Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 300 - Appeals
Chapter 4 - Claim Denials
Rule 23-300-4.2 - Errors Made within the Timely Processing Period
Universal Citation: MS Code of Rules 23-300-4.2
Current through September 24, 2024
A. The Provider may not seek relief from the Division for a claim denied due to an error within the timely processing period until the provider exhausts the applicable process for the type of error as detailed below.
1. Fiscal Agent Error
a) When a claim is denied due to Fiscal Agent
Error(s) within the timely processing period, the provider must notify the
fiscal agent to correct the error.
b) If the Fiscal Agent does not correct the
error within the timely processing period, the provider may contact Division of
Medicaid Office of Provider Solutions within ninety (90) days of the end of the
timely processing period for an Administrative Review for the Denied
Claim.
2. Provider
Billing Errors
a) Claims submitted within the
timely filing period that deny due to a Provider Billing Error(s) may be
resubmitted to the Fiscal Agent within the timely processing period.
b) Claims submitted outside of the timely
filing period will only be reviewed if the requirements listed in Part 200,
Rule 1.6 are met. The Division has
discretion to grant or refuse an Administrative Review for a Denied
Claim.
c) Denial of a request for
an Administrative Review for a Denied Claim is the Division's Final
Administrative Decision.
d) If the
Division does grant a request for Administrative Review of a Denied Claim, the
Division of Medicaid's Office of Provider Solutions will render the Division's
Final Administrative Decision.
3. Providers may not appeal the technical
denial of a claim for failure to timely obtain a prior authorization.
B. Claims Denied for Untimeliness
1. Providers may request an Administrative
Review for a claim denied for untimeliness within ninety (90) calendar days of
the denial of a claim when:
a) The provider is
unable to meet the timely filing requirement due to retroactive beneficiary
eligibility and has:
1) Received prior
authorization, if required, from the Utilization Management/Quality Improvement
Organization (UM/QIO) within ninety (90) days of the system add date of the
eligibility determination, and
2)
Filed the claim within ninety (90) days of the system add date of the
eligibility determination,
b) The Division of Medicaid adjusts claims
after timely filing and timely processing deadlines have expired,
c) A Medicare crossover claim has been filed
within one hundred eighty (180) calendar days from the Medicare paid date and
the provider is dissatisfied with the disposition of the Medicaid claim,
or
d) The Fiscal Agent's
untimeliness decision was incorrect.
2. Requests for an Administrative Review for
a Denied Claim must include:
a) Documentation
of timely filing or documentation that the provider was unable to file the
claim timely due to the beneficiary's retroactive eligibility;
b) Documentation that explains the facts that
support the provider's position as to how the denied claim meets one (1) or
more of the requirements in Miss. Admin. Code, Title 23, Part 300, Rule
4.1.B. and the reasons the provider
believes the Provider complied with Medicaid regulations;
c) A new claim submission for the claim in
question; and
d) Any other
documentation as required or requested by the Division of Medicaid.
3. Requests for an Administrative
Review for a claim adjusted after the expiration of timely filing must include:
a) A copy of the Remittance Advice that
includes the claim adjustment;
b)
Documentation supporting the Provider's position that the claim meets one (1)
or more of the requirements of Rule
4.1.C. of this Chapter;
c) A new claim submission for the subject
claim; and
d) Any other
documentation as required and/or requested by the Division.
C. Medical necessity
1. Providers may request a reconsideration
when a claim is denied due to failure to meet medical necessity requirements by
submitting the required documentation to the fiscal agent within ninety (90)
days of the denial.
2. If the
provider is not satisfied with the fiscal agent's medical necessity
determination, the provider may request, in writing, an administrative hearing
with the Division of Medicaid within ninety (90) days of the receipt of the
fiscal agent's medical necessity determination through the appeal process as
described in Rule 3.1 of this
Part.
Miss. Code Ann. §§ 43-13-113, 43-13-117, 43-13-121
Disclaimer: These regulations may not be the most recent version. Mississippi may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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