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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyPeach State claims submission policy: Timing & rul…
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    CurrentPeach State Health PlanPolicy N/A

    Claims Submission Time Frames (House Bill 1234 Resource Guide)

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    Governance of claims timely filing, resubmission/adjustment, appeals, outlier consideration, emergency and newborn payment responsibility, transition of care and related provider requirements for Peach State Health Plan; applies to providers submitting claims for dates of service on or after July 1, 2008.

    Policy Summary
    PayerPeach State Health Plan
    PolicyClaims Submission Time Frames (House Bill 1234 Resource Guide)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJul 1, 2008
    Next Review DateN/A
    Key ActionVerify member eligibility via the Georgia MMIS web portal and retain a date/time stamped screenshot to support claims within the 72-hour protection window.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6 monthstimely filing window (initial claims)
    30 daysappeal filing window (after EOP)
    15 daysclean claim processing
    72 hourseligibility protection window

    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.

    Coverage and Claims Criteria

    Coverage and claims criteria

    Payment responsibility and coverage-related criteria:

    Initial claims must be received within six (6) months from date of service to be considered for payment.
    Denied claims due to erroneous or missing information must be resubmitted within six (6) months from the month of service or within three (3) months of the month of denial, whichever is later; when resubmitting on paper beyond six months, attach the original EOP to demonstrate original timely filing.
    Claim adjustments to correct billing or payment must be received within six (6) months from the month of service or within three (3) months of the month of payment on the EOP, whichever is later; use the Provider Adjustment form and include supporting documentation.
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    Outlier appeal requests and required documentation (cover letter, original UB-04, itemized bill, EOP, utilization review notes, physician orders, discharge summary, therapy and operative notes) must be submitted within three (3) months of the initial EOP or will be denied; any additional requested information must be returned within 30 days of request.
    Clean claims will be processed within 15 business days of receipt.
    No prior authorization is required for emergency health care services for payment purposes; hospitals participating in automated adjudication will be processed per their agreements; non-participating facilities may be reimbursed at Georgia FFS Medicaid rates for medical emergencies. Medical records may be requested to evaluate whether services met emergency criteria and must be submitted for reconsideration as directed.
    Peach State is responsible for newborn inpatient care for infants born to enrolled mothers for up to 30 days and until discharge to a home environment; responsibility includes transport-required services and continues through the inpatient stay even if eligibility or plan assignment changes during hospitalization.
    Transition of care coverage includes up to 30 days for procedures already authorized and scheduled to occur after a new plan effective date; if a newborn transitions between plans or to fee-for-service, Peach State will coordinate with the receiving plan to ensure appropriate care until discharge.
    Providers must verify member eligibility via the Georgia MMIS web portal prior to services and retain a date/time stamped screenshot; Peach State will honor claims when services are performed within 72 hours of verification and the provider can supply proof as needed during appeals or review.
    Claims originally filed timely with a third party (COB) must be received by Peach State within 180 days of the primary carrier's EOP but no more than twelve (12) months from the month of service.
    Peach State does not require exclusive agreements or multi-product participation as a condition of contracting; providers should contact Provider Solutions for contracting questions.
    Peach State will work with Critical Access Hospitals to amend agreements where appropriate to reflect rate and reconciliation requirements and will provide education on rate changes and notification requirements as applicable.

    Coding and Coordination of Benefits

    Emergency reimbursement notemixed
    Non-par providers reimbursed at DCH FFS Medicaid rates for medical emergencies as applicable.
    Coordination of Benefits (COB) resubmission timing rules
    Timing windowClaims originally filed timely with a third party must be received within 180 days of the primary carrier's EOP but no more than 12 months from the month of service.
    Applies whenOnly applies to claims that were originally filed timely with a third party carrier (COB situations).
    Documentation guidanceRetain primary carrier EOP to demonstrate original timely filing when submitting to Peach State within the 180-day window.

