10A N.C. Admin. Code 45A.0302

Current through Register Vol. 39, No. 9, November 1, 2024

Section 45A .0302 - AUTHORIZATIONS AND CLAIMS PROCESSING TIME FRAMES

(a) The following time frames shall apply to all payment programs:

(1) An Authorization Request must be received by the Department within one year after the date of service or it will be denied.

(2) The Department shall respond to an Authorization Request within 45 days after receipt.

(3) If the Department requests additional information, this information must be received within one year after the date of service or within 30 days after the date of the Department's request, whichever is later, or the Authorization Request will be denied.

(4) The Department shall approve or deny an Authorization Request within 45 days after receipt of all information.

(b) The following timeframes apply to claims payments:

(1) A claim for payment must be received by the Department within one year after the date of service or within 45 days after the date of authorization approval, whichever is later, or the claim will be denied. Corrections to claims and requests for payment adjustment made by the provider must be received by the Department within one year after the date of service or within 45 days after the date the claim is paid or returned for additional information, whichever is later, or the claim will be denied.

(2) If there are other third party payors, a claim must show payments by those payors or it must include copies of the denials of payment from those payors. Providers must bill other payors and wait at least six months after the date of service to receive payment or denial of payment before billing the Department. If no response has been received within six months after the date of service, the provider may bill the Department, but the claim must state the date that the other payors were billed.

(3) The Department shall pay or deny a claim within 45 days after receipt of a completed claim.

(c) Authorization Requests and claims for payment shall be submitted on forms provided by the Department Providers may download forms and the Provider Manual for Division of Public Health Payment Programs at http://www.ncdhhs.gov/control/pomcs/pomcs.htm.

10A N.C. Admin. Code 45A .0302

Authority G.S. 130A-5(3); 130A-124; 130A-127; 130A-129; 130A-205;
Eff. July 1, 1981;
Amended Eff. February 1, 1990; August 1, 1987; October 1, 1985; April 1, 1983;
Transferred and Recodified from 10 NCAC 04C .0302 Eff. April 4, 1990;
Amended Eff. January 1, 2014; April 1, 1999; January 4, 1994; February 1, 1992; December 1, 1990;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 13, 2015.

Authority G.S. 130A-5(3); 130A-124; 130A-127; 130A-129; 130A-205; Eff. July 1, 1981;
Amended Eff. February 1, 1990; August 1, 1987; October 1, 1985; April 1, 1983;
Transferred and Recodified from 10 NCAC 04C .0302 Eff. April 4, 1990;
Amended Eff. January 1, 2014; April 1, 1999; January 4, 1994; February 1, 1992; December 1, 1990.