Timely Filing
Every insurance company has a time window in which you can submit claims. If you file them later than the allowed time, you will be denied.
For most major insurance companies, including Medicare and Medicaid, the filing limit is one year from the date of service. If you are a contracted or in-network provider, such as for BC/BS or for ACN or HSM, the timely filing limit can be much shorter as specified in your provider agreement. It may be six months or even 90 days.
1) Aetna: 120 days. 90 Days
Health Net 120 days
The following is important information regarding recent New York State Managed Care
regulations.
Effective April 1, 2010, New York State Managed Care regulations stipulate that health care
claims must be submitted by health care providers within 120 days of the date of service
Centers for Medicare Medicaid maintenance requires Medicare contractors to deny claims submitted after timely file limit is expired. Circumstances such as backdated Medicare entitlement may as well qualify for a timely extension filing deadline. There have probably been no appeal rights on denied claim. CMS indicates that Medicare contractors could determine good cause exists when an administrative error on an official part Medicare employee acting on Medicare behalf contractor within scope of his/her authority caused the delay. As a result, in such situations, providers must file the claim promptly after error was probably corrected. In rare cases, CMS permits Medicare contractors to extend time limit for filing a claim beyond the usual deadline if provider may show good cause for delay in filing the claim.
WPS Medicare Redeterminations unit cannot grant any waiver to timely filing deadline after the claim probably was processed, since claims denied for timely filing do not have appeal rights. Do not send your request to WPS Medicare using the Redetermination Form.
Please note: Not all Member Contracts/Certificates follow the 15-month claims filing limit.
Blue Cross claims must be filed within 15 months, or length of time stated in the member’s contract, of the date of service. Claims received after 15 months, or length of time stated in the member’s contract, will be denied, and the member and Blue Cross should be held harmless for these amounts. FEP claims must be filed by December 31 of the year after the year the service was rendered.
Medicare claims must be filed within one (1) calendar year after the date of service. Self-insured plans and plans from other states may have different timely filing guidelines. Please call Provider Services at 1-800-922-8866 to determine what the claims filing limits are for your patients.
Blue Cross claims for OGB members must be filed within 12 months of the date of service. Claims received after 12 months will be denied for timely filing and the OGB member and Blue Cross should be held harmless. Claims reviews including refunds and recoupments must be requested within 18 months of the receipt date of the original claim. OGB claims are not subject to late payment interest penalties.
Section 6404 of the Patient Protection and Affordable Care Act (the Affordable Care Act or ACA) reduced the maximum period for submission of all Medicare fee-for-service claims to no more than 12 months — one calendar year — after the date of service. This policy is effective for services furnished on or after January 1, 2010; claims for services furnished prior to that date were required to be submitted no later than December 31, 2010.
CMS released special edition MLN Matters® article SE1426 external pdf file to assist providers with coding instructions and billing scenarios for submitting requests to reopen claims that are beyond the claim filing timeframe.
The following exceptions apply to the time limit for filing initial Medicare claims:
• Retroactive Medicare entitlement
Retroactive Medicare entitlement
• An official letter notifying the beneficiary of Medicare entitlement and the effective date of the entitlement, and
Retroactive Medicare entitlement involving state Medicaid agencies (state buy-in)
• Documentation showing the date that the state Medicaid agency recouped money from the provider/supplier, and
• Documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (i.e., the official letter to the beneficiary), and
• Documentation verifying the service/s furnished to the beneficiary and the date of the furnished service(s).
Retroactive disenrollment from a Medicare Advantage plan or PACE provider organization
• Evidence of prior enrollment of the beneficiary in an MA plan or PACE provider organization, and
Customer service process for time limit exceptions
First Coast has undertaken an initiative to provide an easier mechanism for handling requests from providers to extend the timely filing requirement on claims that exceed the provision. Effective January 1, 2016, as previously mentioned, the Administrative Billing Errors category has been removed from the process listed below. The following guidelines remain the same for all other requests from providers to extend the timely filing extension on their claims:
• First Coast’s written inquiry representatives will retrieve the documentation, review it, and issue an approval or disapproval letter to the provider in response to the timely filing request. The approval or disapproval response will be mailed to the provider’s mailing address listed on our internal files. Be advised that this process could take up to 45 business days to complete. Please do not call the contact center.
If a claim filing extension is granted, the approval letter will instruct the provider to file a new claim. The unique approval number, provided in the approval letter, and the date of the approval letter must be included in the remark section of the claim.
