23 Miss. Code. R. 300-4.2

Current through December 10, 2024

Rule 23-300-4.2 - Errors Made within the Timely Processing Period

A. The Provider may not seek relief from the Division for a claim denied due to an error within the timely processing period until the provider exhausts the applicable process for the type of error as detailed below.

1. Fiscal Agent Error

a) When a claim is denied due to Fiscal Agent Error(s) within the timely processing period, the provider must notify the fiscal agent to correct the error.

b) If the Fiscal Agent does not correct the error within the timely processing period, the provider may contact Division of Medicaid Office of Provider Solutions within ninety (90) days of the end of the timely processing period for an Administrative Review for the Denied Claim.

2. Provider Billing Errors

a) Claims submitted within the timely filing period that deny due to a Provider Billing Error(s) may be resubmitted to the Fiscal Agent within the timely processing period.

b) Claims submitted outside of the timely filing period will only be reviewed if the requirements listed in Part 200, Rule 1.6 are met. The Division has discretion to grant or refuse an Administrative Review for a Denied Claim.

c) Denial of a request for an Administrative Review for a Denied Claim is the Division's Final Administrative Decision.

d) If the Division does grant a request for Administrative Review of a Denied Claim, the Division of Medicaid's Office of Provider Solutions will render the Division's Final Administrative Decision.

3. Providers may not appeal the technical denial of a claim for failure to timely obtain a prior authorization.

B. Claims Denied for Untimeliness

1. Providers may request an Administrative Review for a claim denied for untimeliness within ninety (90) calendar days of the denial of a claim when:

a) The provider is unable to meet the timely filing requirement due to retroactive beneficiary eligibility and has:

1) Received prior authorization, if required, from the Utilization Management/Quality Improvement Organization (UM/QIO) within ninety (90) days of the system add date of the eligibility determination, and

2) Filed the claim within ninety (90) days of the system add date of the eligibility determination,

b) The Division of Medicaid adjusts claims after timely filing and timely processing deadlines have expired,

c) A Medicare crossover claim has been filed within one hundred eighty (180) calendar days from the Medicare paid date and the provider is dissatisfied with the disposition of the Medicaid claim, or

d) The Fiscal Agent's untimeliness decision was incorrect.

2. Requests for an Administrative Review for a Denied Claim must include:

a) Documentation of timely filing or documentation that the provider was unable to file the claim timely due to the beneficiary's retroactive eligibility;

b) Documentation that explains the facts that support the provider's position as to how the denied claim meets one (1) or more of the requirements in Miss. Admin. Code, Title 23, Part 300, Rule 4.1.B. and the reasons the provider believes the Provider complied with Medicaid regulations;

c) A new claim submission for the claim in question; and

d) Any other documentation as required or requested by the Division of Medicaid.

3. Requests for an Administrative Review for a claim adjusted after the expiration of timely filing must include:

a) A copy of the Remittance Advice that includes the claim adjustment;

b) Documentation supporting the Provider's position that the claim meets one (1) or more of the requirements of Rule 4.1.C. of this Chapter;

c) A new claim submission for the subject claim; and

d) Any other documentation as required and/or requested by the Division.

C. Medical necessity

1. Providers may request a reconsideration when a claim is denied due to failure to meet medical necessity requirements by submitting the required documentation to the fiscal agent within ninety (90) days of the denial.

2. If the provider is not satisfied with the fiscal agent's medical necessity determination, the provider may request, in writing, an administrative hearing with the Division of Medicaid within ninety (90) days of the receipt of the fiscal agent's medical necessity determination through the appeal process as described in Rule 3.1 of this Part.

23 Miss. Code. R. 300-4.2

Miss. Code Ann. §§ 43-13-113, 43-13-117, 43-13-121

Adopted 3/1/2023