Section 471-3-003 - APPROVAL AND PAYMENT003.01APPROVAL. Payment for medical care and services through Medicaid funds must be approved by the Department. 003.01(A)CONDITIONS FOR APPROVAL. Claims will be approved for payment when all of the following conditions are met: (i) The provider was enrolled and eligible for payment under the Nebraska Medicaid State Plan on the date the service was provided;(ii) The client was eligible for Medicaid when the service was provided, or the service was provided during the period of retroactive eligibility;(iii) No more than 6 months have elapsed from the date of service when the claim is received by the Department (see 471 NAC 3-002.01A for exceptions);(iv) The medical care and services are within the guidelines of Medicaid;(v) The client's clinical record must contain information to meet state requirements; and(vi) A trading partner agreement has been approved, if required, for clearinghouses, billing agents, and providers submitting claims using electronic transactions.003.01(B)EXCEPTIONS TO TIMELY FILING OF CLAIMS. Payment may be made by the Department for claims received more than six months after the date of service if the circumstances which delayed the submittal were beyond the provider's control. The Department will determine whether the circumstances were beyond the provider's control based on documentation submitted by the provider.003.01(C)TIMELY PAYMENT OF CLAIMS. The Department must pay claims within 12 months of the date of receipt of the claim. This time limitation does not apply to: (i) Retroactive adjustments paid to providers who are reimbursed under a retrospective payment system;(ii) Claims which have been filed in a timely manner for payment by Medicare, for which the Department may pay a Medicaid claim relating to the same services. Claims for the Medicaid portion must be submitted to the Department within six months from the date of the Medicare remittance advice; (iii) Claims from providers under investigation for alleged fraud or abuse;(iv) Payments made: (1) In accordance with a court order;(2) To carry out hearing decisions or agency corrective actions taken to resolve a dispute;(3) To extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it; or(4) Third party casualty situations as specified in 471 NAC 3-004.06C.003.01(D)DENIAL. The Department will not pay claims received more than two years after the date of service, except under the circumstances specified in this chapter.003.01(E)PROVIDER'S FAILURE TO COOPERATE IN SECURING THIRD PARYTY PAYMENT. The Department may deny payment of a provider's claims if the provider fails to apply third party payments to medical bills, to file necessary claims, or to cooperate in matters necessary to secure payment by insurance or other liable third parties.003.02PAYMENT.003.02(A)UPPER LIMITS. The Department has established upper limits for payment as described in each provider chapter.003.02(B)COVERAGE EXCEPTION. Certain medical services, while being medically necessary, may exceed the Nebraska Medicaid coverage guidelines which have been established by the Department. Under these circumstances, the determination of medical necessity for payment purposes is based upon the professional judgment of the Department's consultants and other appropriate staff.003.02(C)PAYMENT IN FULL. Providers participating in Nebraska Medicaid agree to accept as payment in full the amount paid according to the Department's payment methodologies after all other sources have been exhausted. 003.02(C)(i)EXCEPTION. If a client resides in a nursing facility, a payment to the facility for the client to occupy a single room is not considered income in the client's budget if Medicaid is or will be paying any part of the nursing facility care.003.02(D)CHARGES TO THE GENERAL PUBLIC. Providers will not exceed their charges to the general public when billing the Department. A provider who offers a discount to certain individuals will apply the same discount to Medicaid clients who would otherwise qualify for the discount.003.02(E)METHOD OF PAYMENT. Payment for all approved medical services within the scope of Nebraska Medicaid will be made by electronic funds transfer to the provider who supplied the services.003.02(F)BILLED CHARGES. If the provider's billed charges are less than the Department's allowable payment, the Department pays the provider's billed charges. 