Administrative Reviews for Claims

Administrative Reviews for Claims A. Providers may request an Administrative Review regarding claims within ninety (90) calendar days of the denial of a claim when: 1. The provider is unable to meet the timely filing requirement due to retroactive beneficiary eligibility and has: a) Received prior authorization, if required, from the Utilization Management/Quality Improvement Organization (UM/QIO) within 90 days of the system add date of the eligibility determination, and b) Filed the claim within ninety (90) days of the system add date of the eligibility determination, 2. The Division of Medicaid adjusts claims after timely filing and timely processing deadlines have expired, or 3. A Medicare crossover claim has been filed within one hundred eighty (180) calendar days from the Medicare paid date and the provider is dissatisfied with the disposition of the Medicaid claim. B. Requests for an Administrative Review must include: 1. Documentation of timely filing or documentation that the provider was unable to file the claim timely due to the beneficiary's retroactive eligibility, 2. Documentation that explains the facts that support the provider’s position as to how the denied claim meets one (1) or more of the requirements in Miss. Admin. Code, Title 23, Part 200, Rule 1.8.A. and the reasons the provider believes he/she complied with Medicaid regulations, and 3. Other documentation as required or requested by the Division of Medicaid. C. Providers may appeal certain decisions made by the Division of Medicaid as described in Miss. Admin. Code, Title 23, Part 300.