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5.1.6 Exception to Claim Filing Deadline
The DSHS manager with responsibility for oversight of the CSHCN Services Program, or his or her designee, considers a provider's request for an exception to the 95-day claims filing deadline and the 120-day correction and resubmission deadline, if the delay is due to one of the following reasons and is received by the program within 18 months from the date of service:
• Damage to or destruction of the provider's business office or records by a catastrophic event or natural disaster; including, but not limited to fire, flood, or earthquake that substantially interferes with normal business operations of the provider. The request for an exception to the filing deadline must include:
•An affidavit or statement from a person with personal knowledge of the facts detailing the requested exception.
•The cause for the delay.
•Verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider's current employee or agent.
•Any additional information requested by the CSHCN Services Program, including independent evidence of insurable loss; medical, accident or death records and a police or fire department report substantiating the damage or destruction.
•Damage or destruction of the provider's business office or records caused by intentional acts of an employee or agent of the provider, only if the employment or agency relationship was terminated and the provider filed criminal charges against the former employee or agent. The request for an exception to the filing deadline must include:
•An affidavit or statement from a person with personal knowledge of the facts detailing the requested exception.
•The cause for the delay.
•Verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider's employee or agent.
•Any additional information requested by the program, including a police or fire report substantiating the damage or destruction caused by the former employee or agent's criminal activity.
•Delay, error, or constraint imposed by the program in the eligibility determination of a client and/or in claims processing, or delay due to erroneous written information from the program, its designee, or another state agency. The request for an exception to the filing deadline must include:
•An affidavit or statement from a person with personal knowledge of the facts detailing the requested exception.
•The cause for the delay.
•Verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider's employee or agent.
•Any additional information requested by the program, including written documentation from the program, its designee, or another state agency containing the erroneous information or explanation of the delay, error, and/or constraint.
•Delay due to problems with the provider's electronic claims system or other documented and verifiable problems with claims submission. The request for an exception to the filing deadline must include:
•An affidavit or statement from a person with personal knowledge of the facts detailing the requested exception.
•The cause for the delay.
•Verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider's employee or agent.
•Any additional information requested by the CSHCN Services Program, including a written repair statement or invoice; a computer or modem-generated error report indicating attempts to transmit the data failed for reasons outside the control of the provider, or an explanation for the system implementation or other claim submission programs; a detailed, written statement by the person making the repairs or installing the system concerning the relationship and impact of the computer problem or system implementation to delayed claims submission; and the reason alternative billing procedures were not initiated after the problems became known.
The DSHS manager of the unit with responsibility for oversight of the CSHCN Services Program, or his or her designee(s), considers a provider's request for an exception to claims receipt deadlines due to delays caused by entities other than the provider and the program only if the following criteria are met:
•All claims that are to be considered for the same exception accompany the request (only the claims that are attached are considered).
•The exception request is received by the program within 18 months from the date of service.
•The exception request includes an affidavit or statement from a representative of an original payer, a third-party payer, or a person who has personal knowledge of the facts, stating the requested exception, documenting the cause for the delay, and providing verification that the delay was caused by another entity and not the neglect, indifference, or lack of diligence of the provider or the provider's employees or agents.
Send requests for exceptions to claim filing deadlines to:
CSHCN Services Program
Purchased Health Services Unit, MC-1938
Texas Department of State Health Services
PO Box 149347
Austin, TX 78714-9347
Fax: 1-800-441-5133
Note: Correspondence greater than ten pages must be mailed.
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