Definitions

Definitions A. Administrative Review for a Denied Claim is defined as a review of a claim denied for timely filing that is conducted by the Division’s Office of Provider Solutions. B. Final Administrative Decision is defined as the final decision regarding an Administrative Review for a Claim made by the Division’s Office of Provider Solutions, acting as the designee of the Executive Director. This decision may be appealed to the court of proper jurisdiction for Judicial Review. C. Fiscal Agent is defined as the agency, under contract with the Division of Medicaid, for the purpose of disbursing funds to providers of services under the Medicaid program. The fiscal agent collects eligibility and payment information from agencies administering Medicaid and processes the information for payment to providers. D. Fiscal Agent Error is defined as an error made by the Division’s Fiscal Agent in the administration of the services it has been contracted by the Division to perform. E. Provider Billing Error is defined as an error made by a Provider in the submission of a claim, including failure to obtain prior authorization, claims made for services and/or providers not covered, duplicate services, other insurance and/or incorrect beneficiary identification. F. Timely filing period is defined as three hundred and sixty-five (365) days from the date of service. G. Timely processing period is defined as three hundred and sixty-five (365) from the date the claim is filed.