Background: PCG has found that there has been an increase in incorrect
use of Medicaid delay reason codes. It
is the responsibility of the providers to utilize the appropriate delay reason
codes. Delay reason codes are used on
claims billed beyond Medicaid’s 90-day initial filing limit or when
resubmitting claims with updated information within the 60-day resubmission window
of claims denied or rejected. Each delay
reason code has specific guidelines as well as needing to be submitted within
30-days of the situation coming under the control of the provider. Provider delays in working claims issues, which result in past
timely filing rejections/denials are not considered as third-party processing
delays.
For more information on timely filing guidelines, please see
Medicaid’s Power Point presentation that has specific examples on appropriate
use of delay reason codes: “Guide to
Timely Billing” https://www.emedny.org/ProviderManuals/AllProviders/Guide_to_Timely_Billing.pdf
| Number | Proof of eligibility unknown/unavailable | Additional Information |
| 1
| Proof of eligibility unknown/unavailable | - The beneficiary did not inform the
provider on DOS.
- Submission must be within 30 days
that the provider was notified of eligibility.
- Not applicable to adjusted
(corrected) claims
|
| 2 | Litigation | - Used when possibility of claims from
another source (i.e., lawsuit)
- Claims must be submitted within 30
days.
|
| *3
| Authorization delays | - Used when claims are delayed due to rate code issues.
- Must open Salesforce case to
utilize as it is not available for utilization in EI Billing*
- Providers will need to supply
approval from Medicaid or BEI.
- Providers must maintain
Medicaid/BEI approval documentation on file.
|
| 4
| Delay in certifying the provider | - When there is a change in the
provider’s enrollment status that causes a delay.
- Claims must be submitted within 30
days.
|
| 7
| Third party processing delay | - This
applies only when there is a delay in other insurance processing required
before billing Medicaid. (i.e.,
commercial plans)
- Claims must be submitted within 30
days.
- Provider delays in working claims
issues, which result in past timely filing rejections/denials are not
considered as third-party processing delays.
- Please be advised the county is not
considered a third party as it is not insurance.
|
| 8
| Delay in eligibility determination | - Delays due to back dated eligibility, appeals,
administrative delays, or litigation.
- Claims
must be submitted within 30 days.
|
| 9
| Original claim rejected/denied doe to a reason unrelated to timely filing | - Used
when prior submissions were timely and were not denied or rejected for timely
filing. Once there is a timely filing,
this delay reason cannot be used.
- Corrected
claims must be submitted within 60 days of Medicaid remittance.
- Delay
reason codes are invalid for adjustments.
- Adjustments
are corrected claims on previously paid Medicaid claims.
|
| 10 | Administrative delay in prior approval process | - Only when prior approval is granted after DOS if claim
ages over 90 days during this process.
- Claims
must be submitted within 30 days of notification.
|
| 15 | Natural Disaster | - Only when prior approval is granted after DOS if claim
ages over 90 days during this process.
- Claims
must be submitted within 30 days of notification.
|
Article ID: 480, Created On: 6/5/2023, Modified: 6/5/2023