ModifiedNorth Dakota Department of Health & Human ServicesPolicy N/A

Timely Filing

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This policy governs when North Dakota Medicaid providers must submit original, secondary, crossover, replacement, resubmission, void, corrected, and appealed claims, along with acceptable proof and exception processes.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyTimely Filing

Policy CodePolicy N/A

Change TypeAdministrative clarification

Effective DateN/A

Next Review DateN/A

Key ActionSubmit an original Medicaid primary claim so that ND Medicaid receives it within 180 days from the date of service.

SourceLink

POLICY UPDATE CHANGES

Format updates and clarifications were added; no clinical, coverage, or coding changes were identified.

180 daysOriginal Medicaid primary claim deadline

365 daysSecondary or tertiary claim deadline

180 daysMedicare crossover claim deadline

30 daysPayment denial review deadline

90 days

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ModifiedNorth Dakota Department of Health & Human ServicesPolicy N/A

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Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyTimely Filing

Policy CodePolicy N/A

Change TypeAdministrative clarification

Effective DateN/A

Next Review DateN/A

Key ActionSubmit an original Medicaid primary claim so that ND Medicaid receives it within 180 days from the date of service.

SourceLink

POLICY UPDATE CHANGES

Format updates and clarifications were added; no clinical, coverage, or coding changes were identified.

180 daysOriginal Medicaid primary claim deadline

365 daysSecondary or tertiary claim deadline

180 daysMedicare crossover claim deadline

30 daysPayment denial review deadline

90 days

Authorized audit correction deadline

Timely Filing Requirements

Original Claim Filing Requirements

Original claims must be received by ND Medicaid within the applicable deadline and submitted by an enrolled provider with the required provider information. The provider is responsible for supplying proof of timely filing when submitting the claim.

ALL of the following

ONE applicable original-claim filing rule
- ND Medicaid must receive an original Medicaid primary claim within 180 days from the date of service.
- For an original claim involving retroactive member eligibility, ND Medicaid must receive the claim within 180 days from the date of the eligibility determination by ND Medicaid.
- For a newly enrolled provider with retroactive provider eligibility, ND Medicaid must receive the claim within 180 days from the date that retroactive provider eligibility was authorized by ND Medicaid.
  The claim must include the ND Medicaid letter of retroactive eligibility. Claims based on retroactive member eligibility do not require an attachment.
- For an original secondary or tertiary claim involving third-party liability, excluding Medicare crossovers, ND Medicaid must receive the claim within 365 days from the date of service.
  The claim must include third-party payment information. If the retroactive-eligibility deadline would occur before 365 days from the date of service, the 365-day deadline applies.
- For an original Medicare crossover claim, ND Medicaid must receive the claim within 180 days from the date on the Medicare Explanation of Benefits (EOB).
  The claim must include Medicare payment information. For Medicare-primary claims crossing directly to Medicaid, providers must wait 60 days from the Medicare EOB date before submitting. Crossover transactions may take 60–90 days.
For an original third-party-liability claim, the claim must be submitted with the third party's payment information.
For an original Medicare crossover claim, the claim must be submitted with Medicare payment information.
All claims must be submitted by an enrolled provider and contain the appropriate name and all required provider identifiers.
Acceptable proof of timely filing
- ND Medicaid Transaction Control Number (TCN) and Remittance Advice (RA) date.
- Medicare or third-party Explanation of Benefits (EOB).
- Letter of retroactive eligibility from ND Medicaid.
- Returned, date-stamped claim from ND Medicaid.
For Medicare crossover processing when applicable
- If ND Medicaid paid the provider before Medicare adjudication, the provider must adjust the claim to allow ND Medicaid to process it with Medicare payment information.
- Any duplicate payment must be voided with ND Medicaid.

Reconsideration Claim Requirements

Replacement, resubmission, and void claims may be filed as reconsideration claims only when the original claim met the applicable timely filing requirement.

ALL of the following

The original claim was filed within 180 days from the date of service or met an applicable timely filing exception.
The reconsideration claim is a replacement, resubmission, or void claim received within 365 days from the date of service.
The claim includes the Medicaid remittance advice date and Transaction Control Number (TCN) of the original processed claim in the notes section to prove that the original claim met timely filing requirements.
ONE applicable extension or exception
- A replacement or resubmission claim is received within 180 days of a provider rate update when ND Medicaid did not create a mass adjustment.

