SECTION 365.8. Claim Filing Deadlines

(a) The program must receive all claims within the claim filing deadlines established in this section.

(1) Claims must be received no later than 95 days from the last day of the month in which services were provided.

(2) Claims must be received no later than 60 days from the date on the program's notice of eligibility for newly approved clients.

(b) In addition to the requirements in subsection (a) of this section, the program must receive claims for out-patient dialysis and access surgery services within 60 days from the date on the agreement approval letter for newly enrolled providers, but no later than 180 days from the date of service.

(c) The program must receive all billing statements for Medicare Part D premium benefits from eligible PDPs within 95 days from the last day of each month for which the premium coverage applies.

(d) The program must receive resubmitted claims within the deadlines established under subsections (a) - (c) of this section, or within 30 days from the date of the program's return letter or the program's EOB, whichever is later. Resubmitted claims must:

(1) be resubmitted with a copy of the program's return letter or the program's EOB, if applicable;

(2) be resubmitted on the original claim form, if applicable; and

(3) contain no new or additional charges for service.

(e) Pharmacies must submit claims for drug charges to the designated claims processor for the program in accordance with claim filing deadlines contained in 1 Texas Administrative Code, §354.1901, (relating to Pharmacy Claims).

(f) Claims which are not received by the program within the filing deadlines will be denied payment.

Source Note: The provisions of this §365.8 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421