Exceptions to the 12-Month Time Limit
Exceptions to the 12-month claim submission time limit may be allowed if the claim meets one or more of the following conditions:
· New clean claim submitted within six months of the date of the void of the original claim payment date;
· Court or hearing decision;
· Delay in recipient eligibility determination;
· Medicaid delay in updating eligibility file;
· Court ordered or statutory action; or
· System error on a claim that was originally filed within 12 months from the date of service.
Any claim filed more than 12 months from the date of service that meets an exception must be sent to the area Medicaid office for processing, not to the fiscal agent. Each of these exceptions is discussed below.
Original Payment is Voided
When an original Medicaid claim is voided, the provider may submit a new claim and a written request for assistance to the area Medicaid office no later than six months from the void date.
Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court decision, there is no time limit for the submission of a claim.
Delay in Recipient Eligibility Determination
An exception may be granted when there is a delay in the determination of an individual’s Medicaid eligibility by the Department of Children and Families or the Social Security Administration. The provider must send in specific documentation to the area Medicaid office no later than 12 months from the date the recipient’s eligibility is updated on FMMIS. The claim submission must
· A clean claim,
· A copy of the recipient’s proof of eligibility, and
· Documentation of the reason for late submission.
Medicaid Delay in Updating Eligibility File
If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid Management Information System (FMMIS), an exception may be granted. The provider must submit the related clean claims to the area Medicaid office no later than 12 months from the date the recipient’s eligibility file was updated.
Court Ordered or Statutory Action
If the Medicaid office takes corrective action due to a court order or due to final agency action taken under Chapter 120, Florida Statutes, there is no time limit for claim submission.
If a clean claim is denied due to a system error or any error that is the fault of Medicaid or the fiscal agent, an exception may be granted if the provider submits another clean claim along with documentation of the denial to the area Medicaid office no later than 12 months from the date of the original denial.
Evaluate the Claim
The provider must evaluate any claim that is denied and determine if the claim fits any of the conditions for an exception to the 12-month filing limit.
Medicare Guideline posts
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Top Medicare billing tips
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immun...
Procedure code and description 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous ele...
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 36416 Collection of capi...
Coverage Indications, Limitations, and/or Medical Necessity This LCD describes conditions under which the coverage of nail avulsion/ex...
procedure code and description 93922 LIMITED BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, (EG, FOR LOW...
Procedure code and description 95004 Percut Tests w/ Extrac Immed React # Allergy testing - Percut allergy skin tests - Percutaneous ...
Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, provides sensitive, ...