| (a) Claims filing deadlines. Claims must be received
by the Health and Human Services Commission (HHSC) or its designee
in accordance with the following time limits to be considered for
payment. Due to the volume of claims processed, claims that do not
comply with the following deadlines will be denied payment.
(1) Inpatient hospital claims. Final inpatient hospital
claims must be received by HHSC or its designee within 95 days from
the date of discharge or 95 days from the date the Texas Provider
Identifier (TPI) Number is issued, whichever occurs later. In the
following situations, hospitals may, and in one instance, must file
interim claims:
(A) Hospitals reimbursed according to prospective payment
may submit an interim claim after the patient has been in the facility
30 consecutive days or longer.
(B) Children's hospitals reimbursed according to Tax
Equity and Fiscal Responsibility Act of 1982 (TEFRA) methodology may
submit interim claims prior to discharge and must submit an interim
claim if the patient remains in the hospital past the hospital's fiscal
year end.
(2) Outpatient hospital claims must be received by
HHSC or its designee within 95 days from each date of service on the
claim or 95 days from the date the Texas Provider Identifier (TPI)
Number is issued, whichever occurs later.
(3) Claims from all other providers delivering services
reimbursed by the Texas Medicaid acute care program must be received
by HHSC or its designee within 95 days from each date of service on
the claim or 95 days from the date the Texas Provider Identifier (TPI)
Number is issued, whichever occurs later. This requirement does not
apply to providers who deliver long-term care services and are subject
to the billing requirements under Title 40 of the Texas Administrative
Code.
(4) Providers must adhere to claims filing and appeal
deadlines and all claims must be finalized within 24 months of the
date of service. Submitted claims that exceed this time frame and
do not qualify for one of the exceptions listed in subsection (g)
of this section will not be considered for payment by the Texas Medicaid
program.
(5) The following exceptions to the claims-filing deadlines
listed in this subsection apply to all claims received by HHSC or
its designee regardless of provider or service type.
(A) Claims on behalf of an individual who has applied
for Medicaid coverage but has not been assigned a Medicaid recipient
number on the date of service must be received by HHSC or its designee
within 95 days from the date the Medicaid eligibility is added to
HHSC's eligibility file. This date is referred to as the "add date."
(B) If a client loses Medicaid eligibility and is later
determined to be eligible, or if the Medicaid eligibility is established
retroactively, the claim must be received by HHSC or its designee
within 95 days from the "add date" and within 365 days from the date
of service.
(C) When a service is a benefit of Medicare and Medicaid,
and the client is covered by both programs (dually eligible), the
claim must first be filed with Medicare. Claims processed by Medicare
must be received by HHSC or its designee within 95 days from the date
of Medicare disposition or final determination of any Medicare appeal
decision.
(D) When a client is eligible for Medicare Part B only,
the inpatient hospital claim for services covered as Medicaid only
should be submitted directly to Medicaid. The time limits in paragraph
(1) of this subsection apply.
(E) When a service is billed to another insurance resource,
the claim must be received by HHSC or its designee within 95 days
from the date of disposition by the other insurance resource.
(F) When a service is billed to a third party resource
that has not responded, the claim must be received by HHSC or its
designee within 365 days from the date of service. However, 110 days
must elapse after the third party billing before submitting the claim
to HHSC or its designee.
(G) When a Title XIX family planning service is denied
by Title XX prior to being submitted to Medicaid, the claim must be
received by HHSC or its designee within 95 days of the date on the
Title XX Denial Remittance Advice.
(H) Claims for services rendered by out-of-state providers
must be received by HHSC or its designee within 365 days from the
date of service.
(I) Claims for services rendered by the County Indigent
Health Care Program, for which certification of the expenditures of
local or state funds is required, are due to HHSC or its designee
within the 365-day federal filing deadline.
(J) Claims for services rendered by school districts
under the School Health and Related Services (SHARS) program, for
which certification of the expenditures of local or state funds is
required, are due to HHSC or its designee within the 365-day federal
filing deadline or 95 days after the last day of the Federal Fiscal
Year (FFY), whichever comes first.
(K) Claims for services rendered by enrolled Medicaid
providers under the Department of Assistive and Rehabilitative Services'
Blind Children's Vocational Discovery and Development Program (BCVDDP),
for which certification of the expenditures of local or state funds
is required, are due to HHSC or its designee within 365 days from
the date of service.
(b) Appeals. All appeals of claims and requests for
adjustments must be received by HHSC or its designee within 120 days
from the date of the last denial of and/or adjustment to the original
claim. Appeals must comply with §354.2217 of this chapter (relating
to Provider Appeals and Reviews).
(c) Incomplete Claims. Claims received by HHSC or its
designee that are lacking the information necessary for processing
will be denied as incomplete claims. The resubmission of the claim
containing the necessary information must be received by HHSC or its
designee within 120 days from the last denial date.
(d) Extension. If a filing deadline falls on a weekend
or holiday, the filing deadline shall be extended to the next business
day following the weekend or holiday.
(e) Additional Exceptions to the 95-day Claim Filing
Deadline.
(1) HHSC shall consider the following additional exceptions
when at least one of the situations included in this subsection exists.
The final decision of whether a claim falls within one of the exceptions
will be made by HHSC.
(A) Catastrophic event that substantially interferes
with normal business operations of the provider, or damage or destruction
of the provider's business office or records by a natural disaster,
including but not limited to fire, flood, or earthquake; or damage
or destruction of the provider's business office or records by circumstances
that are clearly beyond the control of the provider, including but
not limited to criminal activity. The damage or destruction of business
records or criminal activity exception does not apply to any negligent
or intentional act of an employee or agent of the provider because
these persons are presumed to be within the control of the provider.
The presumption can only be rebutted when the intentional acts of
the employee or agent leads to termination of employment and filing
of criminal charges against the employee or agent; or
(B) Delay or error in the eligibility determination
of a recipient, or delay due to erroneous written information from
HHSC or its designee, or another state agency; or
(C) Delay due to electronic claim or system implementation
problems experienced by HHSC and its designee or providers; or
(D) Submission of claims occurred within the 365-day
federal filing deadline, but the claim was not filed within 95-days
from the date of service because the service was determined to be
a benefit of the Medicaid program and an effective date for the new
benefit was applied retroactively; or
(E) Recipient eligibility is determined retroactively
and the provider is not notified of retroactive coverage.
(2) Under the conditions and circumstances included
in paragraph (1) of this subsection, providers must submit the following
documentation, if appropriate, and any additional requested information
to substantiate approval of an exception. All claims that are to be
considered for an exception must accompany the request. HHSC will
consider only the claims that are attached to the request.
(A) All exception requests. The provider must submit
an affidavit or statement from the provider stating the details of
the cause for the delay, the exception being requested, and verification
that the delay was not caused by neglect, indifference, or lack of
diligence of the provider or the provider's employee or agent. This
affidavit or statement must be made by the person with personal knowledge
of the facts.
(B) Exception requests within paragraph (1)(A) of this
subsection. The provider must submit independent evidence of insurable
loss; medical, accident, or death records; or police or fire report
substantiating the exception of damage, destruction, or criminal activity.
Cont'd... |
