New Jersey Medicaid timely filing limit

The windows

Your participation agreement can set a different window. Where the contract and the manual disagree, the contract applies.

Exceptions the payer allows

What counts as proof of timely filing

• Your claim submission records reconciled against each Remittance Advice; the rule makes you confirm the fiscal agent received every claim and resubmit any claim that does not appear
• A photocopy of the Remittance Advice Claims Status page, with the beneficiary and edit codes highlighted, sent with a fair hearing request on a denied claim
• The Medicare EOB or adjudication date for a combination Medicare and Medicaid claim, which sets the 90-day window and the 45-day crossover wait
• The Retroactive Eligibility Unit letter, for bills submitted with an Application for Retroactive Medicaid Eligibility (FD-74)
• The other carrier's statement of payment, EOB or denial, which has to accompany the claim whenever other health insurance is involved

Notes for billers

• The Medicare rules are the only third-party extension. The rule says they do not reach any other insurance, and the annotated code lists rulings that a primary insurer's mismanagement, or its failure to send a determination, did not excuse a late Medicaid claim.
• A billing agent's mistake does not stretch the year either; the annotated rule cites a case holding exactly that. Inquiries about a claim that arrive after the time limits are treated the same way as late claims: no payment.
• In SSI Medical Services v. Division of Medical Assistance and Health Services (1996), evidence of the provider's routine mailing practice, together with other evidence, was enough to presume disputed claims were mailed and received. Keep submission logs that could carry that weight.
• Medicare adjustments do not cross over. When one creates a Medicaid overpayment or underpayment, notify the fiscal agent within 60 days of receiving it, and void a claim paid in error within 60 days.
• NJ FamilyCare managed care runs on its own clock. The DMAHS contract with the plans requires every provider contract to carry the same terms: claims within 180 calendar days of the date of service, corrected claims within 365 days, and coordination of benefits claims within 60 days of the primary insurer's EOB or 180 days from the date of service, whichever is later. The plans are Aetna Better Health of New Jersey, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan and Wellpoint.