Timely Filing: Questions and Answers

I think if I had a better explanation of why we are having this special filing period, then I would understand what type of claims you are stating are eligible.

In an effort to resolve claims denied for eligibility, Arkansas Medicaid has made modifications to bypass the timely filing edits. This includes claims beginning with dates of services on and after Oct. 1, 2013. Providers will have between Oct. 17, 2016, through April 15, 2017, to submit these claims.

I understand the five-year retention rule, but our eligibility is checked electronically through our EHR and the eligibility is replaced each time it is run. Are we supposed to print that eligibility out and keep it on record?

It is recommended but not required that providers keep a copy of the eligibility strip as proof that the patient was eligible on the date of service. Many providers save a copy in their EMR/EHR instead of printing out each individual eligibility strip.

When I check eligibility online, it doesn’t give a strip. It simply says patient not on file. I have not kept those. Does this affect my claim payment being recouped?

Eligibility strips are not required as proof of eligibility, although they are recommended. In this situation, the patient was not even in the system. Beginning Oct. 17, you may run eligibility to verify that the beneficiary is on Medicaid. If the claim meets the criteria listed in the presentation and on the website, you may bill the claim.

A patient stated they had a Medicaid application pending, but they never informed the practice that they received Medicaid.

You can check eligibility for the date of service the patient was seen. If there is an active eligible segment for that date and the claim meets the criteria, you may rebill the claim.

Providers must verify that an eligibility segment for the dates of service in question is available on file and verify that a PCP, if required, is on file before the claim is submitted. Does this mean that we have to check it and have a copy before we send it, and not that we have to have a paper from 2014 when we originally checked?

Correct. You will need to verify that the patient was eligible for the date of service you are trying to bill.

Are Department of Corrections claims included in the edit?

Yes.

Are Medicaid secondary claims eligible to be submitted?

Yes.

Understanding that there is no grace period after the deadline for submitting claims and that these may take longer to process due to volume, if we submit a claim within the allowed time period, but we do not receive a denial until after the deadline, will there be a certain time limit for corrections/ resubmissions after that denial date?

No. All claims will need to be filed and processed between Oct. 17 and April 15, 2017.

How do I handle name mismatching issues?

Contact your AFMC customer service at 888-987-1200, option 3.

I have billed timely filing claims through the PES system. The claims were all rejected due to not being timely. How do I get these claims to go through the system?

The timely filing edit was removed on Oct. 17. Claims that meet the criteria for eligibility may be rebilled beginning Oct. 17.

If we receive a referral from another provider, can we file that in PES or does the claim have to be filed on paper?

Claims may be filed via PES, paper or vendor.

Can we self-pay the patient since assigning the PCP is really the responsibility of the patient?

Medicaid requires a Medicaid beneficiary to be informed of the service and agree to pay before they can be billed. You can assist the patient by assigning through the Voice Response System or contact ConnectCare.

If the patient was not covered on a date of service and we failed to run the verification, are we able to bill the patient after they are seen and we later discover no coverage or PCP on file?

Medicaid requires a Medicaid beneficiary be informed of the service and agree to pay before they can be billed.

What is the start and end date of the state fiscal year?

July 1 through June 30.

Does section 172.200 of the Arkansas Medicaid Manual still apply for PCP enrollment? “Medicaid does not require PCP enrolment for the period between the beginning of the retroactive eligibility segment and the fifth day (inclusive) following the eligibility authorization date.”

Yes.

How will Medicaid know to differentiate old claims that had eligibility issues from just older claims that are truly timely?

Claims must meet criteria requirements listed on the website to be eligible for filing. Claims will be audited.

Will patients receive anything informing them of this window to file older claims due to eligibility?

No.

We have about 40 patients who have claims that fall in the eligible period, but they have a lapse in their Medicaid coverage. The lapses in coverage range from a couple of weeks to many months. We have previously sent itemized billing for these dates of service to Dave Mills, DHS/DCO Program Administrator, and also to our local DHS office. We have not heard anything back from anyone on any of the patients submitted. With the limited time period to get these claims paid, what can we do regarding these lapses in coverage (mostly due to applications lost or mishandled by the Medicaid program)?