Claim Filing Timeframes

Original Medicaid primary claim

Filing timeframe180 days from date of service

Retroactive member eligibility

Filing timeframe180 days from the date of eligibility determination by ND Medicaid

Retroactive provider eligibility

Filing timeframe180 days from the date retroactive provider eligibility was authorized by ND Medicaid

Secondary or tertiary claim with third-party liability

Submission, Documentation, and Appeals

Billing Rule

Submit Original Primary Claims Within 180 Days

ND Medicaid must receive an original Medicaid primary claim within 180 days from the date of service. Claims may be submitted after this deadline only under applicable exceptions, including retroactive member or provider eligibility, third-party liability, original Medicare crossover claims, or reconsideration claims.

All claims must be submitted by an enrolled provider and include the appropriate name and all required provider identifiers.

Documentation Required

Provide Acceptable Proof of Timely Filing

The provider is responsible for submitting proof of timely filing with the claim when relying on an exception or demonstrating timely submission. For newly enrolled providers, claims must generally be received within 180 days of the date retroactive provider eligibility was authorized; claims based on retroactive provider eligibility must include ND Medicaid’s retroactive eligibility letter, while claims based on retroactive member eligibility do not require an attachment.

Claim and Filing Terms

Claim

DefinitionA bill for one or more services for one beneficiary.

Original claim

DefinitionThe first claim submission.

Mass adjustment

DefinitionAn adjustment generated by ND Medicaid.

Replacement claim

DefinitionAn adjustment of a previously processed claim.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyTimely Filing

Policy CodePolicy N/A

Change TypeAdministrative clarification

Effective DateN/A

Next Review DateN/A

Key ActionSubmit an original Medicaid primary claim so that ND Medicaid receives it within 180 days from the date of service.

SourceLink

On This Page

A replacement, resubmission, or void claim is received within 180 days of retroactive member eligibility or retroactive provider eligibility for a newly enrolled provider.

A replacement or resubmission claim is received within 180 days of an adjustment notice (EOB) from Medicare or a third-party payer that previously processed the claim for the same service, and the adjustment notice is dated after the ND Medicaid timely filing period.

A copy of the primary payer's adjustment notice or EOB must be attached to each replacement, resubmission, or void claim.

The claim is a replacement or resubmission that was erroneously adjudicated by ND Medicaid.

The claim is an orthodontic replacement or resubmission where the primary dental insurance terminated before treatment was completed and ND Medicaid is responsible for additional payment.

The provider has 180 days from the last primary payer EOB date to adjust the previously processed claim.

Timely filing limits do not apply when applicable

The replacement, resubmission, or void claim results in an ND Medicaid overpayment.
The claim is an ND Medicaid-generated mass adjustment.
A provider replacement, resubmission, or void of a mass-adjustment claim must still be submitted within timely filing requirements; an ND Medicaid mass adjustment does not extend timely filing requirements.

365 days from date of service

Medicare crossover claim

Filing timeframe180 days from the Medicare EOB date

Medicare crossover submission wait

Required waiting periodWait 60 days from the Medicare EOB date before submitting a direct crossover claim

Replacement, resubmission, or void claim

Filing timeframe365 days from date of service when the original claim was timely

Rate-update replacement or resubmission

Filing timeframe180 days from the provider rate update when no ND Medicaid mass adjustment was created

Adjustment-notice replacement or resubmission

Filing timeframe180 days from a Medicare or third-party adjustment EOB dated after the ND Medicaid timely filing period

Orthodontic replacement or resubmission

Filing timeframe180 days from the last primary payer EOB when primary dental insurance terminated before treatment completion

Authorized audit correction

Filing timeframe90 days from the Medicaid remittance advice containing the recoupment

Payment denial review request

Review request timeframe30 days from the department's denial date

Accepted proof: ND Medicaid TCN and remittance advice date.
Accepted proof: Medicare or third-party Explanation of Benefits.
Accepted proof: ND Medicaid letter of retroactive eligibility.
Accepted proof: returned, date-stamped claim from ND Medicaid.

Billing Rule

Include Third-Party and Medicare Payment Information

Submit third-party and Medicare payment information on the claim when ND Medicaid is secondary, tertiary, or processing a Medicare crossover. Original secondary or tertiary claims are generally due within 365 days from the date of service, while original Medicare crossover claims are due within 180 days from the Medicare EOB date.

