Frequently Asked Questions

Under section 1902(a)(25)(H) of the Social Security Act (the Act) before passage of the Deficit Reduction Act of 2005 (DRA), states were required to have laws in effect that to the extent Medicaid payment was made, the state was considered to have acquired the rights of the Medicaid beneficiary to reimbursement by any other party that was liable for payment. However, payers sometimes deny Medicaid claims based on procedural requirements. Section 1902(a)(25)(I) of the Act, added by the DRA, strengthens the statute by requiring states to enact laws that require health insurers:

1. To accept the state's right of recovery and the assignment to the state of the right of a Medicaid beneficiary or other entity to payment from such party for an item or service for which Medicaid has made payment; and,
2. To process and, if appropriate, pay the claim for reimbursement from Medicaid to the same extent that the plan would have been liable had the plan's card been used for billing at the ""point of sale"" (POS).

Specifically, the state should pass laws which require an insurer to agree not to deny claims submitted by the state on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation of coverage at the POS that is the basis of the claim.

Whether a plan provision affecting payment for an item or service is solely procedural in nature or whether it defines or limits the covered benefits must be determined on a case-by-case basis.

Note that nothing in the DRA negates the state's responsibility to provide proper documentation when submitting claims to the health insurer so that the insurer can determine that a covered service for which the insurer is liable was provided.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94261

No. States typically do not meet the definition of a covered health care provider under 45 CFR 160.103, and therefore, are not eligible to receive an NPI. If states encounter situations where plans are requiring them to submit an NPI, they can submit a formal complaint to the Office of E-Health Standards and Services (OESS) in CMS by using the online Administrative Simplification Enforcement Tool (ASET). ASET allows individuals or organizations to electronically file a complaint against an entity whose actions they believe violate an Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

States may submit a formal complaint electronically at: https://asett.cms.gov/ASETT_HomePage. ASET users are required to register with OESS and create a user identification name and password. States also may submit a paper complaint. The form is available at: www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Enforcements/Downloads/HIPAANon-PrivacyComplaintForm.pdf.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94266

Section 1902(a)(25)(I) of the Social Security Act requires states to have laws in effect that require health insurers to make payment as long as the claim is submitted by the state within three years from the date on which the item or service was furnished.

Some health insurers currently deny claims submitted by Medicaid if they are not filed within a prescribed time limit, which is applied to plan beneficiaries and providers (e.g., a plan might require beneficiaries and providers to submit claims within 30 days from date of service). If the state Medicaid agency is unable to ascertain the existence of the third party coverage and submit a claim within the time limit, the insurer may attempt to avoid liability.

Any action by the state to enforce its rights with respect to such claim must be commenced within six years of the state's submission of such claim. Health insurers also must respond to any inquiry by a state regarding claims submitted within three years from the date on which the item or service was furnished.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94286

No. Section 1902(a)(25)(I)(iv) of the Social Security Act requires states to pass laws that would require health insurers to accept claims submitted by the state within the 3-year period beginning with the date on which the item or service was furnished. States are not precluded from having laws or regulations that would require insurers to accept claims for a period of time longer than three years.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94291

No. States typically do not meet the definition of a covered health care provider, and therefore, are not eligible to receive a National Provider Identifier (NPI) number to enable them to bill Medicare. The NPI is the standard unique identifier for health care providers that CMS adopted in 2007. At that time, Medicare revoked existing billing numbers previously issued to Medicaid agencies and notified Medicare carriers to stop enrolling Medicaid programs as Medicare providers. Only recognized providers and suppliers of services that have an NPI can enroll in Medicare. Medicare will not enroll state Medicaid programs, as they are not direct providers or suppliers of services.

Medicaid may submit claims to health plans on behalf of Medicaid beneficiaries who have assigned their rights to payment from third parties (other than Medicare) to the Medicaid program, under the authority of sections 1912, 1902(a)(25)(H), and 1992(a)(25)(I)(ii) of the Social Security Act. However, Medicaid doesn't have the same authority to submit claims to Medicare on behalf of a "dually" eligible beneficiary. The rights to Medicare benefits are not assignable; only the Medicare provider and the beneficiary may submit claims to Medicare.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94301

No. The DRA limit applies to health insurers, defined in section 1902(a)(25)(A) of the Social Security Act, that are regulated by the states. Medicare Parts A and B are not subject to state regulation, as they do not need to be licensed to do business in the states. State law requiring health insurers to honor claims submitted within the timely filing period established by the state (minimum of three years) would apply to Medicare Part C and D plans.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94306

Sections 1814(a)(1), 1835(a)(1), and 1842(b)(3)(B) of the Social Security Act, as well as the Medicare regulations at 42 CFR section 424.44, specify the time limits for filing Medicare Fee-For-Service (FFS)--Part A and Part B--claims.

The Affordable Care Act reduced the maximum period for submission of all Medicare FFS claims to no more than 12 months (one calendar year) after the date services were furnished. This time limit policy for claims submission became effective for services furnished on or after January 1, 2010. In addition, claims for services furnished prior to January 1, 2010, had to be submitted no later than December 31, 2010. Section 6404 of the Affordable Care Act also mandated that CMS may specify exceptions to the one calendar year time limit for filing Medicare claims.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94311

Medicare regulations at 42 CFR section 424.44(b) allow for the following exceptions to the 1 calendar year time limit for filing fee for service claims:

1. Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority.
2. Retroactive Medicare entitlement, where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service.
3. Retroactive Medicare entitlement involving state Medicaid agencies, where a state Medicaid agency recoups payment from a provider or supplier 6 months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished, the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service. The state Medicaid agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the timely filing limit has expired.
4. Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups its payment from a provider or supplier 6 months or more after the date the service was furnished.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94316

No. Based upon federal authority set forth at 10 U.S.C. section 1103, Congress explicitly provided for preemption of state and local laws pertaining to health care financing methods for a contract entered into for medical and/or dental care, under Chapter 55 of the Armed Forces Title of the U.S. Code, by the Secretary of Defense or administering Department of Defense secretaries. The preemption applies to contracts entered into for the purpose of administering TRICARE. Thus, it is the position of the Department of Defense that TRICARE's 1-year timely filing limit is not superseded by the 3-year limit established in the DRA for health insurers who are regulated by the states, and that TRICARE is exempt, not only from the DRA timely filing requirements, but from the DRA requirements altogether.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94326