Sec. 10.09.36.06. Billing Time Limitations

A. Definition.

(1) In this regulation, the following term has the meaning indicated.

(2) Term Defined. “Received” means:

(a) The Program taking delivery of a claim after the Program signs a certified mail, return receipt requested parcel from the United States Postal Service; or

(b) The claim is reported on the provider’s remittance advice.

B. Unless specified in Regulation .03A(1) of this chapter, the following apply:

(1) The Department may not reimburse the claims received by the Program for payment more than 12 months after the date of service.

(2) Medicare Claims. For any claim initially submitted to Medicare and for which services have been:

(a) Approved, requests for reimbursement shall be submitted and received by the Program within 12 months of the date of service or 120 days from the Medicare remittance date, as shown on the Explanation of Medicare Benefits, whichever is later; and

(b) Denied, requests for reimbursement shall be submitted and received by the Program within 12 months of the date of service or 120 days from the Medicare remittance date, as shown on the Explanation of Medicare Benefits, whichever is later.

(3) Fee for Service Claims.

(a) Fee for service claims shall be submitted and received by the Program within 12 months of:

(i) The date of service;

(ii) The date of discharge, if the service was a hospital inpatient service; or

(iii) The month of service, if the service was provided in a nursing or rehabilitation facility or is a hospice service.

(b) The Program shall only pay claims for services provided on different dates and submitted on a single claim if the single claim form is received by the Program within 12 months of the earliest date of service.

(c) The Program shall only pay a claim that was initially rejected, denied, or not acted upon within reasonable promptness after being received by the Program, if the claim is:

(i) Complete according to Program billing instructions and the 837 HIPAA compliant and companion guidelines;

(ii) Resubmitted; and

(iii) Received by the Program within the later of 12 months from the date of service or 60 days from the date last received by the Program or last rejected by the Program.

(4) A claim for services provided on different dates and submitted on a single form shall be paid only if it is received by the Program within 12 months of the earliest date of service.

(5) The Program shall only pay a claim that was initially rejected, denied, or not acted upon within reasonable promptness after being received by the Program, if the claim is:

(a) Complete according to Program billing instructions and the 837 HIPAA compliant and companion guidelines;

(b) Resubmitted; and

(c) Received by the Program within the later of:

(i) 12 months from the date of service; or

(ii) 60 days from the date last received by the Program or last rejected by the Program.

(6) Claims submitted after the time limitations because of a retroactive eligibility determination shall be considered for payment if received by the Program within 12 months of the date on which eligibility was determined.

(7) Late Charge Billing.

(a) The Program shall only accept additional or supplemental claims that were not included with a larger primary claim paid by the Program if all of the additional or supplemental claims are:

(i) Submitted together;

(ii) Submitted in accordance with the requirements of §B(3) of this regulation; and

(iii) Received within 60 days of the original paid claim date.

(b) The Program shall only accept one additional or supplemental claim under §B(7)(a) of this regulation for each:

(i) Date of service;

(ii) Date of discharge; or

(iii) Month of service billed.

(8) Adjustment Requests. Requests by providers to adjust information in claims already paid, including but not limited to changing the days billed, the amount charged, the units of service, or the rate of the service, shall be submitted to the Program in accordance with §B(3) and (5) of this regulation.