Know Payer-specific Deadlines for Claims Submission

by | Published on Sep 30, 2019 | Medical Billing

Deadlines for Claims Submission
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The recent announcement by Anthem Blue Cross about changes in timely filing limits for Medicare Advantage plans points to the importance of efficient insurance eligibility verification and claim filing for successful medical billing. When submitting Medicare claims, a medical billing company should know the details of the timely filing rule, which can differ from payer to payer. Timely filing is when a payer fixes a time limit for claims submission. For instance, if the insurance company has a 90-day timely filing requirement, physicians’ offices need to submit the claim within 90 days of the date of service. Timely filing with the correct codes is critical for timely and appropriate payment.

Anthem reduces Timely Filing Deadline for Claims

 On June 21, 2019, Anthem Blue Cross notified their network and contracted Medicare Advantage (MA) providers about a shorter timely filing limit that will become effective as of October 1, 2019. The company’s notification was as follows:

Effective for all commercial and Medicare Advantage Professional Claims submitted to the plan on or after Oct. 1, 2019, your Anthem Blue Cross and Blue Shield (Anthem) Provider Agreement(s) will be amended to require the submission of all commercial and Medicare Advantage professional claims within ninety (90) days of the date of service. This means all claims submitted on or after October 1, 2019 will be subject to a ninety (90) day timely filing requirement.

Check Timely Filing Requirements of Individual MA Plans

 For a Medicare claim, the “Start date” or “From date” recorded on the form is the Date of Service (DOS), the date when a provider performed healthcare services or procedures. The end date for timely filing for the original or traditional Medicare Fee for Service (FFS) plan is exactly one full calendar year after the start date.

Medicare’s rule for timely filing is: “Claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished.”

This rule applies to the Medicare FFS program (Traditional or Original Medicare) and claims that do not meet this deadline risk denial. According to a recent Find-a-Code article, the one-year time limit helps sort out issues that may occur when patients are unsure of their coverage details, including:

  • Unaware who their primary payer and secondary payer are
  • Cannot find their MA plan card and produce their original Medicare card
  • Not sure if they have the right card
  • Uncertain about policy period or start and end dates

However, the rules could be different for a Medicare Advantage (MA) Plan. If a patient has switched from a traditional Medicare plan to a MA Plan, the medical billing service provider needs to follow the timely claim filing rules for that particular MA plan. In other words, as CGS Medicare instructs, “Providers should check with the individual MA Plan to determine their timely claim filing requirements”.

 Preventing /Handling Timely Filing Claim Denials

A shorter time limit for filing claims means that physicians’ offices need to ensure:

  • Efficient claim filing processes
  • Proper insurance eligibility verification before the patient’s office visit
  • Staff is knowledgeable about claim submission deadlines listed in MA and commercial payer contracts

Failing to send out a claim within a payer’s timely filing limit will result in denial. Even if a claim is sent before the end date, but is received after that date, it will still be denied.

If a claim is denied for timely filing, Physicians Practice recommends searching the clearinghouse’s website for proof that the claim was not just sent, but accepted by the payer. The letter appealing the denial should contain the necessary patient information along with the proof that the payer had accepted the claim and wrongfully denied. In most cases, the claim will be paid after a review of the appeal, which usually takes 30-90 days.

Medicare timely filing denials are not subject to formal appeal. Medicare timely filing claim denials can only be appealed based on certain exceptions. If the claim meets the criteria for one of these exceptions, review can be initiated by sending a request letter along with supporting documentation.

Timely filing denials can leave a lot of revenue on the table. Outsourced medical billing services are a practical option to avoid this risk and maximize revenue. Reliable companies have well-trained personnel on board who can manage all phases of the revenue cycle efficiently. They will help practices keep track of all of their contracted requirements, verify patients’ coverage details before services are provided, and ensure timely claim submission and payment.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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