Section He-W 521.04 - Claim Submission(a) Except as allowed by (f) and (h) below, a provider shall submit fee-for-service claims for payment to the department's fiscal agent within 12 months of the earliest date of service, as required by 42 CFR 447.45.(b) Claims may be submitted electronically using the X-12 format.(c) Paper claims shall be submitted using the most current version of the following forms as required in 42 CFR 424.32 and are available as noted in Appendix A: (1) The Centers for Medicare and Medicaid Services (CMS) form CMS-1500, "Health Insurance Claim Form" (2/2012), for billing professional services;(2) The uniform billing (UB) form CMS-1450 "UB-04" (January 2023) for billing services provided in institutional settings; and(3) The American Dental Association (ADA) form, "ADA Dental Claim Form" (2024), for billing all dental services.(d) Providers shall follow provider billing manual requirements and formal provider bulletins when submitting claims.(e) The CMS current and approved diagnosis and treatment codes shall be used on all claims submitted for payment.(f) A non-enrolled provider may submit a fee-for-service claim for emergency services, such as an out-of-state accident. The provider shall submit a NH provider application with the claims for processing under the NH medicaid fee schedule for only the emergency dates of service. The provider shall pass all federally mandated screenings for payment.(g) If a provider submitted a claim within the time period required as described in (a) above, and the claim is denied by the department's fiscal agent or MCO, but the cause for the denial can be corrected, the provider may resubmit the fee-for-service claim within 12 months from the earliest date of service for payment to be made, or for MCO claims per the MCO contract obligation.(h) When a provider is resubmitting a denied fee-for-service claim beyond the 15 months from the earliest date of service as allowed by (g) above, the submission shall include the following: (1) A completed form 957, "Override Request" (February 2024), located on the NH MMIS health enterprise portal website at; and(2) A copy of the remittance advice, which is the notice to the provider of the original denied claim with the denial circled.(i) If a claim was not previously denied and the date of service is more than 15 months from the date of submission of the claim, the claim shall only be approved for payment if: (1) There was a delay in determining the recipient's eligibility for medicaid;(2) The claim is for a medicaid covered item, supply, or service provided during a retroactive eligibility period;(3) The claim was submitted within 6 months of the date that retroactive medicaid eligibility was determined; or(4) The claim could not be processed due to a department or MCO system issue or error.(j) For MCO claims submission and processing, providers shall follow the MCO contract and billing manuals.N.H. Admin. Code § He-W 521.04
Derived from Number 10, Filed March 7, 2024, Proposed by #13884, Effective 2/22/2024, Expires 2/22/2034 (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521).