Va. DMAS Hospice Provider Manual ch. V, Timely Filing

Federal regulations [42 CFR § 447.45(d)] require the initial submission of all Medicaid

claims (including accident cases) within 12 months from the date of service. Only claims

that are submitted within 12 months from the date of service are eligible for Federal

financial participation. To request a waiver of timely filing requirements, providers billing

electronically must submit a Claim Attachment Form (DMAS-3) with the appropriate

attachments.

DMAS is not authorized to make payment on claims that are submitted late, except under

the following conditions:

Retroactive Eligibility - Medicaid eligibility can begin as early as the first day of the third

month prior to the month in which the individual makes application for benefits. All

eligibility requirements must be met within that period for retroactive eligibility to be

granted. In these instances, unpaid bills for that period may be submitted to DMAS as

Medicaid claims.

Delayed Eligibility - Initial denials of an individual’s Medicaid eligibility application may

be overturned or other actions may cause an eligibility determination to be delayed.

DMAS may make payments for dates of service more than 12 months in the past when

the claims are for an individual whose determination of eligibility was delayed.

It is the provider’s obligation to verify the individual’s Medicaid eligibility. The individual’s

local department of social services will notify providers who have rendered care during a

period of delayed eligibility. The notification will indicate notification of the delayed

eligibility and include the Medicaid ID number, and the time span for which eligibility has

been granted. The provider must submit a claim within 12 months from the date of the

notification of the delayed eligibility. A copy of the “signed and dated” letter from the local

department of social services indicating the delayed claim information must be attached

to the claim.

Denied claims - Denied claims must be submitted and processed on or before 13 months

from the date of the initial claim denial where the initial claim was filed according to the

timely filing requirements. The procedures for resubmission are:

• Complete invoice as explained in this billing chapter.

• Attach written documentation to justify/verify the explanation. If billing

electronically and waiver of timely filing is being requested, submit the claim with

the appropriate attachments. (The DMAS-3 form is to be used by electronic

billers for attachments. See exhibits).

Accident Cases - The provider may either bill DMAS or wait for a settlement from the

responsible liable third party in accident cases. However, all claims for services in

accident cases must be billed to DMAS within 12 months from the date of the service. If

the provider waits for the settlement before billing DMAS and the wait extends beyond 12

months from the date of the service, DMAS shall make no reimbursement.

Other Primary Insurance - The provider must bill other insurance as primary. However,

all claims for services must be billed to DMAS within 12 months from the date of the

service. If the provider waits for payment before billing DMAS and the wait extends

beyond 12 months from the date of the service, DMAS will make no reimbursements. If

payment is made from the primary insurance carrier after a payment from DMAS has

been made, an adjustment or void should be filed at that time.

Other Insurance - The member can keep private health insurance and still be covered

by Medicaid. The other insurance plan pays first. Having other health insurance does not

change the co-payment amount that providers may collect from a Medicaid member. For

members with a Medicare supplemental policy, the policy can be suspended with

Medicaid coverage for up to 24 months while the member has Medicaid without penalty

from their insurance company. The member must notify the insurance company within 90

days of the end of Medicaid coverage to reinstate the supplemental insurance.