Medicaid claim submission time limit - primary and secondary claims

Timely Claim Submission
Medicaid providers should submit claims immediately after providing services so
that any problems with a claim can be corrected and the claim resubmitted
before the filing deadline.

Clean Claim 

In order for a claim to be paid, it must be a clean claim. A clean claim is a
Medicaid claim that:
·  Has been accurately and fully completed according to Medicaid billing guidelines.
·  Is accompanied by all necessary documentation.
·  Can be processed and adjudicated by the fiscal agent without obtaining
additional information from the provider.


12-Month Filing Limit
A clean claim for services rendered must be received by the Medicaid office or
its fiscal agent no later than 12 months from the date of service.

Date Received Determined


The date stamped on the claim by any Medicaid office or by the Medicaid fiscal
agent is the recorded date of receipt for a paper claim. The fiscal agent date
stamps the claim the date that it is received in the fiscal agent’s mailroom.
The date electronically coded on the provider’s electronic transmission by the
Medicaid fiscal agent is the recorded date of receipt for an electronic claim.


Third Party Payer and Medicare Insurance Claims
Claims for recipients who have Medicare or other insurance must be submitted
to a third party payer prior to sending the claim to Medicaid.

For non-Medicare claims, the claim must be received by Medicaid or the
Medicaid fiscal agent no later than 12 months from the date of service or six
months from the date of the other insurance payment or denial.

The filing limit for Medicare claims crossing over to Medicaid is the greater of 36
months from the date of discharge or 12 months from Medicare’s adjudication
date.

New and Established CPT code list

New and Established Patient Services


A new patient is one who has not received any professional services from a physician or from another physician of the same specialty who belongs to the same group practice, within the past three years. Providers must use procedure codes 99201, 99202, 99203, 99204, and 99205 when billing for new patient services provided in the office or an outpatient or other ambulatory facility. New patient visits are limited to one every three years, per client, per provider.

An established patient is one who has received professional services from a physician or from another physician of the same specialty within the same group practice, within the last three years. Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient or other ambulatory facility:

When an office visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, the office visit must be billed as an established patient visit. If a new patient visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, then the new patient visit will be denied.

Modifier 25 may be used to identify a significant, separately identifiable E/M service performed by the same physician on the same day as another procedure or service. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client's medical record. The documentation must clearly indicate what the significant problem/abnormality was, including the important, distinct correlation with signs and symptoms to demonstrate a distinctly different problem that required additional work and must support that the requirements for the level of service billed were met or exceeded.

The date and time of both services performed must be outlined in the medical record and the time of the second service must be different than the time of the first service, although a different diagnosis is not required.

An established patient visit that is billed with the same date of service as a new patient visit by the same provider will be denied as part of another procedure except when the established patient visit is billed with a new THSteps medical checkup.

Office visits (procedure codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215) provided on the same date of service as a planned procedure (minor or extensive) are included in the cost of the procedure and are not separately reimbursed.

Office visit procedure code 99211, 99212, 99213, 99214, or 99215 must be billed by the same provider with the same date of service as a group clinical visit.

Procedures that are included in the E/M service (e.g., binocular microscopy, noninvasive ear or pulse oximetry for oxygen saturation, etc.) are denied as part of another procedure when billed by the same provider with the same date of service as one of the following office or outpatient consultation visit procedure codes:

Procedure Codes

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

99241

99242

99243

99244

99245

Emergency department-based physicians or emergency department-based groups may not bill charges for inconvenience or after hours services (procedure code 99050, 99056, or 99060).

New CLIA waived CPT list - 2012

New Waived Tests 

Effective Date : January 1, 2012

Implementation Date : January 3, 2012

STOP- Impact to you

If you do not have a valid, current, Clinical Laboratory Improvement Amendments of 1998 (CLIA) certificate and submit a claim to your Medicare Carrier or A/B MAC for Current Procedural Terminology (CPT) code that is considered to be a laboratory test requiring a CLIA certificate, your Medicare payment may be impacted.

CAUTION _ What you need to know

CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The CPT codes that the Centers for Medicare & Medicaid Services (CMS) considers to be laboratory tests under CLIA (and thus requiring certification) change each year. Change Request (CR) 7566, from which this article is taken, informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits.

GO – What you need to do

Make sure that your billing staffs are aware of these CLIA-related changes for 2012 and that you remain current with certification requirements.

Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. The CPT codes in the following table must have the modifier QW to be recognized as a waived test. However, CPT codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651 do not require a QW modifier to be recognized as a waived test.

CPT Code	Effective Date	Description
81003QW	14-Feb-11	Germaine Laboratories Inc. AimStrip Urine Analyzer
G0434QW	22-Apr-11	UCP Biosciences, Inc. UCP Drug Screening Test Cups
G0434QW	22-Apr-11	Diagnostic Test Group Clarity Multiple Drug Screen Test Cups
81003QW	24-Mar-11	Mediwatch urinewatch Urine Analyzer
G0434QW	17-Jun-11	Insight Medical Drug of Abuse Urine Cassette Test
G0434QW	17-Jun-11	Insight Medical Drug of Abuse Urine Cup Test
G0434QW	17-Jun-11	Instant Technologies, Inc. iScreen Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Instant Technologies, Inc. iScreen Drug of Abuse Urine (Cup) Test
G0434QW	17-Jun-11	Jant Pharmacal Accutest Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Jant Pharmacal Accutest Drug of Abuse Urine (Cup) Test
G0434QW	17-Jun-11	Total Diagnostic Solutions Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Total Diagnostic Solutions Drug of Abuse Urine (Cup) Test
G0434QW	30-Jun-11	Diagnostic Test Group Clarity Simple Drug Screening Cups
G0434QW	30-Jun-11	Diagnostic Test Group Clarity Multi-Drug Test Cards
81003QW	14-Jul-11	Stanbio Uri-Trak 120 Urine Analyzer
G0434QW	21-Jul-11	UCP Biosciences, Inc. U-Checker Drug Screening Test Cups