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180-Day Exception Request - Department of Human Services - 180 day calculation


180-Day Exception Request - Department of Human Services-180 day calculation

INSTRUCTIONS FOR COMPLETING THE
180-DAY EXCEPTION REQUEST DETAIL PAGE AND ATTACHMENT
Item 1 Enter the provider's name.
Item 2 Enter the thirteen digit MA ID Number assigned to the provider.
Item 3 Enter the beneficiary's name.
Item 4 For inpatient services, enter the date the beneficiary was discharged, transferred, etc.
For outpatient services, enter the date of service.
Item 5 If the exception request is based on a county assistance office (CAO) delay in eligibility determination,
enter the date the application was mailed to the CAO. Documentation of the mailing date must be
provided. This documentation may be in the form of a dated transmittal, cover letter, etc., to the CAO.
Item 6 If applicable, enter the process date of the PA 162 Notice of Eligibility form. A copy of the PA 162 form
must be submitted as documentation with the request for an exception.
Item 7 If the exception request is based on a third party resource delay, enter the date the payment
request was mailed to the third party. Documentation of the mailing date must be provided. This
documentation may be in the form of a dated transmittal, cover letter, etc., to the third party.
Item 8 Enter the process date of the third party statement/explanation of benefits (EOB). A copy of the third
party statement/EOB must be submitted as documentation with the request for an exception.
Item 9 If applicable, enter the date the Prior Authorization (PSR/DRG/CHR) was processed by the
department. A copy of the notification letter must be submitted with the request for an exception.
Item 10 If applicable, enter the date the Program Exception (or Benefit Limit Exception) was processed by the
department. A copy of the notification letter must be submitted with the request for exception.
Item 11 If your claim was previously submitted to the MA Program, enter the date the MA invoice was mailed
to the Department of Human Services.
Item 12 Place a check mark ( ) in the block that describes why an exception is being requested.
Item 13 The person responsible for requesting the 180-day exception must sign and date the form.
Item 14 Enter the telephone number of the person whose signature appears in Item 13.
MA 563 3/18
180-Day Exception Request Detail Page
1. PROVIDER'S NAME:
___________________________________________________
2. PROVIDER IDENTIFICATION NUMBER AND SERVICE LOCATION:
___ ___ ___ ___ ___ ___ ___ ___ ___ - ___ ___ ___ ___
3. BENEFICIARY'S NAME:
___________________________________________________
4. DISCHARGE DATE/INPATIENT: OR DATE OF SERVICE/OUTPATIENT:
_______ / _______ / ____________ _______ / _______ / ____________
5. DATE APPLICATION MAILED TO THE CAO: 6. PROCESS DATE OF PA 162:
_______ / _______ / ____________ _______ / _______ / ____________
7. DATE PAYMENT REQUEST WAS MAILED TO 8. PROCESS DATE OF THIRD PARTY STATEMENT/EOB:
THIRD PARTY:
_______ / _______ / ____________
_______ / _______ / ____________
9. PRIOR AUTHORIZATION NOTIFICATION DATE: 10. PROGRAM EXCEPTION NOTIFICATION DATE:
_______ / _______ / ____________ _______ / _______ / ____________
11. DATE BILLING WAS MAILED TO MA:
_______ / _______ / ____________
12. 180-DAY EXCEPTION REQUEST DUE TO:
Delay in processing the PA 162 by the CAO Delay in processing the third party statement
Delay in Prior Authorization Approval Delay in Program Exception approval
13. SIGNATURE AND DATE:
___________________________________________________
14. TELEPHONE NUMBER:
( _______ ) _______ - ____________
MA 563 3/18

How many days are in 180 days?180 days = 180 days * (1 month / 30 days) = 6 months. A month (from the Latin mensis) is each of the twelve time periods, between 28 and 31 days, into which the year is divided.