Timely Filing Review Request

Timely Filing Review Request

Provider Name*

If you do not have a Billing Provider NPI, please check this box

Billing Provider NPI*

Billing Provider Tax ID*

MESA Provider ID*

Please ensure the number is 9 digits including any leading zeroes. This must be the Billing Provider ID that is on the claim.

Submitter Name*

Submitter Email*

Upon submission, a confirmation will be sent to this email address. Please ensure to hit enter on your keyboard when you are done typing your email in order for it to save in this box.

Submitter Phone Number*

Phone

Will there be a different representative for the review?*

Yes

Provider Representative Name*

Provider Representative Email*

Upon submission, a confirmation will be sent to this email address.

Select or enter value

Provider Representative Phone #*

Phone

Please check this box if you wish to upload the claims information using an excel file, but be aware of file limitations below. If you wish to manually enter the claims information, this form allows up to 25 claim submissions for administrative review.

• If you would prefer to use this form to manually enter claim information, do not check this box and continue completing the form below.

• The excel template can be found here: https://medicaid.ms.gov/wp-content/uploads/2023/06/Timely-Filing-Review-Request-Template.xlsx

• There is a 30MB maximum size limit for each file (which can include more than 25 claims) and up to 10 files can be uploaded to this submission (including any supporting documentation that may accompany these claims). If you reach the 10-file limit, you can submit an additional form.

Claim #1

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #2

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #3

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #4

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #5

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #6

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #7

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #8

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #9

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #10

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #11

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #12

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #13

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #14

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #15

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #16

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #17

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #18

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #19

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #20

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #21

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #22

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #23

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #24

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

Would you like to complete another review request?*

Yes

Claim #25

This is the maximum number of claims that can be added to this form. If you have more to add, please submit an additional form.

Date of Service*

Date of Original Submission of Claim to Medicaid Fiscal Agent*

ICN/TCN of Original Submission*

Date of Resubmission of Claim to Medicaid Fiscal Agent*

This should be for the resubmitted claim that was denied for timely filing.

ICN/TCN of Resubmission*

This should be for the resubmitted claim that was denied for timely filing.

Is this a Medicare Crossover Claim?*

Yes

Does this claim involve Retroactive Eligibility?*

Yes

File Upload*

There is a file size limit of 30MB per file and a maximum of 10 files can be uploaded. Please attach any supporting documents that would support your review request below.

For reference, Medicaid guidance around timely filing can be found in our Administrative Code Part 200 Rule 1.6: Timely Filing; Rule 1.7: Timely Processing of Claims; Rule 1.8: Administrative Review for Claims; and Part 300 Chapter 4: Claim Denials for Policy regarding Administrative Reviews. The link to our Administrative Code can be found at https://medicaid.ms.gov/providers/administrative-code/.

The specific guidance around documentation is outlined in the Administrative Code Part 200 Rule 1.8 (B). Failure to provide all required documentation will delay your review.

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