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TO:                   All Participating Medicaid Providers

 

FROM:              Randy May, Deputy Administrator

 

SUBJECT:        CLARIFICATION OF TIMELY FILING REQUIREMENTS

 

Idaho Medicaid recently received communication from the Centers for Medicare & Medicaid Services (CMS) regarding Federal regulation 42 CFR 447.45(d)(1).  This regulation states that Medicaid agencies must require providers to submit all claims no later than twelve months from the date of service.

 

Based on this communication, Idaho Medicaid is clarifying its policy regarding the timely filing of Idaho Medicaid claims.  The following guidelines will become effective for claims received on or after Saturday, January 15, 2005:

 

  • All claims must be submitted to Idaho Medicaid within twelve months (365 days) from the date of service. If a claim was originally submitted within twelve months of the date of service, a provider is no longer required to provide proof of subsequent continued billing activity in order to have those services considered for payment. Once a service has been billed within twelve months of the date of service, it is considered to have been billed timely.  The Internal Control Number (ICN) of the original claim must be documented in the comments field on all electronic or paper resubmissions of the claim in order to prove the timeliness requirement was met.  The ICN must indicate that the original claim was submitted within twelve months from the date of service.  If the ICN of the original claim is not on the resubmitted claim, the claim will be denied, even if it was originally billed timely.
  • If the client has a third party insurance carrier, the claim for services must be submitted to Idaho Medicaid within twelve months of the date of service regardless of the date of payment or date of the explanation of benefits (EOB) from the other insurance carrier. The only exception to this requirement is for Medicare crossover claims.  If a claim for payment under Medicare has been filed in a timely manner, Medicaid will consider claims for payment within six months of the date of payment or date of the EOB of the Medicare claim.
  • Claims for Idaho Medicaid clients receiving retro-eligibility must be submitted within twelve months of the date of service regardless of the date their eligibility was added.
  • Idaho Medicaid providers with a retro-active eligibility date must submit claims within twelve months of the date of service regardless of their enrollment date.
  • Claims for services requiring prior authorization (PA) from the Department or one of its agents must be submitted within twelve months of the date of service regardless of when the PA was issued.

 

Providers who fail to bill timely and have their claims denied for this reason cannot pursue collection actions against the client.

 

Adjustments to paid claims must be made within two years after the calendar quarter in which the payment was received.  Adjustments can only be done on paid claims or paid details.

 

If you have any questions concerning the information contained in this release, please contact EDS Provider Services at (208) 383-4310 or 1-800-685-3757.  Thank you for your continued participation in the Idaho Medicaid Program.

 

IDAHO MEDICAID HANDBOOK

This information replaces information to the following sections of your Idaho Medicaid Provider handbook:  2.1.2, 2.1.2.1, 2.1.2.2., and 2.6.1.

 

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