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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.1 Claims Information : 6.1.4 Claims Filing Deadlines : 6.1.4.1 Claims for Clients with Retroactive Eligibility

6.1.4.1
Claims for clients who receive retroactive eligibility must be submitted within 95 days of the date that the client’s eligibility was added to the TMHP eligibility file (add date) and within 365 days of the DOS.
Title 42 of the Code of Federal Regulations (42 CFR), at 447.45 (d) (1), states “The Medicaid agency must require providers to submit all claims no later than 12 months from the date of service.” The 12-month filing deadline applies to all claims. Claims not submitted within 365 days (12 months) from the date of service cannot be considered for payment.
Retroactive eligibility does not constitute an exception to the federal filing deadline. Even if the patient’s Medicaid eligibility determination is delayed, the provider must still submit the claim within 365 days of the date of service. A claim that is not submitted within 365 days of the date of service will not be considered for payment.
To submit a claim for services provided to a patient who is not yet eligible for Medicaid, Texas Medicaid allows providers to submit claims using a pseudo recipient identification number such as 999999999 or 000000000. Although TMHP will deny the claim, providers should retain the denial or electronic rejection report for proof of timely filing, especially if the eligibility determination occurs more than 365 days after the date of service. Claims denied for recipient ineligibility may be resubmitted when the patient becomes eligible for the retroactive date(s) of service. Texas Medicaid may then consider the claim for payment because the initial claim was submitted within the 365-day federal filing deadline and the denial was not the result of an error by the provider.
If the 365-day federal filing deadline requirement has passed, providers must submit the following to TMHP within 95 days from the add date:
Providers that have submitted their claims electronically can provide proof of timely filing by submitting a copy of an electronic claims report that includes the following information:
Note:
Only reports that were accepted or rejected by TMHP will be honored. The claim filed (client name or PCN, DOS and total charges) should match the information on the batch report.

Texas Medicaid & Healthcare Partnership
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