#Aetna timely filing limit 2015 code#

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#Aetna timely filing limit 2015 code#

To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.Īs a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. § 32.1-325 of the Code of Virginia 42 USC § 1396 et seq.ĭerived from Virginia Register Volume 31, Issue 9, eff. Once DMAS determines that a resubmitted claim cannot be paid and takes a denial action, it shall not be submitted again. The denied claim was not resubmitted to DMAS within 13 months of the date the original claim was initially denied. The previously denied claim was not originally submitted within 12 months of the date of service, orĢ.

DMAS shall not reconsider any resubmitted claim where:ġ. All supporting documentation shall be filed at the time of the claim resubmission. If DMAS denies a provider's original claim for reimbursement, the provider may resubmit the claim for reconsideration, together with any and all documentation to support the previously denied claim. For cases of retroactive Medicaid eligibility, DMAS shall consider the date of the notification of delayed eligibility from the local department of social services as the begin date of the initial 12-month timely filing period.į.

For cases in which a provider's claim was retracted by the third party payer, DMAS shall consider the date of the retraction notice by the third party payer as the begin date of the initial 12-month timely filing period.Ģ. If a claim for payment under Medicare has been filed in a timely manner, DMAS may pay a Medicaid claim for the same service within six months after the provider receives notice of the disposition of the Medicare claim.ġ. The provider shall confirm actual receipt of a claim by DMAS within 12 months from the date of the service reflected on a claim.ĭ. Proof by the provider that a claim was mailed, transmitted, or conveyed to DMAS by any method shall not constitute proof of receipt. In cases where the actual receipt of a claim by DMAS is undocumented, the burden of proof shall be on the provider to show that the claim was actually, physically received by DMAS.

In the absence of the two exception conditions set out in subsection E of this section, all claims otherwise submitted to DMAS after this 12-month time limit shall be denied.Ĭ. Consistent with 42 CFR 447.45, providers shall submit all claims to DMAS no later than 12 months from the date of service for which the provider requests reimbursement. 'Submit' or 'file' means actual, physical receipt by the Department of Medical Assistance Services (DMAS) that is documented in DMAS records.ī.

'Claim' means the term as defined in 42 CFR 447.45 and includes a bill or a line item for services, drugs, or devices. The following words and terms as used in this section shall have the following meanings unless the context clearly indicates otherwise.