Please contact your AFMC provider outreach representative.

Are PCPs being notified to give referrals for this time period?

No.

Are PCPs required for dental claims?

Dental claims do not require a PCP referral.

The initial email states deadline of April 15, 2017. What does the Dec. 31 date on the slide represent?

Timely filing edit dates are Oct. 17 until April 15, 2017. The Dec. 31 date is the proposed deadline for the eligibility applications to be completed.

What categories of Medicaid are included in the timely filing edit? Are secondary Medicaid claims eligible to be submitted?

Yes. If you have an outstanding Arkansas Medicaid claim that is past timely filing (Oct. 1, 2013–present) and meets the requirements to submit, you may submit those claims after Oct. 17, 2016.

Can you mail paper claims? Are extension of benefits claims included?

Yes.

Which Medicaid plan is the beneficiary assigned to for 45 days? When they have plan code 06, how do you determine if they have BCBS Metallic, Qualchoice, Ambetter or Medicaid?

The beneficiary is put in the Medicaid interim plan for up to 45 days. On the third page of the eligibility strip is where the plan is located.

Is this for the “pseudo claims” that were filed during this period? If they do not have active coverage by the deadline, what do we do?

This timely edit removal process is to cover those beneficiaries who had issues with eligibility. If you have claims that are outstanding and related to eligibility issues, please submit between Oct. 17 and April 15, 2017. All eligibility issues should be resolved by Dec. 31. If you have beneficiaries who still have issues with eligibility, please have them contact the AFMC customer service center at 888-987-1200.

Can I rebill any past timely bill rejects from Oct. 1, 2013, to present?

If the claim meets the timely filing edit criteria requirements listed on the website, you may rebill.

For patients who are temporarily assigned to Medicaid during interim periods, then elect to stay with Medicaid, are the benefits for lab and X-ray retroactively applied to the recipient’s benefit limit?

No. Patients have select, unlimited benefits during the alternative benefit interim period and do not require a PCP. When their eligibility is changed to Medicaid standard/traditional coverage, the patient’s benefits will start.

Will we be able to retro prior authorizations from this time frame?

Yes. Providers can submit their medical information through the current submission process via the secure web portal or the secure Accellion email system. With the time frame for requesting a prior authorization being waived, AFMC will perform the review and submit the prior authorization number to HPE in the daily claims process.

For AFMC review of claims, you mentioned filing through the portal. What if you do not have the portal?

Providers who don’t have access to our HIPAA-compliant, secure web portal have multiple options for submitting medical records/documentation to AFMC. Those options include:

  • Secure fax
  • Electronic submission through Accellion, our HIPAA-compliant, secure email system
  • U.S. Postal Service

AFMC is required to provide multiple options to providers for the submission of medical information. For providers who have electronic records but are not a registered user of the web portal, they can register via the link on the AFMC utilization review website and within a few weeks, have the ability to submit via the portal. Providers can call the help desk for assistance with getting registered at 479-573-7777.

Since RSPMI prior authorizations have a five-day filing limit to apply, are we going to be able to get retro prior authorizations for dates older than that?

Any outpatient request over 365 days will be treated as a review as normal.

It was our understanding that we would only have one chance to bill these claims. I think you stated that we can resubmit as many times as needed by April? Did I understand that correctly?

You can file the claim as often as needed.

Can we re-bill a child who has left the facility and has changed their name?

As long as the claim meets the timely filing edit criteria, you may rebill.

Providers must verify that an eligibility segment for the dates of service in question is available on file and verify that a PCP, if required, is on file before the claim is submitted. Does this mean that we have to check it and have a copy before we send it, and not that we have to have a paper from back in 2014 when we originally checked?

Correct. You will need to verify eligibility prior to filing the claim.

