Medical billing services in Vermont

Billing in Vermont: what's different

The rules below change how a claim is filed and paid in Vermont. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.

Rules that change how Vermont claims are billed

• 180 days from the begin date of service, and the fiscal agent's control number is the only proof¹

  The General Billing and Forms Manual dated October 22, 2026 gives Gainwell 180 days from the begin date of service to receive a Medicaid primary claim, 180 days from the discharge date for inpatient stays, 180 days from Medicare's processing date when Medicare is primary, and 365 days from the date of service when other insurance is primary or when a member or provider was granted retroactive eligibility or enrollment. A claim counts as filed when the fiscal agent documents receipt by assigning an internal control number; postmarks, certified mail receipts, dated signatures and clerical claim listings are not proof, holidays and closures do not extend the period, and waiting for prior authorization or correspondence is not an acceptable reason for late filing. If a claim has not appeared on a remittance advice within 30 days of transmission or mailing, the provider is expected to check with the fiscal agent and resubmit.

• The state is the plan: DVHA acts as Vermont's single MCO entity⁵

  CMS's 2024 state tables record the Global Commitment to Health demonstration as a full-benefit MCO plus MLTSS program with one participating plan, the Department of Vermont Health Access, running statewide since October 1, 2005 under section 1115(a) authority with its waiver through December 31, 2027. Enrollment is mandatory and pre-assigned for every population including full duals and foster children, the covered benefits run from inpatient care to HCBS waiver services, private duty nursing and non-emergency transportation, HEDIS and CAHPS reporting are required, and Health Services Advisory Group is the external quality review organization. For a practice that means one Medicaid enrollment, one fee schedule and one claims route, with the Global Commitment rules sitting behind DVHA's own.

• Payers have 30 days to pay or respond, with 12 percent interest behind it⁶

  Under 18 V.S.A. § 9418, a health plan, contracting entity or payer has 30 days after receiving a claim to pay it or to take one of the other steps the section allows, such as notifying the provider that the claim is contested, meaning the payer lacks the information or reasonable access to the information needed to decide liability, or denied. Electronic claims must be acknowledged within 24 hours after the beginning of the next business day following receipt, and unpaid amounts accrue interest at 12 percent a year under the conditions subsection (e) sets. The section does not define a clean claim, so the contract's definition and the 30-day receipt date are what a Vermont commercial follow-up cites.

• Rides come from public transit brokers, and 5 percent of ride requests are verified with the practice¹

  Non-emergency medical transportation is a statewide covered service for members in traditional Medicaid, Primary Care Plus and Dr. Dynasaur, provided through personal services contracts between the Agency of Human Services, DVHA and local public transit brokers rather than a single statewide broker. CMS requires transportation providers to verify that trips go to eligible medical appointments, DVHA currently requires them to verify 5 percent of all ride requests, and every medical provider is required to confirm a member's appointment when a Vermont Medicaid transportation provider asks. Ambulance claims follow a different rule: the physician certifies that other means of transportation would endanger the member's health, and a service the member could have reached by taxi or bus falls under NEMT, not ambulance.

• Medicare crossovers arrive on their own, and a Medicare denial gets twelve months¹

  When Vermont Medicaid eligibility is marked on the Medicare claim, the claim and any later adjustments cross over to Gainwell automatically, and a provider that has not seen the DVHA payment within 30 days of the Medicare paid date submits the claim with the Medicare Attachment Summary Form from the Vermont Medicaid forms page. A service Medicare denies as non-reimbursable but DVHA covers is billed on a CMS-1500 completed to DVHA specifications with the Medicare denial attached, within twelve months of the date of service. Out-of-state providers other than New Hampshire's bill their regional Medicare carrier first and then send Gainwell the coinsurance or deductible claim with the summary form showing the Medicare payment date, and paper crossovers for dates of service more than two years old need both the form and the Medicare EOB.

• Home health EVV was accepted by CMS from the start of 2024⁸

  CMS's December 19, 2023 letter to Vermont's Medicaid Director accepted the state's attestation that its EVV system met section 1903(l) of the Social Security Act for home health care services under the section 1905(a)(7) home health benefit and the section 1115 demonstration, so no FMAP reduction applied to those services. Like the 2021 personal care letter, it reserves CMS's right to apply reductions if the system does not match the attestation and requires the state to update its survey if it adds authorities, which is the standard a home health agency's EVV records are held to.

Services for Vermont practices

Remitwright serves Vermont practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.

• Medical billingClaims worked by one named biller
• CredentialingEnrollment, CAQH and PECOS kept current
• Eligibility verificationCoverage and benefits checked before visits
• Prior authorizationAuths requested, tracked, attached to claims
• Denial managementEvery denial read, worked and appealed
• A/R follow-upUnpaid claims chased before filing limits