WAC 388-502-0150   Time limits for providers to bill MAA.  Providers may bill the medical assistance administration (MAA) for covered services provided to eligible clients.

     (1) MAA requires providers to submit initial claims and adjust prior claims in a timely manner. MAA has three timeliness standards:

     (a) For initial claims, see subsections (3), (4), (5), and (6) of this section;

     (b) For resubmitted claims other than prescription drug claims, see subsections (7) and (8) of this section; and

     (c) For resubmitted prescription drug claims, see subsections (9) and (10) of this section.

     (2) The provider must submit claims to MAA as described in MAA's billing instructions.

     (3) Providers must submit their claim to MAA and have an internal control number (ICN) assigned by MAA within three hundred sixty-five days from any of the following:

     (a) The date the provider furnishes the service to the eligible client;

     (b) The date a final fair hearing decision is entered that impacts the particular claim;

     (c) The date a court orders MAA to cover the service; or

     (d) The date the department certifies a client eligible under delayed certification criteria.

     (4) MAA may grant exceptions to the three hundred sixty-five-day time limit for initial claims when billing delays are caused by either of the following:

     (a) The department's certification of a client for a retroactive period; or

     (b) The provider proves to MAA's satisfaction that there are other extenuating circumstances.

     (5) MAA requires providers to bill known third parties for services. See WAC 388-501-0200 for exceptions. Providers must meet the timely billing standards of the liable third parties in addition to MAA's billing limits.

     (6) When a client is covered by both medicare and MAA, the provider must bill medicare for the service before billing medicaid. If medicare:

     (a) Pays the claim the provider must bill MAA within six months of the date medicare processes the claim; or

     (b) Denies payment of the claim, MAA requires the provider to meet the three hundred sixty-five-day requirement for timely initial claims as described in subsection (3) of this section.

     (7) MAA allows providers to resubmit, modify, or adjust any claim, other than a prescription drug claim, with a timely ICN within thirty-six months of the date the service was provided to the client. This applies to any claim, other than a prescription drug claim, that met the time limits for an initial claim, whether paid or denied. MAA does not accept any claim for resubmission, modification, or adjustment after the thirty-six-month period ends.

     (8) The thirty-six-month period described in subsection (7) of this section does not apply to overpayments that a provider must refund to the department. After thirty-six months, MAA does not allow a provider to refund overpayments by claim adjustment; a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

     (9) MAA allows providers to resubmit, modify, or adjust any prescription drug claim with a timely ICN within fifteen months of the date the service was provided to the client. After fifteen months, MAA does not accept any prescription drug claim for resubmission, modification or adjustment.

     (10) The fifteen-month period described in subsection (9) of this section does not apply to overpayments that a prescription drug provider must refund to the department. After fifteen months a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

     (11) MAA does not allow a provider or any provider's agent to bill a client or a client's estate when the provider fails to meet the requirements of this section, resulting in the claim not being paid by MAA.



[Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.45. 00-14-067, § 388-502-0150, filed 7/5/00, effective 8/5/00.]