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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyMississippi Medicaid Administrative Reviews & Retr…
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    CurrentMississippi Division of MedicaidPolicy N/A

    Administrative Reviews and Retroactive Eligibility

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    Governs providers' rights and procedures to request administrative reviews of denied Medicaid claims related to timely filing and retroactive beneficiary eligibility, and describes retroactive eligibility rules for beneficiaries and related billing/authorization requirements.

    Policy Summary
    PayerMississippi Division of Medicaid
    PolicyAdministrative Reviews and Retroactive Eligibility
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateAug 1, 2020
    Last ReviewAug 1, 2020
    Next Review DateN/A
    Key ActionProviders may request an Administrative Review within 30 calendar days of a claim denial and must obtain any required prior authorization and file claims within 90 days of the system add date of eligibility determination.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    30 daysAdmin Review request window
    90 daysClaim/prior auth filing deadline
    180 daysMedicare crossover filing window
    3 months

    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.

    Retroactive eligibility period

    Administrative Review and Retroactive Eligibility Criteria

    Administrative Review and Retroactive Eligibility Criteria

    Conditions under which providers may request an Administrative Review or bill for services during retroactive eligibility:

    Administrative Review may be requested when ANY of the following apply:

    • Provider unable to meet timely filing due to retroactive beneficiary eligibility AND has received prior authorization, if required, from the Utilization Management/Quality Improvement Organization (UM/QIO) within 90 days of the system add date of the eligibility determination, AND filed the claim within 90 days of the system add date of the eligibility determination.
    • The Division of Medicaid adjusts claims after timely filing and timely processing deadlines have expired.
    • A Medicare crossover claim was filed within 180 calendar days from the Medicare paid date and the provider is dissatisfied with the disposition of the Medicaid claim.

    Documentation required for Administrative Review

    • Documentation of timely filing or documentation that the provider was unable to file timely due to the beneficiary's retroactive eligibility.
    • Documentation explaining the facts that support how the denied claim meets one or more requirements in Miss. Admin. Code, Title 23, Part 200, Rule 1.8.A and reasons the provider believes they complied with Medicaid regulations.
    • Other documentation as required or requested by the Division of Medicaid.

    Prior authorization and filing for services during retroactive eligibility

    • Medically necessary services rendered during the retroactive eligibility period that require authorization cannot be denied for failure to secure prior authorization, PROVIDED authorization is obtained and the claim is filed within 90 days of the system add date of the eligibility determination.

    Time limits

    • Administrative Review request window: within thirty (30) calendar days of a claim denial under the circumstances listed in Rule 1.8.A.
    • Claims and prior authorizations (if required) related to retroactive eligibility must be obtained/filed within ninety (90) days of the system add date of the eligibility determination.
    • For Medicare crossover disputes, the crossover claim must have been filed within one hundred eighty (180) calendar days from the Medicare paid date.

    Filing Deadlines and Coding Notes

    Not specifiedmixed
    No codes listed
    Filing deadlines after eligibility determination
    Claim and prior authorization filing windowClaims and prior authorizations (if required) must be filed/obtained within 90 days of the system add date of the eligibility determination.
    Medicare crossover deadline for disputeMedicare crossover claims must be filed within 180 calendar days from the Medicare paid date for purposes of dispute/Administrative Review.
    Administrative Review request timeframe after denialProviders may request an Administrative Review within 30 calendar days of a claim denial when criteria are met (e.g., retroactive eligibility).

    Prior Authorization and Administrative Review Actions

    Prior Authorization

    Prior authorization and claim filing deadlines for retroactive eligibility

    Providers must obtain prior authorization, if required, from the Utilization Management/Quality Improvement Organization (UM/QIO) within 90 days of the system add date of the eligibility determination; medically necessary services during retroactive eligibility that require authorization cannot be denied for failure to secure prior authorization provided authorization is obtained and the claim is filed within 90 days of the system add date.

    • Authorization (if required) must be obtained within 90 days of the system add date of the eligibility determination.
    • The claim must be filed within 90 days of the system add date of the eligibility determination for services during the retroactive eligibility period.
    Documentation Required

    30-day Administrative Review request window after claim denial

    Providers may request an Administrative Review within thirty (30) calendar days of the denial of a claim when specific conditions apply (for example, inability to meet timely filing due to retroactive eligibility if prior authorization was obtained and the claim filed within required timeframes).

    Key Definitions

    Administrative Review — definition
    DefinitionAdministrative Review: A provider-requested review of a denied claim; requests must be made within 30 calendar days of the denial when specified conditions apply.
    Required documentationRequests must include documentation of timely filing or inability to file timely due to beneficiary retroactive eligibility, factual support showing how the denied claim meets Rule 1.8.A, and other documents as requested by the Division.
    Applicable groundsGrounds include inability to meet timely filing due to retroactive eligibility (with prior authorization and claim filed within 90 days), post-deadline claim adjustments by the Division, and Medicare crossover claims filed within 180 days where the provider is dissatisfied.
    Retroactive eligibility — definition
    DefinitionRetroactive eligibility: Eligibility available to individuals for all or part of the three-month period prior to application when financial and need requirements are met.
    Policy Summary
    PayerMississippi Division of Medicaid
    PolicyAdministrative Reviews and Retroactive Eligibility
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateAug 1, 2020
    Last ReviewAug 1, 2020
    Next Review DateN/A
    Key ActionProviders may request an Administrative Review within 30 calendar days of a claim denial and must obtain any required prior authorization and file claims within 90 days of the system add date of eligibility determination.
    SourceLink
    On This Page
    Administrative Review and Retroactive Eligibility CriteriaFiling Deadlines and Coding NotesPrior Authorization and Administrative Review ActionsKey Definitions
    • The 30-calendar-day window to request an Administrative Review begins from the date of the claim denial.
    • Requests must include documentation of timely filing or documentation that the provider was unable to file timely due to the beneficiary's retroactive eligibility, and other supporting materials as required by the Division.
    Provider billing optionMedicaid-covered services paid for by a beneficiary during the three-month retroactive period may be refunded at the provider's option and billed to Medicaid when eligibility is validated per timely filing requirements.
    Authorization requirement for servicesMedically necessary services during the retroactive period that require authorization cannot be denied for failure to secure prior authorization, provided authorization is obtained and the claim is filed within 90 days of the system add date of eligibility determination.