Current through Register Vol.. 38, No. 17, April 11, 2022
Definitions. The following words and terms as used in this section shall have
the following meanings unless the context clearly indicates otherwise.
"Claim" means the term as defined in
447.45 and includes a bill or a line item for
services, drugs, or devices.
"Submit" or "file" means actual, physical receipt by the
Department of Medical Assistance Services (DMAS) that is documented in DMAS
, providers shall submit all claims to
DMAS no later than 12 months from the date of service for which the provider
requests reimbursement. In the absence of the two exception conditions set out
in subsection E of this section, all claims otherwise submitted to DMAS after
this 12-month time limit shall be denied.
C. In cases where the actual receipt of a
claim by DMAS is undocumented, the burden of proof shall be on the provider to
show that the claim was actually, physically received by DMAS. Proof by the
provider that a claim was mailed, transmitted, or conveyed to DMAS by any
method shall not constitute proof of receipt. The provider shall confirm actual
receipt of a claim by DMAS within 12 months from the date of the service
reflected on a claim.
D. If a claim
for payment under Medicare has been filed in a timely manner, DMAS may pay a
Medicaid claim for the same service within six months after the provider
receives notice of the disposition of the Medicare claim.
1. For cases in which a provider's claim was
retracted by the third party payer, DMAS shall consider the date of the
retraction notice by the third party payer as the begin date of the initial
12-month timely filing period.
For cases of retroactive Medicaid eligibility, DMAS shall consider the date of
the notification of delayed eligibility from the local department of social
services as the begin date of the initial 12-month timely filing
denies a provider's original claim for reimbursement, the provider may resubmit
the claim for reconsideration, together with any and all documentation to
support the previously denied claim. All supporting documentation shall be
filed at the time of the claim resubmission. DMAS shall not reconsider any
resubmitted claim where:
1. The previously
denied claim was not originally submitted within 12 months of the date of
2. The denied claim was
not resubmitted to DMAS within 13 months of the date the original claim was
Once DMAS determines that a resubmitted claim cannot be paid and takes a denial
action, it shall not be submitted again.