Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment changes the claim form
requirements for providers filing Pharmacy Claims, Professional Services
Claims, and Dental Claims.
(1) Claim forms used for filing MO HealthNet
services as appropriate to the provider of services are-
(A) Nursing Home Claim-electronic claim
submission or individualized provider software when authorized by the state's
fiscal agent;
(B) Pharmacy
Claim-Point-of-Service (POS), on-line claim format-National Council for
Prescription Drug Programs (NCPDP) current version, or electronic claim
submission;
(C) Outpatient Hospital
Claim-UB-04 CMS-1450 or electronic claim submission;
(D) Professional Services Claim- CMS-1500
form (02-12) version or electronic claim submission;
(E) Dental Claim-American Dental Association
(ADA) 2019 revision, Dental Form, or electronic claim submission; or
(F) Inpatient Hospital Claim-UB-04 CMS-1450
or electronic claim submission.
(2) Specific claims filing instructions are
modified as necessary for efficient and effective administration of the program
as required by federal or state law or regulation. For specific claim filing
instructions information, reference the appropriate -
(A) MO HealthNet provider manual, which is
incorporated by reference and made a part of this rule as published by the
Department of Social Services, MO HealthNet Division, 615 Howerton Court,
Jefferson City, MO 65109, at its website at
http://manuals.momed.com/manuals/,
January 15, 2020. This rule does not incorporate any subsequent amendments or
additions; and
(B) Forms, which
are incorporated by reference and made a part of this rule as published by the
Department of Social Services, MO HealthNet Division, 615 Howerton Court,
Jefferson City, MO 65109, at its website at
http://manuals.momed.com/manuals/presentation/forms.jsp,
January 15, 2020. This rule does not incorporate any subsequent amendments or
additions.
(3) Time Limit
for Original Claim Filing. Claims from participating providers that request MO
HealthNet reimbursement must be filed by the provider and received by the state
agency within twelve (12) months from the date of service. The counting of the
twelve (12)-month time limit begins with the date of service and ends with the
date of receipt.
(A) Claims that have been
initially filed with Medicare within the Medicare timely filing requirement and
which require separate filing of an electronic claim with MO Health-Net will
meet timely filing requirements by being submitted by the provider and received
by the state agency within twelve (12) months of the date of service or six (6)
months from the date on the Medicare provider's notice of the allowed claim.
Claims denied by Medicare must be filed by the provider and received by the
state agency within twelve (12) months from the date of service. The counting
of the twelve (12)-month time limit begins with the date of service and ends
with the date of receipt. Medicare/Medicaid crossover claims must be submitted
through an electronic media. Claims that have been initially filed with
Medicare and which require separate filing of an electronic claim with MO
HealthNet must include the Medicare internal control number or the Medicare
claim identification number found on the Medicare provider's notice. Paper
billings for Medicare/Medicaid crossover claims will not be processed. Paper
billings (claims) will not be returned to the provider. Paper billings will not
be retained by the MO HealthNet Division or its contractors.
(B) Third-Party Resources.
1. Claims for participants who have a
third-party resource that is primary to MO HealthNet must be submitted to the
third-party resource for adjudication unless otherwise specified by the MO
HealthNet Division. Documentation specified by the MO HealthNet Division which
indicates the third-party resource's adjudication of the claim must be attached
to the claim filed for MO HealthNet reimbursement. If the MO Health-Net
Division waives the requirement that the third-party resource's adjudication
must be attached to the claim, documentation indicating the third-party
resource's adjudication of the claim must be kept in the provider's records and
made available to the division at its request. The claim must meet the MO
HealthNet timely filing requirement by being filed by the provider and received
by the state agency within twelve (12) months from the date of
service.
2. The twelve (12)-month
initial filing rule may be extended if a third-party payer, after making a
payment to a provider, being satisfied that the payment is correct, later
reverses the payment determination, sometime after the twelve (12) months from
the date of service has elapsed, and requests the provider return the payment.
Because a third-party resource was clearly available to cover the full amount
of liability, and this was known to the provider, the provider may not have
initially filed a claim with the MO HealthNet state agency. Under this set of
circumstances, the provider may file a claim with the MO HealthNet agency later
than twelve (12) months from the date of services. The provider must submit
this type of claim to the Third Party Liability Unit at Post Office Box 6500,
Jefferson City, MO 65102-6500 for special handling. The MO Health-Net state
agency may accept and pay this specific type of claim without regard to the
twelve (12)-month timely filing rule; however, all claims must be filed for MO
HealthNet reimbursement within twenty-four (24) months from the date of service
in order to be paid.