003.02(F)(i)EXCEPTION. Inpatient hospital services are paid on a diagnosis-related group or per diem basis, regardless of billed charges.003.03POST-PAYMENT REVIEW. Payment for a service does not indicate compliance with Department policy. Monitoring is accomplished by post-payment review to verify Department policy has been followed. A refund will be requested if post-payment review finds payment has been made for claims or services not in compliance with Department policy. During a post-payment review, claims submitted for payment may be subjected to further review or not processed pending the outcome of the review.003.04PAYMENT FOR MEDICAL EXPENSES. Payment may not be made from Department funds for medical expenses which have been paid from public or private sources.003.05SHARE OF COST. Individuals who are otherwise eligible but who have excess income must obligate the excess amount for medical care before payment for medical services can be approved through Nebraska Medicaid.003.05ADJUSTMENTS TO PAYMENT REDUCTIONS OR DISALLOWANCES. Providers are restricted to a maximum time limitation of 90 days to request an adjustment to a claim, regardless of the reason for the adjustment or whether the claim was disallowed in part or in whole, unless documentation of extenuating circumstances is submitted to and approved by the Department. The 90-day limitation begins with the payment date of the paper remittance advice or with the payment date of the electronic remittance advice.003.06REFUNDS.003.06(A)REFUNDS REQUESTED BY THE DEPARTMENT. When the Department requests a refund of all or part of a paid claim, the provider is allowed 30 days to refund the amount requested, to show the refund has already been made, to document why the refund request is in error, or appeal. The provider's failure to respond within 30 days is cause for the Department to recoup from future provider payments until the refund is paid in full or to sanction the provider. The refund request constitutes notice of the sanction to recoup from future payments. Refunds resulting from third party resource payment must also be made as required in this chapter.003.06(B)THIRD PARTY LIABILITY REFUNDS. When third party liability payments are received after a claim has been submitted to the Department, the provider must refund the Department within 30 days. The refund must be accompanied by a copy of the documentation, such as the explanation of benefits or electronic coordination of benefits.003.06(C)PROVIDER REFUNDS TO THE DEPARTMENT. Providers have the responsibility to review all payments to ensure no overpayments have been received. The provider must refund all overpayments to the Department within 30 days of identifying the overpayment.003.07ADMINISTRATIVE FINALITY. Administrative decision or inaction in the allowable cost determination process for any provider, which is otherwise final, may be reopened by the Department within three years of the date of notice of the decision or inaction in order to examine the accuracy of a determination which is otherwise final. The Director is the sole authority in deciding whether to reopen. 003.07(A)SITUATIONS ALLOWING FOR REOPEN. Action to reopen may be taken:(i) On the initiative of the Department within the three-year period;(ii) In response to a written request from a provider or other entity within the three-year period. Whether the Director will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with the law, regulations and rulings, or general instructions; or(iii) At any time fraud or abuse is suspected.003.07(B)FAIR HEARING. The right to a fair hearing does not apply to a finding by the Director which indicates a reopening or correction of a determination or decision is not warranted.003.08BILLING THE CLIENT. Providers participating in Nebraska Medicaid agree to accept payment from the Department as payment in full. The provider will not bill the client for Nebraska Medicaid covered services if the claim is denied by the Department for lack of medical necessity or for failure to follow a procedural requirement. The provider will not bill the client for services covered by Nebraska Medicaid. It is not a violation of Department regulations for the provider to bill the client for services not covered by Nebraska Medicaid. It is not a violation for a provider to bill the client for services when it is determined the client has received money from a third party resource and the money was designated to pay medical bills. If the client agrees in advance in writing to pay for the non-covered service, the provider may bill the client. 003.08(A)VERIFICATION OF ELIGIBILITY. The provider has the responsibility to verify the client's eligibility for Medicaid and any limitations which apply to a specific client.003.09SECTION 1122 SANCTIONS. When the United States Department of Health and Human Services imposes a sanction under section 1122 of the Social Security Act and instructs the Department to withhold or recoup the federal share of the capital expenditure, the Department will withhold the federal and the state share of the capital expenditure.471 Neb. Admin. Code, ch. 3, § 003
Amended effective 6/6/2022