Current through Reg. 49, No. 38; September 20, 2024
The program reimburses providers for covered services for
clients. Payment may be made only after the delivery of the service, with the
exception of meals, transportation, lodging, and insurance premium payments.
Excluding allowable insurance or health maintenance organization co-payments,
the client or client's family must not be billed for the service or be required
to make a preadmission or pretreatment payment or deposit. Providers may not
request or accept payment from the client or the client's family for completing
any program forms. Providers must agree to accept established fees as payment
in full. The program may negotiate reimbursement alternatives to reduce costs
through requests for proposals, contract purchases, or incentive
programs.
(1) Payment or denial of
claims. Payments made on behalf of a client will be for claims received by the
program or its payment contractor within 95 days of the date of service, within
95 days from the date of discharge from inpatient hospital and inpatient
rehabilitation facilities, within 95 days from the date the client's
eligibility is added to program automation systems, or within the submission
deadlines listed in paragraphs (1)(B)(ii) and (2) of this section, whichever is
later. Claims for family support services, drug co-payments, and insurance
premium payment assistance must be submitted within 95 days of the last day of
the month in which services were provided. If the 95th day for receipt of a
claim falls on a weekend or holiday, the deadline shall be extended to the next
business day following the weekend or holiday. The program must process the
claims of eligible providers within a period not to exceed 30 days of receipt
and determination of proper evidence establishing the validity of claims,
invoices, and statements. In cases where the program determines that a basis
exists for further review, suspension, or other irregularity, extended
processing time may be required. The manager of the department unit having
responsibility for oversight of the program or his or her designee(s) may waive
the filing deadlines according to the conditions and circumstances specified in
paragraphs (3) - (5) of this section. A claim must be processed and paid within
24 months of the date of service. Claims received by the program or its payment
contractor after this time frame will not be considered for payment by the
program.
(A) Claims will be paid if submitted
on claim forms approved by the program (including electronic claims submission
systems) and if the required documentation is received with the
claim.
(B) Denied claims are claims
which are incomplete, submitted on the wrong form, lack necessary
documentation, contain inaccurate information, fail to meet the filing
deadline, are for ineligible persons, services, or providers, or are for
clients who do not qualify for the health care benefit claimed.
(i) Corrected claims must be submitted on
claim forms approved by the program along with required documentation within
the filing deadline established in clause (ii) of this subparagraph.
(ii) Denied claims may be corrected and
resubmitted for reconsideration if received within 120 days of the last denial
or adjustment to the original claim. If the results of the reconsideration
process are unsatisfactory, denied claims may be appealed according to §
351.13 of this title (relating to Right of Appeal).
(2) Claims involving health
insurance coverage, CHIP, or Medicaid. Any health insurance that provides
coverage to the client must be utilized before the program can pay for
services. Providers must file a claim with health insurance, CHIP, or Medicaid
prior to submitting any claim to the program for payment. Claims with health
insurance must be received by the program within 95 days of the date of
disposition by the other third party resource, and no later than 365 days from
the date of service. The program will consider claims received for the first
time after the 365-day deadline if a third party resource recoups a payment
made in error; however, the claim must be received by the program within 95
days from the third party's disposition. The program may pay for covered health
care benefits during CHIP or other health insurance enrollment waiting periods.
During these periods, providers may file claims directly with the program
without evidence of denial by the other insurer.
(A) Health insurance denial. If a claim is
denied by health insurance, the provider may bill the program if the letter of
denial also is submitted with the claim form. If the denial letter is not
available, the provider must include on the claim form the date the claim was
filed with the insurance company, the reason for the denial, name and telephone
number of the insurance company, the policy number, the name of the policy
holder and identification numbers for each policy covering the client, the name
of the insurance company employee who provided the information on the denial of
benefits, and the date of the contact.
(B) Explanation of benefits (EOB). The health
insurance EOB must accompany any claim sent to the program for payment if
available. If the EOB is unavailable, the provider must include on the claim
form the name and telephone number of the insurance company, the amount paid,
the policy number, and name of the insured for each policy covering the
client.
(C) Late filing. Claims
denied by health insurance on the basis of late filing will not be considered
for payment by the program.
(D)
Deductibles and coinsurance. If the client has other third party coverage, the
program may pay a deductible or coinsurance for the client as long as the total
amount paid to the provider does not exceed the allowable amount for the
covered service and conforms with current program policies regarding third
party resources, deductible, and coinsurance.
