| (C) Exception requests within paragraph (1)(B) of this
subsection. The provider must submit the written document from HHSC,
or its designee, that contains the erroneous information or explanation
of the delayed information.
(D) Exception requests within paragraph (1)(C) of this
subsection.
(i) The provider must submit the written repair statement,
invoice, computer or modem generated error report (indicating attempts
to transmit the data failed for reasons outside the control of the
provider), or the explanation for the system implementation problems.
The documentation must include a detailed explanation made by the
person making the repairs or installing the system, specifically indicating
the relationship and impact of the computer problem or system implementation
to claims submission, and a detailed statement explaining why alternative
billing procedures were not initiated after the delay in repairs or
system implementation was known.
(ii) If the provider is requesting an exception based
upon an electronic claim or system implementation problem experienced
by HHSC or its designee, the provider must submit a written statement
outlining the details of the electronic claim or system implementation
problems experienced by HHSC or its designee that caused the delay
in the submission of claims by the provider, any steps taken to notify
the state or its designee of the problem, and a verification that
the delay was not caused by the neglect, indifference, or lack of
diligence on the part of the provider or its employees or agents.
(E) Exception requests within paragraph (1)(D) of this
subsection. The provider must submit a written, detailed explanation
of the facts and documentation to demonstrate the 365-day federal
filing deadline for the benefit was met.
(F) Exception requests within paragraph (1)(E) of this
subsection. The provider must submit a written, detailed explanation
of the facts and activities illustrating the provider's efforts in
requesting eligibility information for the recipient. The explanation
must contain dates, contact information, and any responses from the
recipient.
(f) Exceptions to the 120-day appeal deadline. HHSC
shall consider exceptions to the 120-day appeal deadline if the criteria
listed in this subsection is met and there is evidence to support
paragraphs (1) or (2) of this subsection. The final decision about
whether a claim falls within one of the exceptions will be made by
HHSC. This is a one-time exception request; therefore, all claims
that are to be considered within the request for an exception must
accompany the request. Claims submitted after HHSC's determination
has been made for the exception will be denied consideration because
they were not included in the original request. An exception request
must be received by HHSC within 18 months from the date of service
in order to be considered. This requirement will be waived for the
exceptions listed in paragraphs (2) and (3) of this subsection and
subsection (g) of this section.
(1) Errors made by a third party payor that were outside
the control of the provider. The provider must submit a statement
outlining the details of the cause for the error, the exception being
requested, and verification that the error was not caused by neglect,
indifference, or lack of diligence on the part of the provider, the
provider's employee, or agent. This affidavit or statement should
be made by the person with personal knowledge of the facts. In lieu
of the above affidavit or statement from the provider, the provider
may obtain an affidavit or statement from the third party payor including
the same information, and provide this to HHSC as part of the request
for appeal.
(2) Errors made by the reimbursement entity that were
outside the control of the provider. The provider must submit a statement
from the original payor outlining the details of the cause of the
error, the exception being requested, and verification that the error
was not caused by neglect, indifference, or lack of diligence on the
part of the provider, the provider's employee or agent. In lieu of
the above reimbursement entity's statement, the provider may submit
a statement including the same information, and provide this to HHSC
as part of the request for appeal.
(3) Claims were adjudicated, but an error in the claim's
processing was identified after the 120-day appeal deadline. The error
is not the fault of the provider but an error occurred in the claims
processing system that is identified after the 120-day appeal deadline
has passed.
(g) Exceptions to the 24-month claim payment deadline.
To the extent allowed by federal law, HHSC shall consider exceptions
to the 24-month claim payment deadline for the situations listed in
this subsection. The final decision about whether a claim falls within
one of the exceptions will be made by HHSC.
(1) Refugee Eligible Status: The payable period for
all Refugee Medicaid eligible recipient claims is the federal fiscal
year in which each date of service occurs plus one additional Federal
Fiscal year. The date of service for inpatient claims is the discharge
date.
(2) Medicare/Medicaid Eligible Status: The payable
period for Medicaid/Medicare eligible recipient claims filed electronically
is 24 months from the date the file is received from Medicare by the
claims administrator for Medicaid. The payable period for Medicaid/Medicare
eligible recipient claims filed on paper is 24 months from the date
listed on the Medicare Remittance Advice.
(3) Retroactive Supplemental Security Income Eligible:
The payable period for Supplemental Security Income (SSI) Medicaid
eligible recipients when the Medicaid eligibility is determined retroactively
is 24 months from the date the Medicaid eligibility is added to the
eligibility file. This date is referred to as the "add date."
(4) Other HHSC approved situations: To the extent permitted
by state and federal laws, rules, and regulations, HHSC may, at its
sole discretion, consider other situations as exceptions to the provider
24-month time limit if the provider shows good cause.
|
| Source Note: The provisions of this §354.1003 adopted to be effective July 1, 1992, 17 TexReg 3912; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective October 16, 1996, 21 TexReg 9635; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective May 14, 2003, 28 TexReg 3823; amended to be effective December 25, 2003, 28 TexReg 11248; amended to be effective August 26, 2007, 32 TexReg 5163; amended to be effective November 15, 2009, 34 TexReg 7777; amended tobe effective July 23, 2013, 38 TexReg 4575; amended to be effective February 18, 2021, 46 TexReg 1031 |