Additionally, the approval letter will include a date by which the new claim must be filed. Once the claim is filed, the approval number entered on the remark line and the receipt date of the claim will be compared to the list of approved numbers. If this information matches, the claims timely filing edit will then be overridden on the applicable claim. It is important to note that other edits may fail on the claim which may require that providers correct their billing and resubmit the claims.
If a claim filing extension is not granted, the reason for not granting the extension will be outlined in the letter.
It is important that the above outlined process be followed in its entirety as any deviations could result in documentation being returned and added delays in approvals.
There should seldom be a time when claims are filed outside the filing limit. The only exceptions might be when you are dealing with a Medicare secondary and were appealing a denial prior to submitting to the secondary, or when an account was sent to work comp, then after much review was denied as not liable and now must be billed to health insurance. In these cases, you can appeal the claims, but you must call the insurance company and see what their appeal rights are. Medicare and Medicaid have specific appeal guidelines in their provider manuals, but other insurance companies vary.
If you actually were outside the timely filing limit, many insurance companies and most provider agreements prohibit you from pursuing the patient for the denied balance. It is also poor vconsumer relations to make the patient pay for your office’s failure to submit the claim.
Rebills on Claims Filed Timely
A frustrating problem when doing account follow-up is that most insurance companies only hold or “pend” claims in their system for 60 to 90 days. After that, if they are not paid or denied, they are deleted from their computers. A large insurance company may receive over 100,000 claims a day and their systems cannot hold that volume of pending claims. When you call to follow up, they will state, “we have no record in our system of having received that claim.” Now your only recourse is to rebill the claim. If it is outside their “timely filing”, you will get a denial back. You should and must now appeal the denial. The first thing that you will need is proof that you actually did file the claim within the time window allowed.
Proof of Timely Filing
For paper claims, you can reprint and attach the original claim, however some billing software will put today’s date on the reprinted claim. Ask your software provider to walk you through reprinting a claim with the original date. There is no reason to photocopy all claims just in case you need to prove timely filing. For electronic claims, you should have the claims submittal report from your clearinghouse. These should always be kept (in electronic format) on your computer by date in a folder that is regularly backed-up
[Sample Appeal Letter for Timely Filing]
Name of Insurance Company
Address (get address for appeals if it exists)
Re: Appeal of Denial for Timely Filing
Patient Name:
Group Number: DOS:
Subscriber No: Reference No.: (etc – get this information from the denial) We are appealing the denial of claims for (patient name) and request that these claims be reviewed and paid. On (original submission date) we submitted claims for services rendered to the above patient.
This was well within your timely filing deadline.
The promptly and properly submitted claims were neither paid nor denied by your company. On (date of resubmission) we resubmitted the claims for consideration. On (date of denial) we received a denial of the claims for “timely filing”. Please see the attached EOB from your company.
I have attached copies of the original claims showing the date they were printed. Our office policy is to send all claims on the date they are produced. The printed date is the date of submission and is well within your deadline. (or) I have attached a copy of our Claims Submittal Report provided by our electronic claims clearinghouse showing that the original submission date was well within your deadline. We respectfully request that these claims be promptly processed and that are office is paid for the services rendered to your subscriber as allowed by the State prompt payment regulations. If this claim is further denied, we intend to then file a complaint with the Office of the Insurance Commissionaire.
Special Circumstances
Occasionally, because of coordination of benefits or denials from the primary insurance or questions of liability, you will end up filing outside your agreed limit and get denied. In these cases, you have to call the insurance company and find out what their appeal guidelines are for late filing. I have not run across a company that does not have an appeal process for these rare circumstances, but it does vary from company to company.
Prevention
Submitting Proof of Timely Filing
Timely filing denials are often upheld due to incomplete or invalid documentation submitted with reconsideration requests. The following information has been compiled to help clarify the documentation required as valid proof of timely filing documentation. When submitting a request for reconsideration of a claim to substantiate timely filing, please follow the appropriate instructions below.
For claims submitted electronically:
• Submit an electronic data interchange (EDI) acceptance report. This must show that UnitedHealthcare or one of its affiliates received, accepted and/or acknowledged the claim submission.
Note: A submission report alone is not considered proof of timely filing for electronic claims. It must be accompanied by an acceptance report.
