Healthcare Inpatient Medicaid Contract

HEALTHCARE INPATIENT MEDICAID CONTRACT

Parties and Effective Date

Provider Name:   Provider Address:

Patient Name:   Medicaid ID:

Effective Admission Date: Month Day Year

Patient Information

Month Day Year

Female    Male    Other / Prefer not to say

Insurance / Medicaid Coverage

Medicaid Program / State Plan:   Group / Policy Number:

Medical History and Current Condition

Scope of Services and Coverage

The Provider shall furnish inpatient services deemed medically necessary by the attending physician and covered by the Patient's Medicaid benefit. Services include room and board, nursing care, diagnostic testing, medications administered as an inpatient, and other treatments customarily provided in an inpatient setting. Coverage of any specific service is subject to Medicaid program rules, medical necessity determinations, and prior authorization requirements when applicable.

The Patient acknowledges and agrees that care not covered by Medicaid (including elective services, non-emergent private accommodations, or services denied by a Medicaid eligibility or authorization determination) may result in responsibility for payment by the Patient or the Patient's responsible party.

Financial Terms, Assignment of Benefits and Billing

The Patient assigns to the Provider all rights to payment and benefits payable under the Patient's Medicaid coverage for services rendered by the Provider during the admission period. The Provider is authorized to submit claims, obtain payment directly from Medicaid, and to release medical information necessary for claims processing, appeals, or audits. Payment by Medicaid to the Provider shall be accepted as full payment to the extent permitted by Medicaid rules for covered services.

The Patient remains responsible for any non-covered services, cost sharing, copayments or third-party liabilities permitted under applicable law. If Medicaid denies coverage or payment and no other responsible third party pays, the Patient may be billed for amounts determined to be the Patient's responsibility under applicable law and policy.

Consent for Treatment; Release of Information; HIPAA Acknowledgment

The Patient consents to necessary inpatient treatment, examinations, tests and procedures while admitted to the Provider. The Patient authorizes the Provider to disclose medical and billing information to Medicaid, other insurers, health care entities involved in treatment, and their authorized agents as necessary for payment, care coordination, utilization review, quality improvement, or as otherwise permitted by law.

The Patient acknowledges receipt of the Provider's privacy notice and understands that the Provider will protect protected health information in accordance with applicable privacy and security requirements.

This authorization for treatment, assignment of benefits, and release of information expires on: Month Day Year

Patient Responsibilities and Acknowledgments

The Patient certifies that the information provided in this contract is true and complete to the best of the Patient's knowledge. The Patient agrees to cooperate with the Provider and Medicaid in obtaining necessary certifications, prior authorizations and documentation. The Patient understands that knowingly submitting false information to obtain services or benefits may subject the Patient to civil or criminal penalties under applicable law.

The Patient acknowledges that Provider may communicate regarding care and billing with the individual's authorized representative and emergency contact identified herein. If the Patient does not have valid Medicaid coverage at any time, the Provider may seek payment from the Patient or applicable responsible party for services rendered.

Termination, Appeals, Governing Law

This Contract may be terminated by the Provider upon termination or suspension of the Patient's Medicaid eligibility, for failure to cooperate with required authorizations, or for other material breach by the Patient. Payment obligations that accrued prior to termination remain enforceable as permitted by law.

Disputes relating to coverage determinations or payment under this Contract shall be governed by applicable Medicaid appeals and grievance procedures. To the extent not preempted by federal or state Medicaid law, this Contract is governed by the laws of the state in which the Provider operates.

Certifications and Signatures

By signing below, the Patient (or authorized representative) certifies that they have read and understand the terms of this Inpatient Medicaid Contract, consent to treatment and assignment of benefits as described, and authorize the disclosure of necessary information for payment and care coordination.

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