Current through Register Vol. 54, No. 44, November 2, 2024
(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.
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).