• The acceptance report must:
o Include the actual wording that indicates the claim was either “accepted,” “received” and/or “acknowledged.” (Abbreviations of those words are also acceptable.)
o Show the claim was accepted, received, and/or acknowledged within the timely filing period. For paper claims:
• Submit a screen shot from accounting software that shows the date the claim was submitted. The screen shot must show:
o Correct patient name
o Correct date of service
o Submission date of claim
o The submission date must be within the timely filing period.
Note that timely filing limits can vary greatly, based on state requirements and contract types. If you are not aware of your timely filing limit, please refer to your provider agreement.
Other valid proof of timely filing documentation
Valid when incorrect insurance information was provided by the patient at the time the service was rendered:
• A denial/rejection letter from another insurance carrier
• Another insurance carrier’s explanation of benefits
• Letter from another insurance carrier or employer group indicating coverage termination prior to the date of service of the claim
• Letter from another insurance carrier or employer group indicating no coverage for the patient on the date of service of the claim All of the above must include documentation that the claim is for the correct patient and the correct date of service.
The date on the other carrier’s payment correspondence starts the timely filing period for submission to UnitedHealthcare.
Guideline from Cigna
To ensure your claims are processed in a timely manner, please adhere to the following policies:
** INITIAL CLAIM – must be received at Cigna-HealthSpring within 120 days from the date of service.
** SECONDARY FILING – must be received at Cigna-HealthSpring within 120 days from the date on the Primary Carrier’s EOB.
** CORRECTED CLAIMS – must be received at Cigna-HealthSpring within180 days from the date on the initial Cigna-HealthSpring Remittance Advice. These claims must be clearly marked “CORRECTED” in pen or with a stamp directly on the claim form.
** INITIALLY FILED TO INCORRECT CARRIER – must be received at CignaHealthSpring within 120 days from the date of the denial on the incorrect Carrier’s EOB/RA (as long as the claim was initially filed to that carrier within 120 days of the date of service). The denial MUST BE SUBMITTED along with the claim for payment consideration.
** NOTE: Billing system print screens are NOT ACCEPTED for proof of timely filing. Claims submitted to Cigna-HealthSpring after these time limits will not be considered for payment.
If filing electronically:
** When using EDI, your claims may be sent to your clearinghouse, but may NOT have been received by Cigna-HealthSpring. Therefore, it is imperative to check the daily Rejection Report from your clearinghouse for any claims that may not have been accepted by your clearinghouse, Cigna-HealthSpring’s clearinghouse or Cigna-HealthSpring.
** If you are uncertain of your EDI claims activity, contact your clearinghouse first to ensure your claims are being transmitted correctly.
IMPORTANT: If you have NOT received a Remittance Advice within 45 days for a claim you have submitted, please check status online through HSConnect. If the claim is not in our system, please submit the claim to Cigna-HealthSpring immediately. The claim must be received within 120 days from date of service to be considered timely.
Timely Filing Limits for Claim Submission Medicare Michigan
Effective January 1, 2017, claims must be filed no later than one calendar year from the date of service (DOS). For Institutional invoices, this will be calculated using the Claim Header “To/Through” date of service reported; for professional and dental invoices, this will be calculated using the Claim Line “From” date of service.
In addition, claims for services furnished prior to January 1, 2017 must be submitted no later than December 31, 2017. Claims exceeding the new timely filing limits (over 1 year from the DOS) will be denied unless the claim meets exception(s) as listed below.
A. Exceptions to Timely Filing Limits Acceptable exceptions to the timely filing limits for claims submission include the following:
• Department administrative error has occurred
• Medicaid beneficiary eligibility/authorization was established retroactively
• Judicial action/mandate: A court or Michigan Administrative Hearing System (MAHS) administrative law judge ordered payment of the claim
• Medicare processing was delayed
• Provider returning overpayment
• Primary insurance taking back payment after timely filing billing limitation has passed Retroactive provider enrollment is not considered an exception to timely filing.
Claims meeting all other exceptions are to be submitted as usual through the Community Health Automated Medicaid Processing System (CHAMPS) with appropriate remarks/notes justifying the exception request, such as:
• Court order
• Medicare documentation
• Claims previously billed under a different provider National Provider Identifier (NPI) number
• Claims previously billed under a different beneficiary ID number
• Claims previously billed using a different “statement covers period” for nursing facilities and inpatient hospitals
• Copy of insurance letter or Explanation of Benefits (EOB) showing date money was taken back from paid claim
Timely Filing Suggestions
Please follow these suggestions in order to facilitate timely reimbursement of claims and to avoid timely filing issues:
** Submit your claims within thirty (30) days of providing the service;
** Check the status of your claims no sooner than thirty (30) days from the date of your original submission;
** If, after forty-five (45) days from submission of your claim(s), you have not received payment/denial, please call Member Services to confirm receipt of your claim(s) and be certain to document the name of the person you spoke with and the date of the call; and
** If Molina Healthcare does not have record of receipt of your claim(s), please immediately resubmit. Resubmission should only occur if Molina Healthcare does not have record of your original claim submission.
