Is Medicaid waiver billing different from “regular” Medicaid?

Short answer
Yes. Waiver billing plays by its own rulebook. You’ll see separate enrollment steps, tighter prior authorizations, different codes and modifiers, and often different portals and payment timelines.

What that means in practice

• Enrollment: Many waivers ask for their own applications, credentials, or licenses on top of your standard Medicaid enrollment.
• Authorizations: Waiver services usually need an approved care plan and a specific authorization before you bill a single unit.
• Codes and modifiers: Expect program-specific HCPCS codes and modifiers. For example, personal care might use S5125 with state modifiers that change the rate.
• Documentation: Visit notes tend to be more detailed and EVV rules are enforced more strictly.
• Portals and payments: Some waivers route claims through separate portals and pay on a different cadence than fee-for-service Medicaid.

How to keep it simple
Treat each waiver like its own payer. Know its enrollment steps, codes, rates, documentation rules, and reauth timelines, and build your workflows around those specifics.

If you prefer not to juggle all that, Paradigm can run the whole process for you, from waiver credentialing and authorizations to clean claim submission and payment posting.