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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyAlaska Medicaid timely filing policy update | Open…
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    CurrentAlaska MedicaidPolicy N/A

    Timely filing, adjustments, and appeals for Alaska Medicaid claims

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    Governs deadlines and procedures for submitting claims, adjustments, and provider appeals to Alaska Medicaid; applies to all Alaska Medicaid providers submitting claims or appeals to the Department of Health.

    Policy Summary
    PayerAlaska Medicaid
    PolicyTimely filing, adjustments, and appeals for Alaska Medicaid claims
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit claims within 12 months of date of service or follow specified exception timeframes and include supporting documentation for late submissions.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsstandard claim timely filing deadline from date of service
    180 daysfirst-level appeal deadline from remittance/adverse action
    60 dayssecond-level appeal deadline
    60 daysadjustment window after paid date for older claims

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    30 days
    appeal timeframe for sanctions

    Timely Filing, Exceptions, Adjustments, and Appeals Criteria

    Timely filing, exceptions, adjustments, and appeals criteria

    Covered when ALL of the following criteria and applicable exceptions are met:

    Standard timely filing: claim must be received by Alaska Medicaid no later than 12 months from the date of service.

    Exceptions to the 12-month standard (ONE of the following applies):

    • Retroactive member eligibility: submitted within 12 months from eligibility being issued.
    • Retroactive provider enrollment: submitted within 6 months from enrollment being established or backdated.
    • Medicare processing: submitted within 6 months from the Medicare paid date.
    • Third‑party liability reprocessing: submitted within 60 days from the date the third party reprocessed.
    • State or system error or unexpected/uncontrollable events (e.g., natural disaster): timeframe is situation dependent; provider must submit within the timeframe specified for that situation.
    Documentation required for submissions after the 12‑month deadline: provider must include supporting documentation explaining why timely filing was not possible and must include the OZ attachment indicator.

    Acceptable supporting documentation (ONE or more of the following):

    • Remittance advice showing the claim was billed within timely but processed incorrectly.
    • Proof of retroactive member eligibility.
    • Proof of retroactive provider enrollment.
    • A dated court or administrative hearing decision.
    • Proof of Medicare processing.
    • Proof of third‑party liability reprocessing.

    Adjustments (to correct provider billing errors on paid claims):

    • Adjustments may be submitted at any time within 12 months of the date of service without additional documentation.
    • If submitting an adjustment outside 12 months from the date of service, it must be submitted within 60 days of the paid date of the original claim and include supporting documentation plus the OZ attachment indicator; otherwise the adjustment may be denied for timely filing and subject to recoupment.

    Appeals and appeal timeframes:

    • First‑level appeal for a claim or service authorization: submitted in writing with required documentation within 180 days from the adverse action (remittance/adverse action).
    • Recoupment of overpayment notice: appeal submitted within 60 days from the adverse action.
    • Sanctions: appeal submitted within 30 days from the adverse action.
    • Enrollment appeals: submitted within 180 days.
    • Second‑level appeal: submitted within 60 days from the first‑level determination.
    Submissions (claims, adjustments, or appeals) that are missing required information will be returned and returning does not extend the timely filing period; timely filing cannot be overridden for provider or billing staff error or the member's failure to notify the provider of a hearing decision.

    Timely Filing Windows and Related Coding/Timing Rules

    Timely filing evidence and windowsmixed
    Standard claim timely filing12 months from date of service
    Retroactive member eligibility12 months from eligibility being issued
    Retroactive provider enrollment6 months from enrollment being established or backdated
    Medicare processing6 months from the Medicare paid date
    Third-party liability reprocessing60 days from the date third party reprocessed
    State or system errorSituation dependent
    Unexpected or uncontrollable eventsSituation dependent (e.g., natural disaster, fire, storm)
    Adjustment within standard windowWithin 12 months of date of service (no additional documentation required)
    Adjustment outside 12 monthsWithin 60 days of the paid date of the original claim and must include supporting documentation and OZ attachment indicator
    Late claim/appeal documentation requirementAny claim, adjustment, or appeal submitted after 12 months must include supporting documentation explaining delay and include OZ attachment indicator; acceptable documentation examples provided
    inv-03: Standard claim timely filing — 12 months from date of service
    Standard timely filing windowClaims must be received no later than 12 months from the date of service.
    Includes TPL billing requirementThis 12-month requirement includes claims required to be billed to a third‑party liability before billing Alaska Medicaid.
    Late submissions require documentationAny claim, adjustment, or appeal submitted after 12 months must include supporting documentation explaining the delay and include the OZ attachment indicator.
    Non‑overridable reasonsTimely filing cannot be overridden for provider or billing staff error, staffing deficiencies, or the member’s failure to notify the provider of a hearing decision outside applicable timeframes.
    inv-04: Adjustment submission outside standard window — within 60 days of the paid date of the original claim

