TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Claims Information > Claims Filing Deadlines > Exceptions to the 95-Day Filing Deadline

   
 

6.1.3.2 Exceptions to the 95-Day Filing Deadline

TMHP is not responsible for appeals about exceptions to the 95-day filing deadline. These appeals must be submitted to the HHSC Claims Administrator Contract Management. TAC allows HHSC to consider exceptions to the 95-day filing deadline under special circumstances.

HHSC Claims Administrator Contract Management makes the final decision about whether claims fall within one of the exceptions to the 95-day filing deadline. Only providers can submit exception requests. Requests from billing companies, vendors, or clearinghouses are not accepted unless accompanied by a signed authorization from the provider (with each appeal). Without provider authorization, these requests are returned without further action.

HHSC will only consider exceptions to the 95-day filing deadline for claims that were submitted within the 365-day federal filing deadline from the date of service as outlined in 1 TAC 354.1003. The provider must submit an affidavit or statement and any additional information identifying details of cause for the delay, the exception being requested, and verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider's employee or agent. The person who knows the facts must make the affidavit or statement.

HHSC Claims Administrator Contract Management determines if the claim falls within one of the following exceptions:

1)
Catastrophic event that substantially interferes with normal business operations of the provider, or damage or destruction of the provider's business office or records by a natural disaster, including but not limited to fire, flood, or earthquake; or damage or destruction of the provider's business office or records by circumstances that are clearly beyond the provider's control including, but not limited to, criminal activity. The damage or destruction of business records or criminal activity exception does not apply to any negligent or intentional act of an employee or agent of the provider because these people are presumed to be within the provider's control. The presumption can be rebutted only when the intentional acts of the employee or agent leads to termination of employment and filing of criminal charges against the employee or agent.

Providers requesting an exception based on exception (1) must submit independent evidence of insurable loss claims; medical, accident, or death records; or police or fire report substantiating the exception of damage, destruction, or criminal activity.

2)
Delay or error in the eligibility determination of a client or delay because of erroneous written information from the department, another state agency, or health insuring agent.

Providers requesting an exception based on exception (2) must submit the written document from HHSC or its designee that contains the erroneous information or explanation of the delayed information.

3)
Delay because of electronic claim or system implementation problems.

Providers requesting an exception based on exception (3) must submit the written repair statement, invoice, computer or modem-generated error report (indicating attempts to transmit the data failed for reasons outside the control of the provider), or the explanation for the system implementation problems. The documentation must include a detailed explanation made by the person making the repairs or installing the system specifically indicating the relationship and impact of the computer problem or system implementation to claims submission, and a detailed statement explaining why alternative billing procedures were not initiated after the delay in repairs or system implementation was known.

4)
Submission of claims occurred within the 365-day federal filing deadline but the claim was not filed within 95 days from the date of service because the service was determined to be a benefit of the Medicaid program, and an effective date for the new benefit was applied retroactively.

Providers requesting an exception based on exception (4) must submit a written, detailed explanation of the facts and documentation to demonstrate the 365-day federal filing deadline for the benefit was met.

5)
Client eligibility is determined retroactively and the provider is not notified of retroactive coverage.

Providers requesting an exception based on exception (5) must include a written, detailed explanation of the facts and activities illustrating the provider's efforts in requesting eligibility information for the client. The explanation must contain dates, contact information, and any responses from the client.

Exception requests must be submitted in writing to the following address:

Texas Health and Human Services Commission
HHSC Claims Administrator Contract Management
Mail Code-91X
PO Box 204077
Austin, TX 78720-4077


Texas Medicaid & Healthcare Partnership
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