55 Pa. Code § 1101.68 - Invoicing for services

(a) Invoices. When billing for MA services or items, a provider shall use the invoices specified by the Department or its agents, according to billing and other instructions contained in the provider handbooks.

(b) Time frame. MA providers shall submit invoices correctly and in accordance with established time frames. For purposes of this section, time frames referred to are indicated in calendar days.

(1) A provider shall submit original or initial invoices to be received by the Department within a maximum of 180 days after the date the services were rendered or compensable items provided. Nursing facility providers and ICF/MR providers shall submit original or initial claims to be received by the Department within 180 days of the last day of a billing period. A billing period for nursing facility providers and ICF/MR providers covers the services provided to an eligible recipient during a calendar month and starts on the first day service is provided in that calendar month and ends on the last day service is provided in that calendar month.

(2) Departmental receipt of a claim is evidenced by appearance of the claim on a remittance advice (RA). The claim reference number (CRN) identifies when the claim was received by the Department. The first digit of the CRN indicates the year. The next three digits refer to the Julian Calendar date.

(3) Resubmission of a rejected original claim or a claim adjustment shall be received by the Department within 365 days of the date of service, except for nursing facility providers and ICF/MR providers. Resubmission of a rejected original claim or claim adjustment by a nursing facility provider or an ICF/MR provider shall be received by the Department within 365 days of the last day of each billing period.

(4) A claim which has been submitted to the Department not appearing within 45 days following that submission, should be resubmitted by the provider. Similarly, a claim which appears as a pend on a remittance advice and does not subsequently appear as an approved or rejected claim before the expiration of an additional45 days should be resubmitted immediately by the provider.

(c) Invoice exception criteria. Invoices submitted after the 180-day period will be rejected unless they meet the criteria established in paragraph (1) or (2).

(1) Eligibility determination was requested within 60 days of the date of service and the Department has received an invoice exception request from the provider within 60 days of receipt of the eligibility determination.

(2) Payment from a third party was requested within 60 days of the date of service and the Department has received an invoice exception request from the provider within 60 days of receipt of the statement from the third party.

(d) Other invoice exception requirements. In addition to the requirements in subsection (c), the following requirements apply:

(1) A provider shall submit invoice exception requests in writing to the Office of Medical Assistance Programs.

(2) A request for an invoice exception shall include supporting documentation, including documentation to and from the CAO or third party. A correctly completed invoice shall accompany the request.

(3) The Department may request additional documentation to justify approval of an exception. If the requested documentation is not received within 30 days from the date of the Department's request, a decision will be made based on available information.

(4) Invoice exceptions will be granted on a one time basis. Exception claims rejected through the claims processing system due to provider error will not be granted additional exceptions. Claims may be resubmitted directly to the claims processing system in accordance withsubsection (b). The claim shall indicate the CRN of the exception claim on the invoice.

(5) No exceptions to the normal invoice processing deadlines will be granted other than under this section. In addition, if a provider's claim to the Department incurs a delay due to a third party or an eligibility determination, and the 180-day time frame has not elapsed, the provider shall still submit the claim through the normal claims processing system. A request for an exception to the 180-day time frame is not required whenever the provider can submit the claim within that 180-day period.

(6) No exceptions will be granted for claims which were submitted for normal processing within normal deadlines and rejected by the Department due to provider error.

Notes

55 Pa. Code § 1101.68

The provisions of this § 1101.68 amended December 14, 1990, effective 1/1/1991, 20 Pa.B. 6164; amended December 27, 2002, effective 1/1/2003, 32 Pa.B. 6364.

This section amended under Articles I-XI and XIV of the Public Welfare Code (62 P. S. §§ 101-1411).

This section cited in 55 Pa. Code § 41.92 (relating to expedited disposition procedure for certain appeals); 55 Pa. Code § 52.14 (relating to ongoing responsibilities of providers); 55 Pa. Code § 52.41 (relating to provider billing); 55 Pa. Code § 1187.155 (relating to exceptional DME grants-payment conditions and limitations); and 55 Pa. Code § 6100.483 (relating to provider billing).