    Appeals and Provider Submission Timeframes

    Prior Authorization

    Appeal submission timeframes — deadlines for first‑ and subsequent‑level appeals

    Providers may request a first‑level appeal of a denied claim or authorization no later than 180 days after the remittance advice denying the claim or authorization denial. Providers may appeal a first‑level decision no later than 60 days after the date of the first‑level appeal decision. Other specific appeal timeframes apply: recoupments (60 days), sanctions (30 days), and enrollment appeals (180 days).

    • First‑level appeal for a claim or service authorization: 180 days from the adverse action.
    • Recoupment of overpayment notice: 60 days from the adverse action.
    • Sanctions: 30 days from the adverse action.
    • Enrollment appeals: 180 days from the adverse action.
    • Second‑level appeal: 60 days from the first‑level determination.
    • Incomplete appeals returned to provider do not extend the filing period.

    Definitions: Timely Filing Overrides and Adjustments

    inv-07: Situations where the 12-month timely filing deadline may be extended
    Retroactive member eligibilityTimely filing may be extended: submit within 12 months from the date eligibility is issued.
    Retroactive provider enrollmentTimely filing may be extended: submit within 6 months from enrollment being established or backdated.
    Medicare processingTimely filing may be extended: submit within 6 months from the Medicare paid date.
    Third‑party liability reprocessing (TPL)Timely filing may be extended: submit within 60 days from the date the third party reprocessed the claim.
    State or system errors and uncontrollable eventsTimely filing may be extended in situation‑dependent timeframes for state/system errors or unexpected events (e.g., natural disasters); provider must follow timeframe as directed.
    Policy Summary
    PayerAlaska Medicaid
    PolicyTimely filing, adjustments, and appeals for Alaska Medicaid claims
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit claims within 12 months of date of service or follow specified exception timeframes and include supporting documentation for late submissions.
    SourceLink
    On This Page
    Timely Filing, Exceptions, Adjustments, and Appeals CriteriaTimely Filing Windows and Related Coding/Timing RulesAppeals and Provider Submission TimeframesDefinitions: Timely Filing Overrides and Adjustments
    Adjustment window within standard filingAdjustments to correct a provider’s billing error may be submitted at any time within 12 months of the date of service without additional documentation.
    Adjustment window when beyond 12 monthsIf submitted after 12 months from date of service, the adjustment must be submitted within 60 days of the paid date of the original claim.
    Documentation requirement for late adjustmentsAdjustments submitted outside 12 months must include supporting documentation and the OZ attachment indicator or risk denial/recoupment.
    Denied claims not eligibleAdjustments cannot be made to any denied claim.
    inv-05: Medicare processing exception — 6 months from Medicare paid date
    Medicare processing exception timeframeWhen Medicare processes first, submit to Alaska Medicaid within 6 months from the Medicare paid date.
    Proof required for exceptionsClaims submitted under the Medicare processing exception must include supporting documentation (e.g., proof of Medicare processing) and the OZ attachment indicator if filed after 12 months.
    Relation to standard 12‑month ruleThis 6‑month Medicare exception is a limited override to the standard 12‑month timely filing requirement.
    inv-08: Adjustment — submission to correct a provider's billing error on a paid claim; allowed within 12 months of date of service without extra documentation, or within 60 days of paid date if beyond 12 months.
    Definition — AdjustmentA submission to correct a provider’s billing error on a paid claim; allowed within 12 months of the date of service without additional documentation.
    Adjustment outside 12 monthsIf beyond 12 months from date of service, an adjustment must be submitted within 60 days of the paid date of the original claim and include supporting documentation and the OZ attachment indicator.
    Denied claims exclusionAdjustments cannot be made to denied claims.