Medicaid Providers Should Be Aware of a Change for Submitting Delayed Claims

eMedNY has notified providers that Medicaid claims older than 90 days that are coded with a delay code of 3 (Authorization Delay) must be filed on a paper claim form and be accompanied by the eMedNY Delay Reason Code Form as well as supporting documentation from the applicable state rate setting or policy office. Each paper claim must have its own eMedNY Delay Reason Code Form attached. These paper claims will pend for "edit 02159 – Delay Reason Code 3 (Authorization Delay) Invalid" and will be subject to prepayment review. Electronically submitted claims will be denied. Note that this change only impacts delay code 3, is effective Feb. 15, 2018, and does not impact clinic and inpatient claims.

Medicaid regulations require that claims for payment of medical services to eligible beneficiaries be submitted within 90 days of the date of service unless the claim is delayed due to circumstances outside the control of the provider. Medicaid claims aged over 90 days from the date of service may be submitted if the delay is due to one or more specific conditions.

Additional billing information for providers is available here, and the eMedNY notice is copied below.

Contact: Ken Allison, kallison@leadingageny.org, 518-867-8820

eMedNY Notice:

Beginning in February, claims delayed due to State administrative delay will pend for review when submitted on paper claim forms. All claims submitted electronically will be denied (except clinic and inpatient claims).

NY Medicaid allows limited use of Delay reason 3 “Authorization Delay” when there is a State administrative delay. This delay reason applies if the delay in claim submission was caused by a State administrative delay or problems with the State’s Medicaid information system, and authorization for late submission was requested from the applicable rate setting or program policy office. Claims must be submitted within 30 days from the date of notification of the authorization.

Effective 2/15/2018, All claims (except clinic and inpatient) with dates of service over 90 days old, submitted with Delay Reason 3 “Authorization Delay” cannot be electronically submitted and must be on paper claim forms along with the eMedNY Delay Reason Code Form and supporting documentation from the applicable state rate setting or policy office. These claims will pend for edit 02159 – Delay Reason Code 3 (Authorization Delay) Invalid and will be subject to prepayment review. Electronically submitted claims will deny for edit 02159 and the associated HIPAA reason code will be 29-THE TIME LIMIT FOR FILING HAS EXPIRED.