Avoid Untimely Claim Denials
To avoid receiving an untimely claim denial for services rendered from October 1, 2008 through December 31, 2009, Highmark Medicare Services must receive these claims prior to 4:00 PM Eastern Standard Time (EST) on Thursday, December 30, 2010. Once received electronically, they must also be accepted on the initial acknowledgement report and the next day edit report. Our business office will be closed on Friday, December 31, 2010, in observance of the New Year’s Day holiday.
Therefore, any electronic claims that are received and accepted by Highmark Medicare Services after 4:00 PM EST on Thursday, December 30, 2010, will not be considered received until our next business day of Monday, January 3, 2011, due to our standard system operating hours. We recommend you submit these claims at least 2-3 business days prior to December 30, 2010, to allow time for potential report error resolutions and claim resubmissions.
All claims for services furnished on January 1, 2010 and after, must be filed with Highmark Medicare Services no later than one calendar year (12 months) from the date of service or the claim will be denied as being past the timely filing deadline. Please remember the holiday at the end of the year and the first of the year and submit your claims before one year from the date of service for timely processing.
For more information, please refer to Medicare Learning Network (MLN) Matters Articles MM6960 and MM7080.
Appeal sample letter - Timely filing denial : [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.
If you have any questions, you are welcome to contact me directly at (123) 456-7890.
Sincerely,
Timely Filing denial - Delaware Physicians Care insurance
It is the responsibility of the provider to maintain their account receivables records, and we recommend providers perform reviews and follow up of their account receivables on at least a monthly basis to determine outstanding Delaware Physicians Care, Incorporated (DPCI) claims.
DPCI will not be responsible for claims that were not received and the date of service exceeds the timely filing limit of one hundred twenty days (120) from the date of service.
Recognizing that providers may encounter timely filing claim denials from time to time, we maintain a process to coordinate review of all disputed timely filing claim denials brought to our attention by providers.
DPCI criteria to initiate a review to override timely filing:
Electronic submission
Electronic claim submission (EDI) reports are available from each provider’s claims clearinghouse after each EDI submission. These reports detail the claims that were sent to DPCI and received by DPCI. Provider must submit hard copy or electronic copy of the acceptance report from the provider’s clearinghouse that indicates the claim was accepted by DPCI within the 120-day timely filing limit to override timely filing denial and pay the claim.
Please confirm that the claim did not appear on your rejection report. If DPCI determines the original claim submission was rejected, the claim denial will be upheld and communicated in writing to the provider.
Paper submission
Provider must submit a screen print from the provider’s billing system or database with documentation that shows the claim was generated and submitted to DPCI within the 120-day timely filing limit.
Documentation should include:
The system printout that indicates somewhere on the printout:
· That the claim was submitted to DPCI
· Name and ID number of the DPCI member
· Date of service
· Date the claim was filed to DPCI
· A copy of the original CMS-1500 or UB-04 claim form that shows the original date of submission
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