(3) Exceptions to the claim receipt or
correction and resubmission deadlines. The manager of the department unit
having responsibility for oversight of the program or his or her designee(s)
will consider a provider's request for an exception to the claim receipt or
correction and resubmission deadlines provided in paragraphs (1) and (2) of
this section if the delay in claim receipt or correction and resubmission is
due to one of the following reasons:
(A)
damage to or destruction of the provider's business office or records by a
catastrophic event or natural disaster including, but not limited to fire,
flood, hurricane, or earthquake that substantially interferes with normal
business operations of the provider;
(B) damage to or destruction of the
provider's business office or records caused by the intentional acts of an
employee or agent of the provider only if:
(i) the employment or agency relationship has
been terminated; and
(ii) the
provider has filed criminal charges against the former employee or
agent;
(C) delay, error,
or constraint imposed by the program in the eligibility determination of a
client or in claims processing, or delay due to erroneous written information
from the program or its designee, or another state agency; or
(D) delay due to problems with the provider's
electronic claim system or other documented and verifiable problems with claims
submission.
(4)
Exception requests. Providers requesting an exception under paragraph (3)(A) -
(D) of this section must submit an affidavit or statement from a person with
personal knowledge of the facts detailing the exception being requested, the
cause for the delay, verification that the delay was not caused by neglect,
indifference, or lack of diligence of the provider or the provider's employee
or agent, and any additional information requested by the program. All claims
for which the provider requests an exception must accompany the request. The
program will consider only the claim(s) attached to the request, and the
exception request must be received by the program within 18 months from the
date of service.
(A) For exception requests
under paragraph (3)(A) of this section, the provider must submit:
(i) independent evidence of insurable
loss;
(ii) medical, accident, or
death records; or
(iii) a police or
fire department report substantiating the damage or destruction.
(B) For exception requests under
paragraph (3)(B) of this section, the provider must submit a police or fire
report substantiating the damage or destruction caused by the former employee
or agent's criminal activity.
(C)
For exception requests under paragraph (3)(C) of this section, the provider
must submit written documentation from the program, its designee, or another
state agency containing the erroneous information or explanation of the delay,
error, or constraint.
(D) For
exception requests under paragraph (3)(D) of this section, the provider must
submit the following:
(i) a written repair
statement or invoice, a computer or modem generated error report indicating
attempts to transmit the data failed for reasons outside the control of the
provider, or an explanation for the system implementation or other claim
submission problems;
(ii) a
detailed, written statement concerning the relationship of the computer problem
to delayed claims submission; and
(iii) the reason alternative billing
procedures were not initiated after the problem(s) became known.
(5) Other exceptions to
claims receipt or correction and resubmission deadlines. The manager of the
department unit having responsibility for oversight of the program or his or
her designee(s) will consider a provider's request for an exception to claims
receipt or correction and resubmission deadlines due to delays caused by
entities other than the provider and the program under the following
circumstances:
(A) all claims that are to be
considered for the same exception must accompany the request;
(B) only the claim(s) that are attached to
the request will be considered;
(C)
the exception request has been received by the program within 18 months from
the date of service; and
(D) the
exception request includes an affidavit or statement from a representative of
an original payer, a third party payer, or a person who has personal knowledge
of the facts, stating the exception being requested, documenting the cause for
the delay, and providing verification that the delay was caused by another
entity and not the neglect, indifference, or lack of diligence of the provider
or the provider's employee(s) or agent(s).
(6) Program fees. The program establishes
fees and payment methodologies for covered medical, dental, and other services
based upon appropriated funds. All fees are subject to reductions or
limitations authorized by § 351.16(b)(2)(E) of this title (relating to
Procedures to Address Program Budget Alignment).
(7) Required documentation. The program may
require documentation of the delivery of goods and services from the
provider.
(8) Overpayments.
(A) Overpayments are payments made by the
program due to the following:
(i) duplicate
billings;
(ii) services paid by
public or private insurance or other resources;
(iii) payments made for services not
delivered;
(iv) services disallowed
by the CSHCN Services Program; and
(v) subrogation.
(B) Overpayments made to providers must be
reimbursed to the department by lump sum payment or, at the department's
discretion, offset against current payments due to the provider for services to
other clients. The department also shall require reimbursement of overpayments
from any person or persons who have a legal obligation to support the client
and have received payments from a payer of other benefits. Providers, clients,
and person(s) responsible for clients may appeal proposed recoupment of
overpayments by the department according to § 351.13 of this
title.
