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5.1.5 Claims Filing Deadlines
For claims payment to be considered, providers must adhere to the following time limits. Claims received after the following time limits are not payable because the CSHCN Services Program does not provide coverage for late claims.
• Inpatient claims filed by a hospital must be submitted to TMHP within 95 days from the discharge date. Hospitals may submit interim claims before discharge. These claims must be submitted to TMHP within 95 days from the last date of service on the claim.
•Outpatient hospital services must be submitted to TMHP within 95 days from the date of service.
•For clients receiving retroactive eligibility, TMHP must receive claims within 95 days from the date the eligibility was added to the TMHP eligibility file (add date).
•Claims for clients with other group or private health insurance coverage must be received by the CSHCN Services Program within 95 days of the date of disposition by the other third-party resource (TPR) and no later than 365 from the date of service. A copy of the disposition must be submitted with the claim and mailed to TMHP.
If more than 110 days have elapsed from the date a claim was filed with the TRP and no response has been received, the claim may be submitted to the CSHCN Services Program for consideration of payment. Claims must be submitted with documentation indicating the TPR has not responded.
Refer to: Section 5.2, "Third-Party Resource (TPR)".
•TMHP must receive claims from out-of-state providers within 365 days of the date of service.
•All other claims must be submitted to TMHP within 95 days from each date of service.
•When a service is a benefit of Medicare, Medicaid, and the CSHCN Services Program, and the client is covered by all programs, the claim must be filed with Medicare first, then with Medicaid. If a Medicaid claim is denied or recouped for client ineligibility, the claim may be submitted to the CSHCN Services Program within 95 days from the date of Medicaid disposition.
When a filing deadline falls on a weekend or holiday, the filing deadline is extended to the next business day following the weekend or holiday. Holidays that may extend the deadlines in 2009 and 2010 are:
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