The following scenario, claim will not be denied as timely filing limit exceeded.
Exceptions to the 12-Month Time Limit
Exceptions to the 12-month claim submission time limit may be allowed if the
claim meets one or more of the following conditions:
· New clean claim submitted within six months of the date of the void of the
original claim payment date;
· Court or hearing decision;
· Delay in recipient eligibility determination;
· Medicaid delay in updating eligibility file;
· Court ordered or statutory action; or
· System error on a claim that was originally filed within 12 months from the
date of service.
Any claim filed more than 12 months from the date of service that meets an
exception must be sent to the area Medicaid office for processing, not to the
fiscal agent.
Each of these exceptions is discussed below.
Original Payment is Voided
When an original Medicaid claim is voided, the provider may submit a new claim
and a written request for assistance to the area Medicaid office no later than six
months from the void date.
Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court
decision, there is no time limit for the submission of a claim.
Delay in Recipient Eligibility Determination
An exception may be granted when there is a delay in the determination of an
individual’s Medicaid eligibility by the Department of Children and Families or the
Social Security Administration. The provider must send in specific
documentation to the area Medicaid office no later than 12 months from the date
the recipient’s eligibility is updated on FMMIS. The claim submission must
include:
· A clean claim,
· A copy of the recipient’s proof of eligibility, and
· Documentation of the reason for late submission.
Medicaid Delay in Updating Eligibility File
If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid
Management Information System (FMMIS), an exception may be granted. The
provider must submit the related clean claims to the area Medicaid office no
later than 12 months from the date the recipient’s eligibility file was updated.
Court Ordered or Statutory Action
If the Medicaid office takes corrective action due to a court order or due to final
agency action taken under Chapter 120, Florida Statutes, there is no time limit
for claim submission.
System Error
If a clean claim is denied due to a system error or any error that is the fault of
Medicaid or the fiscal agent, an exception may be granted if the provider
submits another clean claim along with documentation of the denial to the area
Medicaid office no later than 12 months from the date of the original denial.
Evaluate the Claim
The provider must evaluate any claim that is denied and determine if the claim
fits any of the conditions for an exception to the 12-month filing limit.
