Filing of Claims, MO HealthNet Program

PURPOSE: This rule establishes the general provisions for submission or resubmission of claims and adjustments of claims to MO HealthNet. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (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 HealthNet 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 HealthNet 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 thirdparty 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 HealthNet 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. AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016.* This rule was previously filed as 13 CSR 40-81.070 and 13 CSR 40-81.071. Original rule filed June 2, 1976, effective Oct. 11, 1976. Emergency rescission filed July 18, 1979, effective July 31, 1979, expired Nov. 10, 1979. Emergency rule filed July 18, 1979, effective Aug. 1, 1979, expired Nov. 10, 1979. Rescinded and readopted: Filed July 18, 1979, effective Nov. 11, 1979. Rescinded and readopted: Filed Sept. 12, 1984, effective Jan. 12, 1985. Amended: Filed April 21, 1992, effective Jan. 15, 1993. Amended: Filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed Sept. 23, 1993, effective May 9, 1994. Amended: Filed Sept. 28, 2001, effective March 30, 2002. Amended: Filed June 15, 2006, effective Dec. 30, 2006. Amended: Filed Jan. 2, 2008, effective June 30, 2008. Amended: Filed July 31, 2008, effective Jan. 30, 2009. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended: Filed Sept. 27, 2018, effective May 30, 2019. Amended: Filed Jan. 22, 2020, effective Aug. 30, 2020. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.