New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.11 - BILLING AND CLAIMS FILING LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Claims must be received within the MAD
				filing limits as determined by the date of receipt by MAD or its selected
				claims processing contractor.
(1) Claims for
				services must be received within 90 calendar days of the date of service unless
				an alternative filing limit is stated within this section.
(2) Inpatient hospital and other inpatient
				facility claims must be received within 90 calendar days of the date of the
				eligible recipient or member's discharge, transfer, or otherwise leaving the
				facility.
(3) When the provider can
				document that a claim was filed with another primary payer including medicare,
				a HSD contracted MCO, medicare replacement plans, or another insurer, the claim
				must be received within 90 calendar days of the date the other payer paid or
				denied the claim as reported on the explanation of benefits or remittance
				advice of the other payer, not to exceed 210 calendar days from the date of
				service. It is the provider's responsibility to submit the claim to another
				primary payer within a sufficient timeframe to reasonably allow the primary
				payer to complete the processing of the claim and also meet the MAD timely
				filing limit. Denials by the primary payer due to the provider not meeting
				administrative requirements in filing the claim must be appealed by the
				provider to the primary payer. MAD only considers payment for a claim denied by
				the other primary payer when under the primary payer's plan the eligible
				recipient or member is not eligible, the diagnosis, service or item is not
				within the scope of the benefits, benefits are exhausted, pre-existing
				conditions are not covered, or out-of-pocket expenses or the deductibles have
				not been met. MAD will evaluate a claim for further payment including payment
				toward a deductible, co-insurance, co-payment or other patient responsibility.
				Claims for payment towards a deductible, co-insurance, co-payment or other
				patient responsibility also must be received within 90 calendar days of the
				date of the other payer's payment, not to exceed 210 calendar days from the
				date of service.
(4) For an
				eligible recipient or member for whom MAD benefits were not established at the
				time of service but retroactive eligibility has subsequently been established,
				claims must be received within 90 calendar days of the date the eligibility was
				added to the eligibility record of MAD or its selected claims processing
				contractor.
(5) For a provider of
				services not enrolled as a MAD provider at the time the services were rendered,
				including a provider that is in the process of purchasing an enrolled MAD
				provider entity such as a practice or facility, claims must be received within
				90 calendar days of the date the provider is notified of the MAD approval of
				the PPA, not to exceed 210 calendar days from the date of service. It is the
				provider's responsibility to submit a PPA within a sufficient timeframe to
				allow completion of the provider enrollment process and submission of the claim
				within the MAD timely filing limit.
(6) For claims that were originally paid by a
				HSD contracted MCO from which the capitation payment is recouped resulting in
				recoupment of a provider's claim by the MCO, the claim must be received within
				90 calendar days of the recoupment from the provider.
(7) For claims that were originally paid by
				MAD or its selected claims processing contractor and subsequently recouped by
				MAD or its selected claims processing contractor due to certain claims
				conflicts such as overlapping duplicate claims, a corrected claim subsequently
				submitted by the provider must be received within 90 calendar days of the
				recoupment.