Public Health and for any costs not covered fully by the Medicaid reimbursement. You may not use your consolidated contract funds for Medicaid-reimbursable costs.

Nursing Education Visit

What is a billable unit for a nursing education visit in the home?

A billable unit is a single block of time up to 15 minutes. Up to four billable units (totaling up to 1 hour) may be billed per day, per provider, per child.

For example, you visit a home and provide services to two children and the visit is two hours long. You can bill one hour to one child and the other hour to the other child.

Are the home visit education services conducted by a registered nurse billable only up to 15 minutes, or in 15-minute increments, up to an hour?

Home visits for education by a registered nurse are submitted for 15-minute increments. Up to four units (totaling up to 1 hour) can be submitted per day, per provider, per child.

Can you bill for services if a public health educator does the in-home lead education instead of a registered nurse?

No. A claim for an in-home lead education visit may only be submitted when provided by a registered nurse. The billing procedure code (T1002) is for registered nursing services.

Can the nurse education visit be billed if it is done over the phone?

Due to the COVID-19 pandemic, a temporary telehealth policy is in effect. A nurse education visit performed over the phone can be billed until the switch to permanent policy occurs, effective on the first day of the first month after the federal public health emergency related to the COVID-19 pandemic expires. For more information, please visit the December 2021 ForwardHealth Update.

Environmental Lead Investigations

If the certified lead risk assessor conducting the risk assessment works for another health department, who bills for those services?

The local health department that employs the certified lead risk assessor submits the claim for the services conducted.

Can I use LeadCheck swabs to test for lead hazards in a risk assessment or clearance investigation?

No. LeadCheck swabs may not be used when conducting a lead risk assessment or a clearance investigation. Paint may be tested using an x-ray fluorescence analyzer (XRF), or by taking paint chip samples. Dust may only be tested by taking dust wipe samples.

A clearance investigation requires both a visual assessment and dust wipe sampling for interior work. If the visual assessment does not pass because not all work was completed or visible dust and debris was present, can we submit a claim without having collected dust wipe samples?

Yes. Submit a claim for the cost of the time spent doing the visual assessment, even though you were not able to collect dust wipe samples.

For the clearance investigation, can we use an x-ray fluorescence (XRF) analyzer instead of collecting dust wipe samples for interior work?

No, dust wipe samples are required when conducting clearance after interior work.

Can we hire a private lead risk assessor to perform the environmental lead investigation and pay for it out of the $800 Medicaid reimbursement?

Yes. Medicaid policy allows a local health department to bill for a lead investigation that was performed by a private lead risk assessor and use the funds to pay the risk assessor.

What amount do I put in as the cost of my services? For example, do I put in $900 for an environmental lead investigation because that is my cost, even though I may only get the maximum reimbursement of $800?

Submit a claim for the actual amount it cost your program to provide the service, even though you will only be reimbursed for the maximum fee allowable for that service. Putting in your actual costs will provide the Medicaid Program with the reality of what it costs to perform the work.

Can I bill for a lead investigation of a supplemental address for a child?

You can bill for investigations of two residences in cases of shared custody where the child regularly spends time at each respective parent’s home. Reimbursement is not allowed for other supplemental addresses for the child, such as the babysitter’s or grandparent’s home, because they are not considered residences for the child.

If a child moves out of the home where he or she lived when found to have lead poisoning before the investigation of the home could be conducted, can the local health department submit a claim for the investigation of the home where the child tested high?

Yes. The local health department can bill for the lead investigation of the property where the child tested high, even if the child no longer lives there.

I need to update a risk assessment that's over a year old because the lead hazard remediation work still hasn't been completed, but the child originally lead-poisoned in that home is no longer living there. Can I bill for a new lead investigation of the home, even if the child is no longer living there?

Yes, you can bill for one investigation per property every 12 months. You can bill for the lead investigation of the property where the child tested high, even if the child no longer lives there.

To qualify for reimbursement, is there a required timeframe between when the child’s blood lead level is drawn and when the environmental investigation must be conducted?

No, Medicaid policy does not indicate a time period between when the child’s blood lead level is drawn and when the environmental investigation is conducted.

If a lead-poisoned child moves to a new home and the local health department conducts a risk assessment to make sure the home is safe for the child, is the risk assessment of the new home covered by Medicaid?

No, the property has to be associated with a blood lead level of 5 µg/dL or more for the child while residing at the property.

Nursing and Environmental

Does the clearance investigation have to be done by a certified lead hazard investigator/risk assessor or can it be conducted by a registered nurse?

Only a certified lead hazard investigator or certified lead risk assessor may conduct the clearance investigation.

Can a lead investigation and education home visit be billed on the same day if done by the same individual?

Yes. If the individual is a registered nurse and a certified lead hazard investigator or risk assessor, you can submit claims for both services conducted on the same day by the same person.

If both the environmental health specialist and the registered nurse conduct the lead poisoning prevention education with the family during a home visit, can we bill for services for both staff?

You may only bill for the education home visit conducted by the registered nurse. The billing procedure code (T1002) is for registered nursing services. Services billable for an environmental health specialist are the initial environmental lead investigation (i.e., risk assessment) and follow-up investigation (i.e., clearance).

 

Are you able to bill for the nursing assessment (like behavior, nutrition, etc.) as part of nursing education or the lead investigation? Or are they included in the $800 charge?

The nursing assessment should be included when billing for the education visit and is separate from billing for the lead investigation. If a nurse conducts both the education visit and the lead investigation, these two services should be billed separately.

When local health departments conduct risk assessments as part of a grant program, such as HUD Lead Hazard Reduction, what is the best way to bill for these services?

In general, federal grant programs do not allow you to cover items that are allowable under other federal programs. You should always refer to the requirements or restrictions of the specific grant program in question. With the consolidated contract, the funds should only be used for services that are not reimbursable by a third party, such as Medicaid.

Can I bill for nurse education visits and environmental investigations at the new CDC blood lead reference value of 3.5 µg/dL now?

No, until the Medicaid reimbursement policy is changed, you may only bill for a child with a blood lead level of 5 µg/dL or more.

Last Revised: August 4, 2022