1. (a) Except for good cause, bills for service provided pursuant to the Medi-Cal Program (Welfare and Institutions Code, Division 9, Part 3, Chapter 7), shall be received by the fiscal intermediary, or otherwise as designated by the Director, not later than the sixth month following the month of service and shall be in the form prescribed by the Director.

2. (b) As used in this section:

   1. (1) “Month of service” means the month in which a:

      1. (A) Service is provided or supplies are furnished.
      2. (B) Dental prosthesis, custom-made eye appliance, custom-made prosthetic appliance, or custom-made orthotic appliance is ordered from the fabricating laboratory.

      3. (C) Trial period prior authorized or required under these regulations is completed for a prosthetic appliance or orthotic appliance covered under Section 51315, a hearing aid covered under Section 51319, or an item of durable medical equipment covered under Section 51321.

         “Good cause” means circumstances beyond the control of the provider, as specified in Section 51008.5.

3. (c) A Resubmission Turnaround Document (RTD), which has been sent by the fiscal intermediary for correction or additional information, must be received back from the provider not later than 60 days following the date of the RTD. The claim is subject to denial of payment if corrections or additional information furnished by the provider on the RTD are incomplete, inaccurate or untimely.
4. (d) A request for adjustment or reconsideration of an adjudicated claim must be received by the fiscal intermediary not later than six months following the date of payment or denial of the claim by the fiscal intermediary. If favorable resolution of a claim is not obtained, a grievance or complaint concerning the processing or payment of the claim must be filed in accordance with Section 51015.

Note: Authority cited: Section 20, Health and Safety Code; and Sections 10725, 14105, 14115 and 14124.5, Welfare and Institutions Code. Reference: Sections 14021, 14053, 14115, 14124.1, 14124.2, 14124.24, 14131 and 14133, Welfare and Institutions Code.

History

1. New section filed 9-7-66 as an emergency; effective upon filing; Certificate of Compliance included (Register 66, No. 30).

2. Amendment filed 7-1-70; designated effective 8-1-70 (Register 70, No. 27).

3. Amendment of subsection (a) filed 5-9-73 as an emergency; effective upon filing (Register 73, No. 19).

4. Certificate of Compliance filed 9-5-73 (Register 73, No. 36).

5. Amendment of subsection (b) filed 12-23-75; effective thirtieth day thereafter (Register 75, No. 52).

6. Amendment of subsection (b) filed 11-29-79; effective thirtieth day thereafter (Register 79, No. 48).

7. New subsections (c) and (d) filed 4-25-80; effective thirtieth day thereafter (Register 80, No. 17).

8. New subsections (b)(3) and (e) filed 7-31-81; effective thirtieth day thereafter (Register 81, No. 31).

9. Amendments of subsection (a)-(d), and renumbering and amendment of former subsection (e) to section 51008.5 filed 12-6-85; effective thirtieth day thereafter (Register 85, No. 49).

10. Repealer of subsections (b)(1)(D) and (E) and amendment of subsections (a), (c), (d) and Note filed 9-16-92; operative 10-16-92 (Register 92, No. 38).

11. Change without regulatory effect amending Note filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).