03/04/2024

ODM Issues Important Information on Timely Filing Rule for EDI Submitted Claims

 

Source:  ODM Press 3/01/2024

Ohio Department of Medicaid (ODM) understands that since the February 1, 2023, launch of the Electronic Data Interchange (EDI) providers have experienced issues with the claim submission process. ODM acknowledges this and is working diligently with its vendors to resolve system challenges and improve the provider experience.

As a result, ODM is issuing a limited exception to timely filing requirements for fee-for-service and managed care claims submitted through trading partners via the EDI and subsequently processed in the Fiscal Intermediary. This exception applies to claims impacted by EDI related submission delays and does not include MyCare claims. If providers submit EDI claims that are older than 365 days and have a date of service or inpatient discharge date of January 25, 2022, or later, they will be considered timely if submitted on or before September 30, 2024. However, claims submitted within this window must include the appropriate Delay Reason Code in the specified field below.

You should select the CLM 20 Delay Reason using the following guidance:

• A – Delay Reason Code = 7 (Third Party Processing Delay). Use this code if the claims could not be submitted through the system at all.
• B – Delay Reason Code = 9 (Original Claim Rejected). Use this code if the original claim was submitted, but it could not be processed through the OMES system at that time. 

Although ODM is issuing a limited exception to timely filing requirements, claims submitted after the standard 365-day limit are still subject to post payment review. ODM may verify evidence of system submission issues, such as reviewing past Integrated Helpdesk (IHD) call logs to verify that providers attempted to troubleshoot their issue. If issues are not evident, the claim payment may be reversed.

For any other dates of service or discharge dates, the timely filing requirements and exceptions in Ohio Administrative Code rule 5160-1-19 still apply. If you wish to dispute a claim payment or denial, for fee-for-service claims you should submit the Medical Claim Review Request (i.e. form 6653) and for managed care claims follow the appropriate managed care organization's appeal process.

For additional help:  For claim assistance, contact the Ohio Medicaid IHD, option 1, or email IHD@medicaid.ohio.gov. Representatives are available Monday-Friday, 8 a.m.-4:30 p.m. Eastern time.