1 Tex. Admin. Code § 354.1003 - Time Limits for Submitted Claims
(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
(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.
(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.
Notes
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