Claim Resubmission/Adjustments
ALL requests must include any/all documentation to support the request. The Provider Reconsideration Review Request Form (PRR) is included in this Section for your convenience.
All claims resubmission or adjustment requests must be submitted and received by Molina Healthcare within:
** One Hundred Eighty (180) days of dated correspondence from Molina Healthcare referencing theclaim (correspondence must be specific to the referenced claim);
** One (1) year from the date of service when Molina Healthcare is the secondary payor when the primary carrier’s filing limit is one (1) year, and ninety (90) days of the other carrier’s EOB; and
** Ninety (90) days of the other carrier’s EOB when submitted to the wrong payor.
Acceptable Proof of Timely Filing
Acceptable proof of timely filing includes, but is not limited to any one item or combinationof:
** EOB issued by Molina Healthcare;
** Practitioner/provider statements/ledgers indicating the original submission date as well as all follow-up attempts;
** Dated copy of Molina Healthcare correspondence referencing the claim (correspondence must bespecific to the referenced claim);
** Other carrier’s EOB when Molina Healthcare is the secondary payor (one [1] year from the dateof service);
** Other carrier’s EOB when submitted to the wrong carrier (ninety [90] days); and
** Documentation of inquiries (calls or correspondence) made to Molina Healthcare for follow-up that can be verified by Molina Healthcare.
“Clean” Claim Criteria
The following items must be included to be considered a “clean” claim:
** Member’s name;
** Member’s correct date of birth;
** Provider’s National Provider Identifier (NPI);
** Complete diagnosis code carried out to the highest degree (4th or 5th digit);
** Valid date of service;
** Valid Current Procedural Terminology (CPT-4) code or Health Care Procedure Coding System (HCPCS) code;
** Valid Revenue (REV) codes – please refer to Section K-5;
** Valid modifiers (if appropriate); and
** All other requirements as specified in Subsection L of 8.305.1.7 NMAC.
Electronic Claims Submission
The State of New Mexico Human Services Department requires that all of Molina Healthcare practitioners/providers file all claims electronically for the following reasons:
** Claims filed electronically are processed more efficiently;
** Saves mailing time, postage, and paper;
** Provides an electronic record of claims sent; and
** Allows instant feedback on claims that require correction(s). All contracted practitioners/providers that are unable to file claims electronically must notify Provider Services with the reason(s).
In order for practitioners/providers to file claims electronically the following will be required:
** A personal computer (PC) system where Practice Management Software resides;
** The ability to produce a print image for a claim or an electronic claim or file (the clearinghouse technical representative will help to determine this); and
** A modem or internet connection. Some clearinghouses provide web based claim submission. Clearinghouses may also provide eligibility validation so health care practitioners/providers may check patient eligibility easily. Molina Healthcare is contracted with a single Electronic Data Interchange (EDI) vendor, Emdeon. All other EDI vendors must submit through Emdeon. Emdeon (aka) Medifax
Exceptions to Original Claim Deadlines for Providers and Members
o Added language to indicate network providers, certain plans and products, and delegated arrangement contracts may have specific filing deadlines listed in their contract; when this occurs the contract dictates the filing deadline
o Removed langauge indicating:
** Certain products may have specific timeframes regarding the submission of claims; refer to the member’s certificate for specific limitations/ maximums
** Delegated arrangements may have different filing deadlines; refer to the contract with the delegated arrangement
** Certain providers may have specific filing deadlines listed in their contract Submission of Additional Information
o Revised language pertaining to exceptions to indicate network providers, certain plans and products, and delegated arrangement contracts may have specific filing deadlines for additional information listed in their contract that conflict with the information listed in the policy; when this occurs, the contract dictates the filing deadline
Claims timely filing guidelines FAQ
Q: What are the claims timely filing guidelines? How can I prevent claim denials and/or rejects for untimely filing?
A: Per Section 6404 of the Patient Protection and Affordable Care Act (ACA), Medicare fee-for-service (FFS) claims for services furnished on or after January 1, 2010, must be filed within one calendar year from the date of service. Claims with dates of service January 1, 2010, and later, received more than one calendar year (12 months) from the date of service will be denied or rejected.
