| (a) Claim submission deadline. A physician or a provider
must submit a claim to an MCC not later than the 95th day after the
date the physician or the provider delivers the medical care or health
care services for which the claim is made. An MCC and a physician
or a provider may agree, by contract, to extend the period for submitting
a claim. For a claim submitted by an institutional provider, the 95-day
period does not begin until the date of discharge. For a claim for
which coordination of benefits applies, the 95-day period does not
begin for submission of the claim to the secondary payor until the
physician or the provider receives notice of the payment or the denial
from the primary payor.
(b) Failure to meet claim submission deadline. If a
physician or a provider fails to submit a claim in compliance with
this section, the physician or the provider forfeits the right to
payment unless the physician or the provider has certified that the
failure to timely submit the claim is a result of a catastrophic event
in compliance with §21.2819 of this title (relating to Catastrophic
Event).
(c) Manner of claim submission. A physician or a provider
may submit claims by United States mail, first class; United States
mail, return receipt requested; overnight delivery service; electronic
transmission; hand delivery; facsimile, if the MCC accepts claims
submitted by facsimile; or as otherwise agreed to by the physician
or the provider and the MCC. An MCC must accept as proof of timely
filing a claim filed in compliance with this subsection or information
from another MCC showing that the physician or the provider submitted
the claim to the other MCC in compliance with this subsection.
(d) Determining date of submission. Section 21.2816
of this title (relating to Date of Receipt) determines the date an
MCC receives a claim.
(e) Duplicate claims.
(1) A physician or a provider may not submit a duplicate
claim before the 46th day, or the 31st day if filed electronically,
after the date the original claim is received according to the provisions
of §21.2816 of this title, except as provided in paragraph (2)
of this subsection for prescription benefit claims.
(2) A physician or a provider may not submit a duplicate
claim for prescription benefits before the 22nd day, or the 19th day
if filed electronically, after the date the original claim is received
according to the provisions of §21.2816 of this title.
(3) An MCC that receives a duplicate claim before the
applicable date specified in paragraphs (1) and (2) of this subsection
is not subject to the provisions of §21.2807 of this title (relating
to Effect of Filing a Clean Claim) or §21.2815 of this title
(relating to Failure to Meet the Statutory Claims Payment Period)
with respect to the duplicate claim.
|
