480- Use of Delay Reason Codes and Medicaid Timely Filing

Jun 05, 2023

Background:

PCG has found that there has been an increase in incorrect use of Medicaid delay reason codes. It is the responsibility of the providers to utilize the appropriate delay reason codes. Delay reason codes are used on claims billed beyond Medicaid’s 90-day initial filing limit or when resubmitting claims with updated information within the 60-day resubmission window of claims denied or rejected. Each delay reason code has specific guidelines as well as needing to be submitted within 30-days of the situation coming under the control of the provider. Provider delays in working claims issues, which result in past timely filing rejections/denials are not considered as third-party processing delays.

For more information on timely filing guidelines, please see Medicaid’s Power Point presentation that has specific examples on appropriate use of delay reason codes: “Guide to Timely Billing”https://www.emedny.org/ProviderManuals/AllProviders/Guide_to_Timely_Billing.pdf

Number	Proof of eligibility unknown/unavailable	Additional Information
1	Proof of eligibility unknown/unavailable	The beneficiary did not inform the provider on DOS. Submission must be within 30 days that the provider was notified of eligibility. Not applicable to adjusted (corrected) claims
2	Litigation	Used when possibility of claims from another source (i.e., lawsuit) Claims must be submitted within 30 days.
*3	Authorization delays	Used when claims are delayed due to rate code issues. Must open Salesforce case to utilize as it is not available for utilization in EI Billing* Providers will need to supply approval from Medicaid or BEI. Providers must maintain Medicaid/BEI approval documentation on file.
4	Delay in certifying the provider	When there is a change in the provider’s enrollment status that causes a delay. Claims must be submitted within 30 days.
7	Third party processing delay	This applies only when there is a delay in other insurance processing required before billing Medicaid. (i.e., commercial plans) Claims must be submitted within 30 days. Provider delays in working claims issues, which result in past timely filing rejections/denials are not considered as third-party processing delays. Please be advised the county is not considered a third party as it is not insurance.
8	Delay in eligibility determination	Delays due to back dated eligibility, appeals, administrative delays, or litigation. Claims must be submitted within 30 days.
9	Original claim rejected/denied do to a reason unrelated to timely filing	Used when prior submissions were timely and were not denied or rejected for timely filing. Once there is a timely filing, this delay reason cannot be used. Corrected claims must be submitted within 60 days of Medicaid remittance. Delay reason codes are invalid for adjustments. Adjustments are corrected claims on previously paid Medicaid claims.
10	Administrative delay in prior approval process	Only when prior approval is granted after DOS if claim ages over 90 days during this process. Claims must be submitted within 30 days of notification.
15	Natural Disaster	Only when prior approval is granted after DOS if claim ages over 90 days during this process. Claims must be submitted within 30 days of notification.

Article ID: 79, Created: 7/13/2026 at 6:08 AM, Modified: 7/13/2026 at 6:08 AM