[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR447.45]



[Page 311-313]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 447_PAYMENTS FOR SERVICES--Table of Contents

 

                 Subpart A_Payments: General Provisions

 

Sec.  447.45  Timely claims payment.



    (a) Basis and purpose. This section implements section 1902(a)(37) 

of the Act by specifying--

    (1) State plan requirements for--

    (i) Timely processing of claims for payment;

    (ii) Prepayment and postpayment claims reviews; and

    (2) Conditions under which the Administrator may grant waivers of 

the time requirements.

    (b) Definitions. Claim means (1) a bill for services, (2) a line 

item of service, or (3) all services for one recipient within a bill.

    Clean claim means one that can be processed without obtaining 

additional information from the provider of the service or from a third 

party. It includes a claim with errors originating in a State's claims 

system. It does not include a claim from a provider who is under 

investigation for fraud or abuse, or a claim under review for medical 

necessity.

    A shared health facility means any arrangement in which--

    (1) Two or more health care practitioners practice their professions 

at a common physical location;

    (2) The practitioners share common waiting areas, examining rooms, 

treatment rooms, or other space, the services of supporting staff, or 

equipment;

    (3) The practitioners have a person (who may himself be a 

practitioner)--



[[Page 312]]



    (i) Who is in charge of, controls, manages, or supervises 

substantial aspects of the arrangement or operation for the delivery of 

health or medical services at the common physical location other than 

the direct furnishing of professional health care services by the 

practitioners to their patients; or

    (ii) Who makes available to the practitioners the services of 

supporting staff who are not employees of the practitioners; and

    (iii) Who is compensated in whole or in part, for the use of the 

common physical location or related support services, on a basis related 

to amounts charged or collected for the services rendered or ordered at 

the location or on any basis clearly unrelated to the value of the 

services provided by the person; and

    (4) At least one of the practitioners received payments on a fee-

for-service basis under titles V, XVIII, and XIX in an amount exceeding 

$5,000 for any one month during the preceding 12 months or in an 

aggregate amount exceeding $40,000 during the preceding 12 months.



The term does not include a provider of services (as specified in Sec.  

489.2(b) of this chapter), a health maintenance organization (as defined 

in section 1301(a) of the Public Health Service Act), a hospital 

cooperative shared services organization meeting the requirements of 

section 501(e) of the Internal Revenue Code of 1954, or any public 

entity.

    Third party is defined in Sec.  433.135 of this chapter.

    (c) State plan requirements. A State plan must (1) provide that the 

requirements of paragraphs (d), (e)(2), (f) and (g) of this section are 

met; and

    (2) Specify the definition of a claim, as provided in paragraph (b) 

of this section, to be used in meeting the requirements for timely 

claims payment. The definition may vary by type of service (e.g., 

physician service, hospital service).

    (d) Timely processing of claims. (1) The Medicaid agency must 

require providers to submit all claims no later than 12 months from the 

date of service.

    (2) The agency must pay 90 percent of all clean claims from 

practitioners, who are in individual or group practice or who practice 

in shared health facilities, within 30 days of the date of receipt.

    (3) The agency must pay 99 percent of all clean claims from 

practitioners, who are in individual or group practice or who practice 

in shared health facilities, within 90 days of the date of receipt.

    (4) The agency must pay all other claims within 12 months of the 

date of receipt, except in the following circumstances:

    (i) This time limitation does not apply to retroactive adjustments 

paid to providers who are reimbursed under a retrospective payment 

system, as defined in Sec.  447.272 of this part.

    (ii) If a claim for payment under Medicare has been filed in a 

timely manner, the agency may pay a Medicaid claim relating to the same 

services within 6 months after the agency or the provider receives 

notice of the disposition of the Medicare claim.

    (iii) The time limitation does not apply to claims from providers 

under investigation for fraud or abuse.

    (iv) The agency may make payments at any time in accordance with a 

court order, to carry out hearing decisions or agency corrective actions 

taken to resolve a dispute, or 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.

    (5) The date of receipt is the date the agency receives the claim, 

as indicated by its date stamp on the claim.

    (6) The date of payment is the date of the check or other form of 

payment.

    (e) Waivers. (1) The Administrator may waive the requirements of 

paragraphs (d) (2) and (3) of this section upon request by an agency if 

he finds that the agency has shown good faith in trying to meet them. In 

deciding whether the agency has shown good faith, the Administrator will 

consider whether the agency has received an unusually high volume of 

claims which are not clean claims, and whether the agency is making 

diligent efforts to implement an automated claims processing and 

information retrieval system.



[[Page 313]]



    (2) The agency's request for a waiver must contain a written plan of 

correction specifying all steps it will take to meet the requirements of 

this section.

    (3) The Administrator will review each case and if he approves a 

waiver, will specify its expiration date, based on the State's 

capability and efforts to meet the requirements of this section.

    (f) Prepayment and postpayment claims review. (1) For all claims, 

the agency must conduct prepayment claims review consisting of--

    (i) Verification that the recipient was included in the eligibility 

file and that the provider was authorized to furnish the service at the 

time the service was furnished;

    (ii) Checks that the number of visits and services delivered are 

logically consistent with the recipient's characteristics and 

circumstances, such as type of illness, age, sex, service location;

    (iii) Verification that the claim does not duplicate or conflict 

with one reviewed previously or currently being reviewed;

    (iv) Verification that a payment does not exceed any reimbursement 

rates or limits in the State plan; and

    (v) Checks for third party liability within the requirements of 

Sec.  433.137 of this chapter.

    (2) The agency must conduct post-payment claims review that meets 

the requirements of parts 455 and 456 of this chapter, dealing with 

fraud and utilization control.

    (g) Reports. The agency must provide any reports and documentation 

on compliance with this section that the Administrator may require.



(Secs. 1102 and 1902(a)(37) of the Social Security Act (42 U.S.C. 1302, 

1396a(a)(37)))



[44 FR 30344, May 25, 1979, as amended at 55 FR 1434, Jan. 16, 1990]