For retroactive member eligibility, the applicable deadline is 180 days from North Dakota Medicaid’s eligibility determination; for newly enrolled providers, it is 180 days from authorization of retroactive provider eligibility. If that deadline would occur before the 365-day secondary/tertiary limit, the 365-day limit applies.
For Medicare-primary claims crossing directly to Medicaid, wait 60 days from the Medicare EOB date before submitting; crossover transactions may take 60–90 days.
If Medicaid paid before Medicare adjudication, adjust the claim to include Medicare payment information and void any duplicate Medicaid payment.

Documentation Required

Document Reconsideration Claims With the Original TCN and RA Date

Replacement, resubmission, and void claims may be filed within 365 days from the date of service only when the original claim met timely filing requirements. Each claim must include the Medicaid remittance advice date and TCN of the original processed claim in the notes section.

Extensions may apply for provider rate updates without a mass adjustment, retroactive member or newly enrolled provider eligibility, later Medicare or third-party adjustment notices, erroneously adjudicated ND Medicaid claims, and certain orthodontic claims after primary dental coverage terminates.
For a later primary-payer adjustment, submit the replacement, resubmission, or void within 180 days of the adjustment EOB, dated after the ND Medicaid timely filing period, and attach the EOB to each claim.
For qualifying orthodontic adjustments, submit within 180 days of the last primary payer EOB date.

Prior Authorization

Obtain Written Authorization Before Resubmitting Audit-Adjusted Claims

Do not resubmit a claim adjusted through a Program Integrity Unit or SURS audit unless the audit recovery notice gives written authorization to submit a corrected claim. When authorized, the corrected claim is due within 90 days from the Medicaid remittance advice date that includes the recoupments.

Include the Medicaid remittance advice date and TCN of the state-adjusted claim.
Attach a copy of the written audit recovery notice to each corrected claim submission.

Documentation Required

Request a Timely Filing Override With Documentation

Use the Timely Filing Override Request Form for an override request, state the reason, and attach supporting documentation. The form does not replace the existing appeals, reconsideration, or resubmission process.

Accepted potential reason: the claim appeared on an ND Medicaid accepted claim report without errors but was not processed or returned; include reports showing acceptance by both the clearinghouse and ND Medicaid.
If the member identification card was unavailable, document at least three attempts to obtain identification and show that the Medicaid portal was checked within the timely filing period without returning eligibility information.
If other insurance was not disclosed, include a member-signed statement that the member had no other insurance on the date of service.
ND Medicaid may consider other reasons not specifically listed, but supporting documentation is required.

Denial Risk

Avoid Unacceptable Proof and Override Reasons

Some submissions do not establish timely filing and will not support an override. ND Medicaid will deny requests based on excluded reasons or insufficient documentation.

Not accepted as proof: provider-generated reports from billing software, claims previously denied for timely filing, or a provider statement that claims were held and not submitted.
A clearinghouse-only acceptance report is insufficient; the report must also show ND Medicaid acceptance without errors. Cover sheets attached to returned paper claims are not proof of timely filing.
Incorrect patient name or ID is not an override reason; void the incorrectly processed claim and submit a new claim before the deadline.
Rejected or returned claims that do not meet claim-processing requirements, and provider system issues or human error causing late filing, are not considered for an override.

Denial Risk

Review Denials and File Appeals on Time

A provider may request written review of a denial by submitting the request to the department within 30 days of the department’s denial of payment. Include the applicable remittance advice or notice of recoupment or adjustment and identify each disputed item with the reason or basis for the dispute.

A timely-filing appeal cannot be filed when a claim submitted within one year of service was denied solely because the provider failed to establish that the original claim was filed within 180 days; first resubmit the claim with proof of timely filing of the original claim.
Review is unavailable for the rate paid for a service or for denials, recoupments, or adjustments caused by required federal or state changes, payment-system defects, or improper claim submission.
The Timely Filing Override Request Form does not replace the appeals process.

Resubmission claim

DefinitionA resubmission of a previously processed denied claim.

Timely Filing Override Request Form

Definition and useA form that may be submitted to request a timely filing override for limited exceptions outside the policy's standard provisions.

Transaction Control Number (TCN)

DefinitionA 17-digit claim number.

Void claim

DefinitionA reversal of a previously processed claim.