(4) Time Limit for Resubmission of a Claim
After Twelve (12) Months From the Date of Service.
(A) Claims which have been originally
submitted and received within twelve (12) months from the date of service and
denied or returned to the provider may be resubmitted within twenty-four (24)
months of the date of service. Those claims must be filed by the provider and
received by the state agency within twenty-four (24) months from the date of
service. The counting of the twenty-four (24)-month time limit begins with the
date of service and ends with the date of receipt.
(B) Documentation specified by the MO
HealthNet Division in MO HealthNet provider manuals which indicates the claim
was originally received timely must be attached to the resubmission or entered
on the claim form (electronic or paper).
(C) Claims will not be paid when filed by the
provider and received by the state agency beyond twenty-four (24) months from
the date of service.
(5)
Denial. Claims that are not submitted in a timely manner and as described in
sections (1) and (2) of this rule will be denied. Except that at any time in
accordance with a court order, the agency may make payments to carry out
hearing decision, corrective action, or court order to others in the same
situation as those directly affected by it. The agency may make payment at any
time when a claim was denied due to state agency error or delay, as determined
by the state agency. In order for payment to be made, the state agency must be
informed of any claims denied due to state agency error or delay within six (6)
months from the date of the remittance advice on which the error occurred; or
within six (6) months of the date of completion or determination in the case of
a delay; or twelve (12) months from the date of service, whichever is
longer.
(6) Time Limit for Filing
an Adjustment. Adjustments to a paid claim must be filed within twenty-four
(24) months from the date of service.
(7) Definitions.
(A) Claim A-claim is each individual line
item of service on a claim form, for which a charge is billed by a provider,
for all claim form types except inpatient hospital. An inpatient hospital
service claim is all the billed charges contained on one (1) inpatient claim
document.
(B) Date of
payment/denial-The date of payment or denial of a claim is the date on the
remittance advice at the top center of each page under the words remittance
advice.
(C) Date of receipt-The
date of receipt of a claim is the date the claim is received by the state
agency. For a claim which is processed, this date appears as a Julian date in
the internal control number (ICN). For a claim which is returned to the
provider, this date appears on the Return to Provider form letter.
(D) Date of service-The date of service which
is used as the beginning point for determining the timely filing limit applies
to the various claim types as follows:
1.
Nursing home-The through date or ending date of service for each line item for
each participant listed on the claim;
2. Pharmacy-The date dispensed for each line
item for each individual participant listed on electronically submitted claims
through point-of-service (POS) or the Internet;
3. Outpatient hospital-The ending date of
service for each individual line item on the claim;
4. Professional services (CMS-1500)-The
ending date of service for each individual line item on the claim;
5. Dental-The date service was performed for
each individual line item on the claim;
6. Inpatient hospital-The through date of
service in the area indicating the claimed period of service; and
7. For service which involves the providing
of dentures, hearing aids, eyeglasses, or items of durable medical equipment;
for example, artificial larynx, braces, hospital beds, wheelchairs, the date of
service will be the date of delivery or placement of the device or
item.
(E) Internal
control number (ICN)-The fiscal agent prints a thirteen (13)-digit number on
each document it processes through the Medicaid Management Information System
(MMIS). The year of receipt is indicated by the third and fourth digits and the
Julian date appears as the fifth, sixth, and seventh digits. In an example ICN,
490600152006, 06 is the year 2006 and 001 is the Julian date for January
1.
(F) Medicare internal control
number- The number assigned to a Medicare claim by the Medicare provider which
is used for identification purposes. The Medicare internal control number is
also referred to as the Medicare claim identification number.
(G) Julian date-In a Julian system, the days
of a year are numbered consecutively from 001 (January 1) to 365 (December 31)
or 366 in a leap year. For example, in 1984, a leap year, June 15 is the 167th
day of that year, thus, 167 is the Julian date for June 15, 1984.
(H) Twelve (12)-month time limit-This unit is
defined as three hundred sixty-six (366) days.
(I) Twenty-four (24)-month time limit- This
unit is defined as seven hundred thirty-one (731) days.
*Original authority: 208.153, RSMo 1967, amended 1967,
1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended
2007.
