PURPOSE: This rule establishes the general provisions for submission or resubmission of claims and adjustments of claims to Missouri Medicaid.

1. (1) Claim forms used for filing Medicaid services as appropriate to the provider of services are—

   1. (A) Nursing Home Claim—Fast Electronic Nursing Institution Xmission (FENIX), or individualized provider software when authorized by the state’s fiscal agent;
   2. (B) Pharmacy Claim—MO-8803, Revision 09/99 or POS, on-line claim format— NCPDP current version;
   3. (C) Outpatient Hospital Claim—UB-92 HCFA-1450;
   4. (D) Professional Services Claim—HCFA- 1500, Revision 12/90;
   5. (E) Dental Claim—ADA Dental Form; or 13 CSR 70-3
   6. (F) Inpatient Hospital Claim—UB-92 HCFA-1450;
2. (2) Specific claims filing instructions are modified as necessary for efficient and effective administration of the program as required by federal or state law or regulation. Reference the appropriate Medicaid provider manual and claim filing instructions for specific claim filing instructions information. Medicaid Manuals, sample forms, and the Missouri Medicaid Forms Request document are available via the Internet at the Division of Medical Services web site— www.dss.state.mo.us/dms.

3. (3) Time Limit for Original Claim Filing. Claims from participating providers that request Medicaid reimbursement must be filed by the provider and received by the state agency within twelve (12) months from the date of service. The counting of the twelve (12)-month time limit begins with the date of service and ends with the date of receipt.

   1. (A) Claims that have been initially filed with Medicare within the Medicare timely filing requirement and which require separate filing of a paper claim with Medicaid will meet timely filing requirements by being submitted by the provider and received by the state agency within twelve (12) months of the date of service or six (6) months of the date on the Medicare provider’s notice of the disposition of the claim.
   2. (B) Claims for recipients who have a thirdparty resource that is primary to Medicaid must be submitted to the third-party resource for adjudication unless otherwise specified by the Division of Medical Services. Documentation specified by the Division of Medical Services which indicates the third-party resource’s adjudication of the claim must be attached to the claim filed for Medicaid reimbursement. If the Division of Medical Services waives the requirement that the thirdparty resource’s adjudication must be attached to the claim, documentation indicating the third-party resource’s adjudication of the claim must be kept in the provider’s records and made available to the division at its request. The claim must meet the Medicaid timely filing requirement by being filed by the provider and received by the state agency within twelve (12) months from the date of service.

4. (4) Time Limit for Resubmission of a Claim After Twelve (12) Months From the Date of Service.

   1. (A) Claims which have been originally submitted and received within twelve (12) months from the date of service and denied or returned to the provider may be resubmitted within twenty-four (24) months of the date of service. Those claims must be filed by the provider and received by the state agency within twenty-four (24) months from the date of service. The counting of the twenty-four (24)-month time limit begins with the date of service and ends with the date of receipt.
   2. (B) Documentation specified by the Division of Medical Services in Medicaid provider manuals which indicates the claim was originally filed timely must be attached to the resubmission.
   3. (C) Claims will not be paid when filed by the provider and received by the state agency beyond twenty-four (24) months from the date of service.
5. (5) Denial. Claims that are not submitted in a timely manner and as described in sections
6. (1) and (2) of this rule will be denied. Except that at any time in accordance with a court order, the agency may make payments to carry out hearing decision, corrective action or court order to others in the same situation as those directly affected by it. The agency may make payment at any time when a claim was denied due to state agency error or delay, as determined by the state agency.
7. (6) Time Limit for Filing an Adjustment. Adjustments to a paid claim must be filed within eighteen (18) months from the date of payment.

8. (7) Definitions.

   1. (A) Claim A—claim is each individual line item of service on a claim form, for which a charge is billed by a provider, for all claim form types except inpatient hospital. An inpatient hospital service claim is all the billed charges contained on one (1) inpatient claim document.
   2. (B) Date of payment/denial—The date of payment or denial of a claim is the date on the remittance advice at the top center of each page under the words remittance advice.
   3. (C) Date of receipt—The date of receipt of a claim is the date the claim is received by the state agency. For a claim which is processed, this date appears as a Julian date in the internal control number (ICN). For a claim which is returned to the provider, this date appears on the Return to Provider form letter.

   4. (D) Date of service—The date of service which is used as the beginning point for determining the timely filing limit applies to the various claim types as follows:

      1. 1. Nursing home—The through date or

ending date of service for each line item for each individual recipient listed on the Turn- Around Document;

1. 2. Pharmacy—The date dispensed for

each line item for each individual recipient listed on the claim form;

1. 3. Outpatient hospital—The ending date

of service for each individual line item on the claim form;

1. 4. Professional services (HCFA-1500)—

The ending date of service for each individual line item on the claim form;

1. 5. Dental—The date service was per-

formed for each individual line item on the claim form;

1. 6. Inpatient hospital—The through date

of service in the area indicating the claimed period of service; and

1. 7. For service which involves the pro-

viding of dentures, hearing aids, eyeglasses or items of durable medical equipment; for example, artificial larynx, braces, hospital beds, wheelchairs, the date of service will be the date of delivery or placement of the device or item.

1. (E) Internal control number (ICN)—The fiscal agent prints a fourteen (14)-digit number on each document it processes through the Medicaid Management Information System (MMIS). The year of receipt is indicated by the third and fourth digits and the Julian date appears as the fifth, sixth and seventh digits. In an example ICN, 1084167520060, 84 is the year 1984 and 167 is the Julian date for June 15.
2. (F) Julian date—In a Julian system, the days of a year are numbered consecutively from 001 (January 1) to 365 (December 31) or 366 in a leap year. For example, in 1984, a leap year, June 15 is the 167th day of that year, thus, 167 is the Julian date for June 15, 1984.
3. (G) Twelve (12)-month time limit—This unit is defined as three hundred sixty-six

1. (366) days.

   1. (H) Twenty-four (24)-month time limit— This unit is defined as seven hundred thirtyone (731) days.

AUTHORITY: sections 208.153, and 208.201, RSMo 2000.* This rule was previously filed as 13 CSR 40-81.071. Original rule filed June 2, 1976, effective Oct. 11, 1976. Emergency rescission filed July 18, 1979, effective July 31, 1979, expired Nov. 10, 1979. Emergency rule filed July 18, 1979, effective Aug. 1, 1979, expired Nov. 10, 1979. Rescinded and readopted: Filed July 18, 1979, effective Nov. 11, 1979. Rescinded and readopted: Filed Sept. 12, 1984, effective Jan. 12, 1985. Amended: Filed April 21, 1992, effective Jan. 15, 1993. Amended: Filed June 3, 1993, effective Dec. 9, 1993. Amended: Filed Sept. 23, 1993, effective May 9, 1994. Amended: Filed Sept. 28, 2001, effective March 30, 2002. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991 and 208.201, RSMo 1987.