Administrative Code

Virginia Administrative Code
11/29/2021

Chapter 95. Standards Established and Methods Used for Fee-For-Service Reimbursement

12VAC30-95-5. Applicability; general definitions.

A. The requirements of this chapter shall operate in addition to the provider requirements set out in other chapters of the Virginia Administrative Code, including but not limited to 12VAC30-50 through 12VAC30-90.

B. The following words and terms when used in 12VAC30 shall have the following meanings unless the context clearly indicates otherwise:

"ASAM" means the American Society of Addiction Medicine.

"ICD" means (i) for claims with dates of service on or prior to September 30, 2015, the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Volumes 1, 2, and 3, OptumInsight, Inc., and (ii) for claims with dates of service on or after October 1, 2015, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Procedure Coding System (ICD-10-PCS) pursuant to 45 CFR 162.1002, OptumInsight, Inc.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 30, Issue 18, eff. June 5, 2014; amended, Virginia Register Volume 31, Issue 2, eff. October 22, 2014; Volume 31, Issue 9, eff. February 13, 2015.

12VAC30-95-10. Timely claims filing.

A. Definitions. The following words and terms as used in this section shall have the following meanings unless the context clearly indicates otherwise.

"Claim" means the term as defined in 42 CFR 447.45 and includes a bill or a line item for services, drugs, or devices.

"Submit" or "file" means actual, physical receipt by the Department of Medical Assistance Services (DMAS) that is documented in DMAS records.

B. Consistent with 42 CFR 447.45, providers shall submit all claims to DMAS no later than 12 months from the date of service for which the provider requests reimbursement. In the absence of the two exception conditions set out in subsection E of this section, all claims otherwise submitted to DMAS after this 12-month time limit shall be denied.

C. In cases where the actual receipt of a claim by DMAS is undocumented, the burden of proof shall be on the provider to show that the claim was actually, physically received by DMAS. Proof by the provider that a claim was mailed, transmitted, or conveyed to DMAS by any method shall not constitute proof of receipt. The provider shall confirm actual receipt of a claim by DMAS within 12 months from the date of the service reflected on a claim.

D. If a claim for payment under Medicare has been filed in a timely manner, DMAS may pay a Medicaid claim for the same service within six months after the provider receives notice of the disposition of the Medicare claim.

E. Exceptions.

1. For cases in which a provider's claim was retracted by the third party payer, DMAS shall consider the date of the retraction notice by the third party payer as the begin date of the initial 12-month timely filing period.

2. For cases of retroactive Medicaid eligibility, DMAS shall consider the date of the notification of delayed eligibility from the local department of social services as the begin date of the initial 12-month timely filing period.

F. If DMAS denies a provider's original claim for reimbursement, the provider may resubmit the claim for reconsideration, together with any and all documentation to support the previously denied claim. All supporting documentation shall be filed at the time of the claim resubmission. DMAS shall not reconsider any resubmitted claim where:

1. The previously denied claim was not originally submitted within 12 months of the date of service, or

2. The denied claim was not resubmitted to DMAS within 13 months of the date the original claim was initially denied.

G. Once DMAS determines that a resubmitted claim cannot be paid and takes a denial action, it shall not be submitted again.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 31, Issue 9, eff. February 13, 2015.

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