Key points to remember
For all claims:
• Claims with a date of service of February 29 must be filed by February 28 of the following year to be considered filed timely.
• Electronic claims — The electronic data interchange (EDI) system accepts claims 24/7; however, claims received after 6 p.m. eastern time (ET) or on a weekend or holiday are considered received the next business day.
• Paper claims — Timeliness is calculated based on contractor receipt date, not the postmark date of when the claims are mailed, so please allow time for mailing.
For claims with “span dates of service” (“from” and “through” date span on the claim):
• Part A institutional claims – “Through date” is used to determine the date of service for claim timely filing.
• Part B claims – “From date” is used to determine the date of service for claim timely filing.
Exceptions allowing extension of time limit:
• Exceptions to the 12-month timely filing period are outlined in the Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) Medicare Claims Processing Manual, Chapter 1 external pdf file.
Health Net 120 days
foundation 1 yr
Tricare 1yr
Pacificare 90 days
Name of Insurance Timely Filing Period
Abrazo 180 days
Arizona BCBS 365 days
Arizona Physicians IPA 120 days
Aetna 450 days
Evercare 60 days
Harrington 365 days
Mercy Care 180 days
Pacificare 90 days
Phoenix Health Plan 180 days
Secure Horizons 90 days
United Health Care 90 days
Hi Guys,
I am in Adjudication Department and handling timely filing denials for our Insurance for the last three years. Please find the below mentioned tips related to Timely Filing Appeal:
1. For an Insurance company if the initial filing limit is 90 days, Claim being submitted after 90th day will be automatically denied by the system for Timely Filing.
2. File the appeal with the Correct Appeal form and fill up all the details in it.
3. Sometimes when the appeal itself is being filed after one year or so, your appeal will be definitely denied.
4. When the appeal is related to other insurance, submit the EOB or Denial letter or Refund letter of other insurance company.
5. When the appeal is not related to other insurance, submit the proofs like patient ledger, clearing house report which should clearly indicate that claim being billed to the concerned insurance company within the timely filing limit from the DOS mentioned on the claim.
6. When the appeal is patient being billed, submit the patient billed proof with all the required documentation like Patient name, DOS, Charges, Patient billed date which should be within one year from the DOS (which may vary from Insurance to Insurance).
BCBS Timely Filing is 180 days, not 365. ~Ben
IT IS 1 YR FROM DOS
Medicaid Is 95-Days Effective 01/01/2010.
BCBS is 180 days for initial clean claim submission – 365 days to submit an appeal.
Actually, the above person has the BCBS timely backwards. You have 365 days from the DOS to submit the initial claim and 180 days to respond to denials/payments for appeals.
Aetna is also now 90 days.
Sam Jones sd All of the above is incorrect …. im telling is correct…SU
Actually, most of the below info is incorrect except for Medicare/Medicaid statments. STATE LAWS FOR TIMELY FILING TAKE PRECEDENCE OVER WHATEVER CONTRACTS SAY IF THE CONTRACT IS LESS THAN STATE LAW. If there is NO contract, STATE LAW is what takes precedence. IF there is no state law for timely filing (like here in Colorado) contract takes precedence. IF you are in a state without timely law, NON-contracted, and the payer insurer says denied for timely filing, then start the appeal process letting them know there is no timely filing law for that state.(Their denial is baloney, and they just hope you will write it off) If it is a Medicare replacement plan, then they will follow Medicare timely filing.
What is bcbs timely filing deadline in the state of Nevada? My Premera plan is administered by bcbs, and I've heard 365 days and 180 days, does anyone know which is correct for Nevada?
why timely filing limit is different for each insurance
Great information, you have a wonderful blog and an excellent article.
Alternative Treatment For Hip Replacement Surgery
What is the time frame to submit an adjusted bill after the original bill has been sent? Would the adjusted bill need to be submitted within the same time frame from the date of service?
Does anyone know timely filing for WC in MAryland?
Humana updated: 180 days from the date of service for physicians.
90 days from the date of service for facilities and ancillary providers.
SUPERIOR HEALTHPLAN – 95 Days (Appeals – 120 Days from EOB)
Medicaid is now 95 days from date of service
Cigna updated – 90 Days for the initial claim
Wellcare – 180 Days from DOS
United healthcare timely filing can depend on the type of policy.
Pls tell me tha covenant insurance TFL limits
Plz tell me the covenant insurance tfl limit