Wiki Retroactive insurance billing

[seanny]

Does anyone know of any legalities regarding filing retroactive claims, namely Medicaid for previously self-pay patients?

We are having several patients that are getting retroactive Medcaid eligibilty as much as 8 months in the past.

We have always refiled and refunded the patient what they paid. The adjustment, of course, brings us to about 30% of what they paid before. Some patients are seen monthly, so this process of filing retroactively so far back is costing us money.

I am attempting to put in place a policy that would put a "time limit" on these claims. Does anyone know if we can legally place a time limit on filing retroactive claims that's shorter than the insurers timely filing limit?

 

[airart]

Check with your State

It can be frustrating, but eight months is way too long. Medicaid.gov says no more than 3months, and for Texas, the filing deadline for claims is 95 days from the add date. If the add date was 8 months ago, then that would not give providers enough time to file the claim for payment to Medicaid. Check with your state, it will probably be near the national time frame as well. I think 3 months prior to date of service for retro to kick in would be satisfactory.

Per Medicaid.gov,

Retroactive Eligibility
Medicaid coverage may start retroactively for up to 3 months prior to the month of application, if the individual would have been eligible during the retroactive period had he or she applied then. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.
(Link: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Eligibility.html)

For Texas (TMHP):
Per Texas Administrative Code (Texas Regulation Law)
TITLE 1 ADMINISTRATION
PART 15 TEXAS HEALTHS AND HUMAN SERVICES COMMISSION
CHAPTER 354 MEDICAID HEALTH SERVICES
SUBCHAPTER A PURCHASED HEALTH SERVICES
DIVISION 1 MEDICAID PROCEDURES FOR PROVIDERS
RULE §354.1003

(a) Claims filing deadlines. Claims must be received by the Health and Human Services Commission (HHSC) or its designee in accordance with the following time limits to be considered for payment. Due to the volume of claims processed, claims that do not comply with the following deadlines will be denied payment.

(5) The following exceptions to the claims-filing deadlines listed in this subsection apply to all claims received by HHSC or its designee regardless of provider or service type.

(B) If a client loses Medicaid eligibility and is later determined to be eligible, or if the Medicaid eligibility is established retroactively, the claim must be received by HHSC or its designee within 95 days from the "add date" and within 365 days from the date of service.

 

[seanny]

What a helpful resource! Thank you so much for your detailed explanation!!