Due to the influx of retro approved applications, we were not always aware of the MCD ID before the Filing deadline. Will we be able to bill those if the add date was before FDL without fear of recoupment?

If the DOS is on or after 10/13/2013, and the claim meets all the requirements listed in the presentation and on the website, you can submit those claims. Normally a pseudo claim should be filed before the DOS becomes timely but this requirement is being lifted from 10/17/16-04/15/17. After 4/15/17 providers will need to refer to section 302.400.

Claims that were sent for extension and were denied for timely … would that be patient responsibility?

If the extension of benefits is denied for not being medically necessary, then the patient is not responsible.  Please refer to Section 131.000 for a list of charges that are not the responsibility of the beneficiary.

On the extension of benefits claims, if they are denied for timely, can we rebill?

Yes, please re-bill the claims as indicated and the reviews will be performed.

Patients who sign up for a commercial expansion plan is AR Medicaid going to eventually provide the insurance ID #. Example: Ambetter, we contact Ambetter and they have a different name. We contact the patient and they have never changed names. We have been advised that AR Medicaid can give info AR Medicaid says contact Ambetter. We are unable to assist this patient to get the care that she needs. We have contacted DHS and the main customer service #. Who can help her?

Please contact your AFMC provider outreach representative for assistance.

Has something been sent out to the PCPs giving them guidance on retro referrals during this time?

No. We have researched this; however, and if a beneficiary has retroactive eligibility a PCP should not be required during the period of retroactivity.

How do we handle patients whose coverage was not retroactive back to date of birth, but a few days later. How do we correct the coverage issue?

Please contact AFMC service center @888.987.1200 opt 3.

If Beacon was unable to process a PA due to eligibility, will they do a retroactive PA?

Beacon will review all request older than 365 days as a normal review and will require justification of medical necessity. Reviews under 365 days will be treated at a retroactive request and all documents will need to be submitted as part of that review.

I have a patient that was in 7-20-2015 and was assigned a PCP. The PCP was never changed. How can I get that paid?

Please contact ConnectCare for assistance.

Why would you need to have a PCP for 2-3 years ago, when that specific doctor didn't even see the patient years ago? What purpose does this serve?

We researched this and if a beneficiary has retroactive eligibility a PCP should not be required during the period of retroactivity.

Is the retroactive eligibility only for Aid Category-06 clients?

No. This is in regards to any claim that meets the requirements listed in the presentation.

If a PCP was assigned on 4/15/15 but we saw the patient before that date and they have updated coverage, how is a PCP retro assigned?

Please contact ConnectCare.

How do we tell on the AR Medicaid website which plan they picked when in the 06 aid category?

The eligibility strip, when pulled from the Medicaid website, will state which commercial insurance the recipient has transitioned to.  Page 3 of the strip should show the plan.

The claim has no perimeters of what can be billed? As long as it meets the MCD eligibility, PCP requirements, and retro dates during this special time?

All claims must meet the claim eligibility requirements listed on the Medicaid website.

What was the phone number for the newborn date of birth issue?

AFMC Customer Service  1-888-987-1200, opt 3.

The providers get 6 months to bill the “timely claims,” however, AFMC and SSI can take years in getting the coverage active. Can AFMC allow more time?

This is a Medicaid policy not AFMC or SSI. The timely filing dates are Oct. 17, 2016 – April 15, 2017.

Procedures that require attachments for review how will those be processed? We normally send them by paper.

You can still send paper claims.

Would the claim need to have been submitted before in the past to qualify? Should we bill only claims that have denied for eligibility?

You can bill any claim that meets the claim requirements during this time period. Requirements can be found on the website.

If the patient failed to provide Medicaid information and it is now timely, it does not meet timely criteria?

The timely filing edits are being lifted for all claims (on or after 10/13/13) that meet the criteria listed in the presentation and on the website.

How can you tell if the claim is retroactive or a claim that you just missed getting Medicaid information on?

