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TIMELY FILING FOR MEDICARE PROFESSIONAL
TIMELY FILING FOR MEDICARE FREE

R8=New and material evidence is available.

R7=Correction other than Clerical Error.

R6=Other Clerical Error or Minor Error or Omission (Failure to bill for services is not consider a considered a minor error.

R1=Mathematical or computational mistake.

Providers must submit appeal requests for such denials. Providers are reminded that submission of adjustment bills (TOB xxx7) or reopening requests (TOB xxxQ) in response to claim denials resulting from review of medical records (including failure to submit medical records in response to a request for records) is not appropriate. The reopening request (TOB xxxQ) should only be utilized when the submission falls outside of the period to submit an adjustment bill. When the need for a correction is discovered beyond the claims timely filing limit, an adjustment bill is not allowed and a provider must utilize the reopening process to remedy the error. Reopening Claims Beyond Claim Filing Timeframes

For claims submitted by physicians and other suppliers that include span DOS, line item "From" date is used for determining date of service for claims filing timeliness.

For institutional claims that include span DOS (i.e., a "From" and "Through" date on claim), "Through" date on claim is used for determining DOS for claims filing timeliness.

Claims with a February 29 DOS must be filed by February 28 of following year to meet timely filing requirements.

In general, start date for determining 1-year timely filing period is DOS or "From" date on claim.

TIMELY FILING FOR MEDICARE FREE

Physicians with questions are encouraged to contact Anthem Network Relations at a summary of California's unfair payment practices law, see " Know Your Rights: Identify and Report Unfair Payment Practices" More information on timeframes for claim submission can be found in “ Know Your Rights: Timely Filing Limitations” or in CMA health law library document #7511, “ Payment Denials by Managed Care Plans and IPAs.” available free to members on CMA’s Reimbursement Assistance page.As a result of the Patient Protection and Affordable Care Act (PPACA), all claims for services furnished on/after January 1, 2010, must be filed with your Medicare Administrative Contractor (MAC) no later than one calendar year (12 months) from the date of service (DOS) or Medicare will deny the claim. As a reminder, California law states plans must allow a minimum of 180 days from the date of service for receipt of a claim for non-contracted providers. Remember, even if a physician fails to submit a claim on time, California law provides a “good cause” exception that requires payors to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay.Īnthem has clarified that the change does not affect non-contracting physicians. CMA is assessing the issue to determine potential next steps.

While the change in Anthem’s claim submission timeframe meets the minimum timeframe allowed by law for contracting physicians, the California Medical Association (CMA) has received several calls from physicians concerned that the June 21 letter of the material contract change was not sufficient advance notice, given the policy change impacts claims with July dates of service.Īs a result of CMA sponsored unfair payment practices law and the resulting regulations, plans are required to provide a minimum of 45 days prior written notice before instituting any changes or amendments about claim submission requirements.ĬMA raised this concern with Anthem, but the payor believes it provided sufficient advance notice. However, as an example, the notice indicates that the change will impact claims with July dates of service if not submitted within 90 days. Under the new requirement, all claims submitted on or after October 1, 2019, will be subject to the new 90 day filing requirement.

TIMELY FILING FOR MEDICARE PROFESSIONAL

Anthem Blue Cross has notified physicians that it is amending sections of its Prudent Buyer Plan Participating Physician Agreement, significantly reducing the timely filing requirement for commercial and Medicare Advantage claims to 90 days from the date of service.Ĭurrently, Anthem requires physicians to submit all professional claims for commercial and Medicare Advantage plans within 365 days of the date of service.