I work in a Neurosurgery office located in Texas. I'm not sure if this is the correct forum to post my question, so I apologize in advance if it's not. We have the following situation with a patient but our provider representative has offered us no guidance as to what we should do.
Patient is initially seen in the office January 2016 as a self-pay patient. Has surgery in March 2016, still self-pay. Makes consistent payments from January 2016 until April 2017. Then in January 2018 presents our office with a letter dated December 1, 2017 from TMHP (Texas Medicaid) with the following information:
1) Date of certificate - December 1, 2017
2) Date coverage began - March 1, 2016
3) Date coverage ended - November 30, 2017
When I checked eligibility online it showed an add-date of 11/21/2017. Since I'm very familiar with Texas Medicaid billing guidelines, I knew we had 95 days from the add-date to submit a claim. So I did so. Within a couple of days it failed clearinghouse edits stating "REJECTED AND NOT ENTERED INTO THE ADJUDICATION SYSTEM DATES OF SERVICE OVER ONE YEAR FROM PROCESS DATE ARE NOT PAYABLE". So I submitted a hardcopy claim and it denied for the same reason. I submitted an appeal because there was no way we could have submitted the claim within either the 95 day deadline or the 24 month payment deadline. His eligibility was more than 1 year from the date of service. I have submitted an administrative appeal and the denial has been upheld.
Can the patient still be liable for the balance? I know in every instance as providers we are told if the patient has Medicaid we cannot bill them. But in this case, there was no way we could ever meet any deadline set forth by TMHP. In all my years of billing I cannot recall ever seeing a patient's eligibility go back more than 1 year.
Any input or guidance would be greatly appreciated!
Tammy Marugg, CPC
Patient is initially seen in the office January 2016 as a self-pay patient. Has surgery in March 2016, still self-pay. Makes consistent payments from January 2016 until April 2017. Then in January 2018 presents our office with a letter dated December 1, 2017 from TMHP (Texas Medicaid) with the following information:
1) Date of certificate - December 1, 2017
2) Date coverage began - March 1, 2016
3) Date coverage ended - November 30, 2017
When I checked eligibility online it showed an add-date of 11/21/2017. Since I'm very familiar with Texas Medicaid billing guidelines, I knew we had 95 days from the add-date to submit a claim. So I did so. Within a couple of days it failed clearinghouse edits stating "REJECTED AND NOT ENTERED INTO THE ADJUDICATION SYSTEM DATES OF SERVICE OVER ONE YEAR FROM PROCESS DATE ARE NOT PAYABLE". So I submitted a hardcopy claim and it denied for the same reason. I submitted an appeal because there was no way we could have submitted the claim within either the 95 day deadline or the 24 month payment deadline. His eligibility was more than 1 year from the date of service. I have submitted an administrative appeal and the denial has been upheld.
Can the patient still be liable for the balance? I know in every instance as providers we are told if the patient has Medicaid we cannot bill them. But in this case, there was no way we could ever meet any deadline set forth by TMHP. In all my years of billing I cannot recall ever seeing a patient's eligibility go back more than 1 year.
Any input or guidance would be greatly appreciated!
Tammy Marugg, CPC