DMS will get a report that includes the date of application, the date the application was approved and the dates of service.

Regarding recoupment: If we did not receive Medicaid eligibility details until now, can we file the charges even though we had not billed the charge before?

You can rebill all claims that are eligible based on the claim criteria listed on website. If you just received the eligibility information and it meets the requirements, you can bill.

If we submitted a claim for timely with "Smith" and when number was added the patient’s name has been changed. How will those be processed?

You will need to contact DCO or AFMC @ 888.987.1200 opt 3.

If I heard correctly, there must be a denial from Medicaid stating the patient was ineligible for the DOS in order for a claim to be refiled under this edit override? If so, what about those patients whose eligibility denied at the time of service and no claim was filed?

You do not need a denial from Medicaid to rebill a claim. If the claim meets the criteria for the timely edit, you simply refile the claim

Why can't you turn off the PCP referral requirement if we already know that we can't get a retro referral?

Turning off the PCP referral would require another month or two of work at HPE. Since the new system stands up in May 2017, this did not give us enough time to allow for billing. We researched this and if a beneficiary has retroactive eligibility, a PCP should not be required during the period of retroactivity.

We have several claims where the mother's date of birth has been mistakenly changed to the baby’s date of birth on our OB claims.

You will need to contact the Department of County operations or the AFMC customer service line @ 1.888.987.1200 option 3

Are office visits and outpatient claims included in this timely filing edit?

Yes

The local office has the eligibility updated when we call them but, when we look in the Medicaid system it still shows incorrectly. It seems like the two systems are not "communicating" and the eligibility is not being updated. Who would we contact?

You will need to contact DCO or AFMC @ 888.987.1200 opt 3.

Is this for Skilled nursing facilities or Assisted Living facilities?

This edit is for all providers

These claims have to be billed through PES. Is that correct?

You can submit claims through PES, the Medicaid website or through your vendor.

We submitted our claims with the pseudo number to HP to key for timely which they denied. Once coverage has been granted can we still key those to PES in our office?

Yes

Is Medicaid going to waive any eligibility fees as you are advising to run eligibilities as often as necessary?

No, eligibility fees still apply.

Between 10/17/16 - 04/15/2017, you will be auditing ALL claims that are outside timely so you can differentiate the ones effected by the eligibility error?

This is the plan however; it is still under review.

One of the slides gave a 12/31/16 deadline. What is that for?

Pending applications will be completed by DCO estimated date of 12/31/2016.

Patient has a letter from Medicaid stating they are approved for Medicaid but Medicaid website says it's inactive. Who do I need to contact?

You will need to check the website for eligibility for the date of service you are trying to bill. Please keep checking the website as applications are still being processed.

When checking eligibility, how can we tell if they fall into this eligibility window? Or when the coverage was approved?

You will type in the date of service that you are trying to bill to determine if the patient is eligible for Medicaid.

What about lapses in coverage? We have turned in billing to DHS to get the gaps closed, but have not had success with this. Who can we contact to get these resolved?

Please contact AFMC customer service @ 888.987.1200 option 3 or contact your AFMC Provider Outreach Representative for assistance.

Are the timely filing claims opening just for adult Medicaid? Is ARKIDS A & B included?

The timely filing claims edit removal will cover any claim that fits the claim criteria.

What is the current PES version?

2.24

It is understood that for timely filing requests the provider is allowed to bill as many times as needed to obtain a correct claim/RA. For claims that are timely and still within the 365 day timeframe, are providers allowed to bill multiple times to obtain a correct claim/RA? For example, a provider has an RA dated 06/30/2016 (for a timely DOS); however, they fail to send in the EOB request before the 90-day allowed timeframe (09/28/2016), are they allowed to rebill the same service and obtain a new RA and then submit the request with the current RA for EOB review? Thank you.

For claims that are timely and still within the 365 day timeframe, Nothing in policy today or in claims processing prevents the provider from rebilling the same service and obtaining a new RA and then submitting the request with the current RA for EOB review.