HAR §17-1739.1-15. Timely claims payment

(a) The department shall pay ninety per cent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within thirty days, and ninety-nine per cent of the clean claims within ninety days of the date of receipt. (b) The department shall pay all other claims within twelve months of the date of receipt, except where: UNOFFICIAL 1739.1-23 (1) Retroactive adjustments are paid to providers who are reimbursed under a retrospective payment system; (2) Claims are from providers under investigation for fraud or abuse; or (3) Payments are made in accordance with a court order, hearing decision, corrective action, or to extend benefits of these actions to others in the same situation as those directly affected. (c) Prepayment and post-payment claims review shall be conducted for all claims to verify: (1) Eligibility and proper authorization of service; (2) The number of visits and services for consistency with age, sex, and illness; (3) That payment does not exceed reimbursement rates or limits; and (4) Third party liability, if any. (d) Post-payment claims review shall meet the requirements dealing with fraud and utilization control. (e) The department shall provide any reports and documentation in compliance with this chapter and any conditions that the federal Centers for Medicare and Medicaid Services may require. [Eff 10/26/01; am 05/05/05] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.45) §17-1739.1-16 Time limit for claims submittal and one year claim filing deadline waiver request. (a) The provider shall submit all claims for payment within twelve months from providing care or services. No Medicaid payment shall be made for any claim submitted after this period except as allowed by subsections (c) and (d). For retroactive cases involving retroactive assistance, the twelve-month period for claim submittal shall start from the date of service or the date retroactive eligibility was determined, whichever is later. This subsection shall not apply to payment of deductibles and coinsurance for cases that are eligible for both Medicare and Medicaid in which the circumstances leading to a UNOFFICIAL 1739.1-24 submittal of claim after twelve months are acceptable to Medicare’s fiscal agent or carrier. (b) In cases where the provider disputes the department’s allowance or claim adjudication, a request for reconsideration of the payment amount or claim adjudication must be made within sixty days of the Medicaid payment or claim adjudication date. The Medicaid payment or claim adjudication date is the date on the remittance advice or the date on the explanation of benefit (EOB). (c) A claim received after the twelve-month period shall only be accepted for consideration of payment if all of the following conditions are met: (1) The department finds that the delay was caused by the provider’s efforts to obtain coverage from Medicare or any other source or third party liability; (2) The provider filed a claim with Medicare or another source of third party liability on a timely basis, as determined by Medicare or the source of third party liability involved; and (3) The claim is received by the department or its Medicaid fiscal agent within six months of a final disposition of coverage by Medicare or the source of third party liability involved. (d) In addition to the conditions stated in subsection (c), a claim for medical assistance payment that is received more than twelve months after the date of service by the department or its Medicaid fiscal agent, may, with the approval of the department, be accepted and processed in accordance with: (1) A court order; (2) An administrative hearing decision; or (3) As a corrective action to resolve a dispute. The request shall be made in writing to the department and include a clear statement and documentation of the reason for the delayed filing of the claim. (e) A request for payment of a claim that has been filed after the twelve-month deadline for claim submittal shall be made in writing to the department. The request shall include a clear statement and UNOFFICIAL 1739.1-25 documentation of the reason(s) for the delayed filing of the claim. (f) Providers may appeal the denial of a claim. [Eff 05/05/05] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.45)