Claim Submission Timeliness Guidelines New Mexico Medicaid

Derrick Douglas

Provider Relations Manager

Xerox State Healthcare, LLC

Purpose

Xerox Internal Use Only

This module will familiarize participants with an overview of the timely filing billing policy and the advantages of the electronic submission of your Provider Enrollment application.

Objectives

• High level overview of the claim submission timely filing limitations

• Identify when Xerox State Healthcare, LLC may waive timely filing limits

• Discuss the advantages of enrolling as a Provider through online submission

• Resources

Timely Filing Limits

Providers have 90 days from the date of service to submit their claim.

Exceptions to the 90 day timely filing limit:

• Schools have 120 days for the initial filing period and 120 days for the grace period

• IHS and Tribal 638 compact facilities have 2 years from the date of service with no additional grace period.

• IHS Providers can submit claims electronically within 2 years from the date of service

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Timely Filing Limits

• For a claim which met the initial filing period, but was denied, partially denied, or requires an adjustment, there is an additional one-time 90 day grace period counted from the date of payment or denial, during which the claim can be re-filed or an adjustment submitted to Xerox.

• It is to the provider’s advantage to resubmit a claim, if necessary, within the initial 90 day filing period in order to have the greatest amount of time in which to re-file or submit an adjustment during the 90 day grace period if another re-filing or adjustment is necessary.

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Grace Period

• The claim may be re-filed during the 90-day grace period as many times as necessary, but claims filed after the 90 day grace period will be denied.

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Exceptions:

Exceptions to the filing limit:

• When other primary payers have denied or made payment on a claim, the filing limit of 90-days is counted from the date of payment or denial by the other party, but not to exceed 210 days from the date of service. A provider should file claims in sufficient time with other payers to allow submission in time to meet the Medicaid 210 day limit.

• If 210 days have already past must include a Reconsideration Request form along with the claim. Claim(s) can be submitted hardcopy or through the Medicaid Portal.

• When the recipient has retroactive eligibility, the initial filing limit is 120 days from the date the eligibility was added to the eligibility file and was therefore available to providers. Claims may also be billed electronically.

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Exceptions: Continued

• When the provider was not originally enrolled as a MAD provider on the date of service, the filing limit of 90 days is counted from the date the provider was notified of their enrollment, but must not exceed 210 days from the date of service. A provider should submit a provider participation agreement in sufficient time to allow processing and still meet the Medicaid 210 day limit for submitting the claim.

• When a claim previously paid by a Medicaid managed care organization is recouped from a provider due to retroactive disenrollment of the client from the managed care organization, the filing limit of 90 days is counted from the date of the managed care organization’s notice or recoupment from the provider.

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Denials

• When resubmitting a claim or requesting an adjustment on a claim that is past the 90 day filing limit but originally met the filing limit, the “TCN” number which appears on the remittance advice (RA) will be used by Xerox to evaluate the claim. The provider must supply that TCN number in order for Xerox to be able to evaluate the claim.

• Utilize the same TCN number that is posted on the most recent RA within the original 90 days (120 days if SBHC) when resubmitting during the grace period.

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Helpful Hints

• When requesting an adjustment on a paid claim, use the TCN of the final payment.

• The filing limit does not apply when the provider is returning an overpayment to the Medicaid program.

• When submitting a paper claim each claim needs to include one of the following documentation:

• Reconsideration Request

• Adjustment Request

• Void Request

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Electronic Provider Application Submission

Advantages

Save money.

• Reduce postage, printing and paper costs associated with paper submission

• Submit attachments electronically using the New Mexico Medicaid Portal

Save time.

• Enter Provider information directly into the New Mexico Medicaid Portal

• Faster, user friendly and a cleaner application process (less errors)

• Track application status online

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Resources • NM Medicaid Call Center

• 505-246-0710 or 800-299-7304

• Provider Field Representatives

• Contact the Call Center

• Human Services Department

• http://www.hsd.state.nm.us/providers/Default.aspx

• New Mexico Medicaid Portal

• https://nmmedicaid.acs-inc.com/static/index.htm

• Provider Information section

• Links and FAQ section

• PowerPoint Presentations

Summary

• Identified the claim submission guidelines

• Discussed timeliness billing exceptions

• Highlighted the Provider Enrollment electronic submission process and

the advantages.

• Who to contact for assistance

Thank You