Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-502 - Administration of medical programs-Providers
TIME LIMITS FOR BILLING
Section 182-502-0150 - Time limits for providers to bill the agency

(1) The agency requires providers to submit initial claims and adjust prior claims in a timely manner. The agency has three timeliness standards:

(2) The provider must submit claims to the agency as described in the agency's current published billing instructions.

(3) Providers must submit the initial claim to the agency and have a transaction control number (TCN) assigned by the agency within three hundred sixty-five calendar days from any of the following:

(4) The agency may grant exceptions to the time limit of three hundred sixty-five calendar days for initial claims when billing delays are caused by either of the following:

(5) The agency requires providers to bill known third parties for services. See WAC 182-501-0200 for exceptions. Providers must meet the timely billing standards of the liable third parties in addition to the agency's billing limits.

(6) When a client is covered by both medicare and medicaid, the provider must bill medicare for the service before billing the initial claim to the agency. If medicare:

(7)

Within twenty-four months of the date the service was provided to the client, a provider may resubmit, modify, or adjust an initial claim, other than a prescription drug claim or a claim for major trauma services.

(8) After twenty-four months from the date the service was provided to the client, the agency does not accept any claim for resubmission, modification, or adjustment. This twenty-four-month period does not apply to overpayments that a provider must refund to the agency by a negotiable financial instrument, such as a bank check.

(9) The agency allows providers to resub-mit, modify, or adjust any prescription drug claim with a timely TCN within fifteen months of the date the service was provided to the client. After fifteen months, the agency does not accept any prescription drug claim for resubmission, modification, or adjustment.

(10) The fifteen-month period described in subsection (9) of this section does not apply to overpayments that a prescription drug provider must refund to the agency. After fifteen months a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

(11) The agency allows a provider of trauma care services to resubmit, modify, or adjust, within three hundred and sixty-five calendar days of the date of service, any trauma claim that meets the criteria specified in WAC 182-531-2000 (for physician claims) or WAC 182-550-5450 (for hospital claims) for the purpose of receiving payment from the trauma care fund (TCF).

(12) The three hundred sixty-five-day period described in subsection (11) of this section does not apply to overpayments from the TCF that a trauma care provider must refund to the agency. A provider must refund an overpayment for a trauma claim that received payment from TCF using a method specified by the agency.

(13) If a provider fails to bill a claim according to the requirements of this section and the agency denies payment of the claim, the provider or any provider's agent cannot bill the client or the client's estate. The client is not responsible for the payment.