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December 2016 Texas Medicaid Provider Procedures Manual

Section 7: Appeals : 7.3 Appeals to HHSC Texas Medicaid Fee-for-Service : 7.3.1 Administrative Claim Appeals : 7.3.1.2 Exceptions to the 95‑Day Filing Deadline

7.3.1.2
Exceptions to the 95‑Day Filing Deadline
HHSC Claims Administrator Operations Management is responsible for reviewing requests for exceptions to the 95‑day filing deadline for Texas Medicaid fee-for-service. 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 are submitted within the 365‑day federal filing deadline from the date of service as outlined in 1 TAC §354.1003.
Exceptions to the filing deadline are considered when one of the following situations exists:
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 control of the provider, 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 persons are presumed to be within the control of the provider. The presumption can only be rebutted when the intentional acts of the employee or agent lead to termination of employment and filing of criminal charges against the employee or agent.
Providers requesting an exception for catastrophic events must include independent evidence of insurable loss; medical, accident, or death records; or police or fire report substantiating the exception of damage, destruction, or criminal activity.
Providers requesting an exception for the delay or error in the eligibility determination of a client or delay due to erroneous written information from HHSC, its designee, or another state agency must include the written document from HHSC or its designee that contains the erroneous information or explanation of the delayed information.
Providers requesting an exception for the delay due to electronic claim or system implementation problems experienced by HHSC, its designee, or Texas Medicaid providers must include 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.
If the provider is requesting an exception based upon an electronic claim or system implementation problem experienced by HHSC or its designee, the provider must submit a written statement outlining the details of the electronic claim or system implementation problems experienced by HHSC or its designee that caused the delay in the submission of claims by the provider, any steps taken to notify the state or its designee of the problem, and a verification that the delay was not caused by the neglect, indifference, or lack of diligence on the part of the provider or its employees or agents.
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 for claims that were submitted within the 365-day federal filing deadline, but were not filed within the 95-days of the date of service because the service was determined to be a benefit of Texas Medicaid and an effective date for the new benefit was applied retroactively, must include a written, detailed explanation of the facts and documentation to demonstrate the 365‑day federal filing deadline for the benefit was met.
Providers requesting an exception for client eligibility determined retroactively and the provider is not notified of retroactive coverage 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.

Texas Medicaid & Healthcare Partnership
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