23 Miss. Code. R. 200-1.7 - Timely Processing of Claims
A. The Division of
Medicaid defines a clean claim as a claim that can be processed without
obtaining additional information from the provider of the service or from a
third party.
1. Claims with errors
originating in the Division of Medicaid's claims system are considered clean
claims.
2. The following are not
considered clean claims:
a) Claims from
providers under investigation for fraud or abuse, or
b) Claims under review for medical
necessity.
B.
The Division of Medicaid processes claims in accordance with federal and state
timely processing requirements.
C.
The Division of Medicaid processes all claims within three hundred sixty-five
(365) calendar days from the date of receipt except:
1. If a claim for payment under Medicare has
been filed in a timely manner, the Division of Medicaid will process a Medicaid
claim relating to the same services within one hundred eighty (180) calendar
days of the Medicare paid date.
2.
Retroactive adjustments paid to providers who are reimbursed under a
retrospective payment system.
3.
When the claim is from a provider that is under investigation for fraud or
abuse.
4. When payments are made to
carry out:
a) A court order,
b) Hearing decision, or
c) Agency corrective actions taken to resolve
a dispute.
5. To extend
the benefits of a hearing decision, corrective action, or court order to others
in the same situation as those directly affected by it.
D. The processing period begins on the date a
claim is timely received by the Division of Medicaid and ends three hundred
sixty-five (365) calendar days from the date the original claim is received by
the Division of Medicaid.
E.
Providers may submit a corrected claim during the processing period.
F. If the Division of Medicaid adjusts claims
after the processing period has ended, providers may submit a written request
for an Administrative Review within ninety (90) calendar days of the date of
the remittance advice (RA). Providers must submit additional documentation to
support claims payment.
G.
Providers may request an administrative hearing if they are dissatisfied with
the disposition of their claim as described in Miss. Admin. Code, Title 23,
Part 300, Rule
1.1.
Notes
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