    Provider Responsibilities and Action Items

    Prior Authorization

    Emergency services prior authorization — no prior auth required; medical records may be requested to evaluate

    Peach State does not require prior authorization or prior notification for payment of emergency health care services. However, medical records may be requested to evaluate whether services met emergency criteria; if records are requested you must submit a reconsideration request and provide the medical records as instructed in the EOP. Non-participating facilities may be reimbursed at Georgia FFS Medicaid rates for medical emergencies as applicable.

    • No prior authorization/notification required for emergency services for payment purposes.
    • If the plan requests medical records to evaluate severity/nature of presenting symptoms, submit a reconsideration request and provide the records per the EOP.
    • Non-par providers may be reimbursed at DCH FFS Medicaid rates for emergency services when applicable.

    Definitions and Special Requests

    Resubmission / Claim Adjustment (operational notes)
    DefinitionResubmission/Claim Adjustment: resubmitting a claim to correct billing errors or to request payment adjustment when payment is believed to be incorrect.
    Timing requirementMust be received within six (6) months from the month of service or within three (3) months of the month of payment on the EOP (whichever is later) for adjustments; denied-claim resubmissions must be within six (6) months from month of service or within three (3) months of the month of denial (whichever is later).
    Required form and infoInclude the word 'resubmission' and the original claim number; complete a Provider Adjustment form for all resubmission requests and attach supporting documentation.
    Submission methodsClaims may be resubmitted via the provider website or via paper; when resubmitting on paper more than six (6) months after the month of service, attach the EOP showing the original timely filing.
    Outlier request — required documentation
    Policy Summary
    PayerPeach State Health Plan
    PolicyClaims Submission Time Frames (House Bill 1234 Resource Guide)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJul 1, 2008
    Next Review DateN/A
    Key ActionVerify member eligibility via the Georgia MMIS web portal and retain a date/time stamped screenshot to support claims within the 72-hour protection window.
    SourceLink
    On This Page
    Coverage and Claims CriteriaCoding and Coordination of BenefitsProvider Responsibilities and Action ItemsDefinitions and Special Requests
    Billing Rule

    Batching of provider appeals — use revised Provider Adjustment Form for DOS after July 1, 2008

    Providers may batch multiple similar claim appeals for dates of service after July 1, 2008 using the revised Provider Adjustment Form; the form must indicate the nature of the complaint and the number of items attached. Appeals must be initiated in writing within 30 days of the EOP.

    • Batching allowed only for DOS after July 1, 2008 using the revised Provider Adjustment Form.
    • Adjustment form must be marked to indicate nature of complaint and number of items attached.
    • Providers have 30 days from the EOP date to initiate a written appeal; late appeals will be denied.
    Documentation Required

    Eligibility verification (72-hour rule) — verify via Georgia MMIS and retain timestamped proof

    Verify member eligibility via the Georgia MMIS web portal (www.mmis.georgia.gov) prior to providing services and retain a printed, date/time‑stamped screenshot of the eligibility screen; Peach State will honor claims when services are performed within 72 hours of that verification if proof is supplied (usually via appeal).

    • Complete eligibility verification on the Georgia MMIS web portal before services.
    • Print and keep a valid screenshot containing the date/time stamp to support the claim.
    • If reimbursement relies on the 72‑hour rule, initiate an appeal and supply the MMIS screenshot as proof.
    Required cover letterA cover letter indicating the request is for outlier appeal consideration must accompany the submission.
    Claims and billing docsSubmit the original UB-04 (red and white) claim and an itemized bill along with a copy of the EOP on which the original claim appears.
    Clinical/supporting recordsInclude utilization review notes signed and dated, physician's orders, physician's discharge summary, inhalation therapy notes, and operative notes; utilization review notes must document the severity of illness/intensity of service (SI/IS).
    Timing and additional infoOutlier requests must be received within three (3) months of the initial EOP; if additional information is requested it must be returned within 30 days or the request may be denied.
    Mailing addressMark the request 'Outlier Appeal Consideration Request' and mail to Peach State Health Plan, P.O. Box 3030, Farmington, MO 63640-3812.