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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyMississippi Medicaid Timely Filing Policy Update |…
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    CurrentMississippi Division of MedicaidPolicy N/A

    Timely Filing, Processing, and Reconsideration of Claims

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    Governs timely filing, processing, and reconsideration procedures for providers billing the Mississippi Division of Medicaid; affects all enrolled providers submitting Medicaid claims.

    Policy Summary
    PayerMississippi Division of Medicaid
    PolicyTimely Filing, Processing, and Reconsideration of Claims
    Policy CodePolicy N/A
    Change TypeAdministrative — no material coverage changes
    Effective DateJul 1, 2019
    Last ReviewJul 1, 2019
    Next Review DateN/A
    Key ActionSubmit claims no later than 365 calendar days from the date of service.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    365timely filing deadline
    180Medicare-related window
    30reconsideration window
    60retroactive eligibility allowance

    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.

    Claims Filing, Processing, and Reconsideration Criteria

    Claims filing/processing/reconsideration criteria

    Rules governing when claims will be accepted, processed, corrected, and reconsidered:

    Claims must be submitted no later than 365 calendar days from the date of service.
    Newly enrolled providers must submit claims within 365 calendar days from the date of service and only for services provided on or after the provider's enrollment effective date.
    If a Medicare claim was timely filed, Medicaid will pay a related Medicaid claim within 180 calendar days after the agency or provider receives notice of the disposition of the Medicare claim.
    Providers and beneficiaries: if a provider fails to meet the timely filing requirements, the beneficiary cannot be billed for those services.

    Clean claim definition

    • A clean claim is one that can be processed without obtaining additional information from the provider or a third party.
    • Claims with errors originating in the Division of Medicaid's claims system are considered clean claims.

    • Not considered clean

      • Claims from providers under investigation for fraud or abuse.
      • Claims under review for medical necessity.

    Timely processing and exceptions

    • The Division pays all claims within 365 calendar days from the date of receipt (processing period begins on the date a claim is timely submitted).

    • Exceptions to 365-day processing deadline

      • Medicare-related timing: when a Medicare claim was timely filed, the Division will pay within 180 calendar days after notice of Medicare disposition.
      • Retroactive adjustments paid to providers reimbursed under a retrospective payment system.
      • Claims from providers under investigation for fraud or abuse.
      • Payments made to carry out a court order, hearing decision, or agency corrective actions (including extending benefits of a hearing decision, corrective action, or court order to others).
    Providers may submit a corrected claim during the processing period if the claim was denied for any reason except medical necessity.

    Reconsideration window and requirements

    • Providers may request reconsideration within 30 calendar days of the denial of a claim when one of the following applies:

    • Applicable circumstances

      • Provider was unable to meet the timely filing requirement due to retroactive eligibility and filed the claim within 60 days of the eligibility determination.
      • The Division adjusted claims after timely filing and timely processing deadlines had expired.
      • A Medicare crossover claim was filed within 180 calendar days from the Medicare paid date and the provider is dissatisfied with the Medicaid claim disposition.
    • Reconsideration requests must include documentation of timely filing or documentation that timely filing was prevented by beneficiary retroactive eligibility, documentation supporting the reason for reconsideration, and any other documentation requested by the Division.

    Code References and Time Limits

    No specific procedure or diagnosis codes referencedmixed
    No codes listed
    Filing and appeals time limits
    Standard filing/processing deadlineClaims must be submitted and are processed within 365 calendar days from the date of service or receipt (timely filing and processing).
    Medicare‑related timingIf a Medicare claim was timely filed, Medicaid will pay the related Medicaid claim within 180 calendar days after notice of the Medicare disposition.
    Reconsideration request windowProviders may request reconsideration within 30 calendar days of a claim denial in specified circumstances (see criteria).
    60‑day exception for retroactive eligibilityIf the provider could not meet timely filing due to beneficiary retroactive eligibility, the claim may be filed within 60 days of the eligibility determination to qualify for reconsideration.

    Provider Requirements and Actions

    Billing Rule

    Timely Filing: 365‑Day Deadline

    Submit claims no later than 365 calendar days from the date of service. Newly enrolled providers must also submit claims within 365 days and only for services provided on or after the effective date of the provider's enrollment. If a provider fails to meet timely filing requirements, the beneficiary cannot be billed for those services.

    • 365-day filing deadline from date of service for all providers
    • Newly enrolled providers: claims must be for services on/after enrollment effective date
    • Beneficiary billing prohibited when provider misses timely filing
    Documentation Required

    Clean Claim Definition and Exceptions

    A 'clean claim' is defined as a claim that can be processed without obtaining additional information from the provider or a third party. Claims with errors originating in the Division's claims system are considered clean; claims from providers under fraud/abuse investigation and claims under medical necessity review are not considered clean.

    • Clean claim: processable without additional information
    • System-originating errors are still considered clean claims
    • Not clean: claims from providers under fraud/abuse investigation
    • Not clean: claims under review for medical necessity
    Billing Rule

    Timely Processing: 365‑Day Standard and Enumerated Exceptions

    The Division pays claims in accordance with federal and state timely processing requirements and pays all claims within 365 calendar days from the date of receipt except for specified exceptions such as Medicare-related timing, retroactive adjustments, fraud investigations, and court/hearing/corrective actions.

    • Standard processing window: 365 calendar days from date of receipt
    • Medicare-related exception: Medicaid will pay related claims within 180 days after notice of Medicare disposition
    • Other exceptions: retroactive adjustments, providers under fraud/abuse investigation, court orders, hearing decisions, or agency corrective actions
    Billing Rule

    Corrected Claims Allowed During Processing Period

    Providers may submit a corrected claim during the processing period if the original claim was denied for any reason except medical necessity.

    • Corrected claims allowed only within the defined processing period (begins on timely submission date and ends 365 days after original submission)
    • Cannot submit a corrected claim to overturn a denial based on medical necessity
    Prior Authorization

    Request Reconsideration within 30 Days and Provide Required Documentation

    Providers may request reconsideration within 30 calendar days of a claim denial in specified circumstances; requests must include documentation of timely filing or proof the provider was unable to file timely due to the beneficiary's retroactive eligibility, supporting documentation for the reconsideration, and any other documentation requested by the Division.

    • Reconsideration eligible if claim untimely due to retroactive eligibility and filed within 60 days of eligibility determination
    • Eligible when the Division adjusts claims after filing/processing deadlines have expired
    • Eligible for certain Medicare crossover timing issues (Medicare claim filed timely and Medicaid disposition disputed)
    • Required contents: documentation of timely filing or reason for untimely filing, documentation supporting the reconsideration, and other requested materials

    Key Definitions

    Clean claim — definition & exceptions
    Clean claim definitionA clean claim is one that can be processed without obtaining additional information from the provider or a third party.
    System errors treated as cleanClaims with errors originating in the Division of Medicaid's claims system are considered clean claims.
    Excluded from clean claim statusClaims from providers under investigation for fraud or abuse and claims under medical necessity review are not considered clean claims.
    Policy Summary
    PayerMississippi Division of Medicaid
    PolicyTimely Filing, Processing, and Reconsideration of Claims
    Policy CodePolicy N/A
    Change TypeAdministrative — no material coverage changes
    Effective DateJul 1, 2019
    Last ReviewJul 1, 2019
    Next Review DateN/A
    Key ActionSubmit claims no later than 365 calendar days from the date of service.
    SourceLink
    On This Page
    Claims Filing, Processing, and Reconsideration CriteriaCode References and Time LimitsProvider Requirements and ActionsKey Definitions