claims not submitted within the time limit - exceptional scenrio

Exceptions to the 12-Month Time Limit

Exceptions to the 12-month claim submission time limit may be allowed if the claim meets one or more of the following conditions:

·  New clean claim submitted within six months of the date of the void of the original claim payment date;
·  Court or hearing decision;
·  Delay in recipient eligibility determination;
·  Medicaid delay in updating eligibility file;
·  Court ordered or statutory action; or
·  System error on a claim that was originally filed within 12 months from the date of service.

Any claim filed more than 12 months from the date of service that meets an exception must be sent to the area Medicaid office for processing, not to the fiscal agent. Each of these exceptions is discussed below.

Original Payment is Voided

When an original Medicaid claim is voided, the provider may submit a new claim and a written request for assistance to the area Medicaid office no later than six  months from the void date.

Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court decision, there is no time limit for the submission of a claim.

Delay in Recipient Eligibility Determination

An exception may be granted when there is a delay in the determination of an individual’s Medicaid eligibility by the Department of Children and Families or the Social Security Administration. The provider must send in specific documentation to the area Medicaid office no later than 12 months from the date the recipient’s eligibility is updated on FMMIS. The claim submission must
include:
·  A clean claim,
·  A copy of the recipient’s proof of eligibility, and
·  Documentation of the reason for late submission.

Medicaid Delay in Updating Eligibility File

If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid Management Information System (FMMIS), an exception may be granted. The provider must submit the related clean claims to the area Medicaid office no later than 12 months from the date the recipient’s eligibility file was updated.

Court Ordered or Statutory Action

If the Medicaid office takes corrective action due to a court order or due to final agency action taken under Chapter 120, Florida Statutes, there is no time limit for claim submission.

System Error

If a clean claim is denied due to a system error or any error that is the fault of Medicaid or the fiscal agent, an exception may be granted if the provider submits another clean claim along with documentation of the denial to the area Medicaid office no later than 12 months from the date of the original denial.

Evaluate the Claim

The provider must evaluate any claim that is denied and determine if the claim fits any of the conditions for an exception to the 12-month filing limit.