Hawaii Administrative Rules
Title 17 - DEPARTMENT OF HUMAN SERVICES
Department of Human Services
Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES
Section 17-1739.1-16 - Time limit for claims submittal and one year claim filing deadline waiver request

Universal Citation: HI Admin Rules 17-1739.1-16

Current through February, 2024

(a) The provider shall submit all claims for payment within twelve months from providing care or services. No Medicaid payment shall be made for any claim submitted after this period except as allowed by subsections (c) and (d). For retroactive cases involving retroactive assistance, the twelve-month period for claim submittal shall start from the date of service or the date retroactive eligibility was determined, whichever is later. This subsection shall not apply to payment of deductibles and coinsurance for cases that are eligible for both Medicare and Medicaid in which the circumstances leading to a submittal of claim after twelve months are acceptable to Medicare's fiscal agent or carrier.

(b) In cases where the provider disputes the department's allowance or claim adjudication, a request for reconsideration of the payment amount or claim adjudication must be made within sixty days of the Medicaid payment or claim adjudication date. The Medicaid payment or claim adjudication date is the date on the remittance advice or the date on the explanation of benefit (EOB).

(c) A claim received after the twelve-month period shall only be accepted for consideration of payment if all of the following conditions are met:

(1) The department finds that the delay was caused by the provider's efforts to obtain coverage from Medicare or any other source or third party liability;

(2) The provider filed a claim with Medicare or another source of third party liability on a timely basis, as determined by Medicare or the source of third party liability involved; and

(3) The claim is received by the department or its Medicaid fiscal agent within six months of a final disposition of coverage by Medicare or the source of third party liability involved.

(d) In addition to the conditions stated in subsection (c), a claim for medical assistance payment that is received more than twelve months after the date of service by the department or its Medicaid fiscal agent, may, with the approval of the department, be accepted and processed in accordance with:

(1) A court order;

(2) An administrative hearing decision; or

(3) As a corrective action to resolve a dispute. The request shall be made in writing to the department and include a clear statement and documentation of the reason for the delayed filing of the claim.

(e) A request for payment of a claim that has been filed after the twelve-month deadline for claim submittal shall be made in writing to the department. The request shall include a clear statement and documentation of the reason(s) for the delayed filing of the claim.

(f) Providers may appeal the denial of a claim.

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