Document accepted as proof of TFL

Filing Deadline

Filing Deadline Policy

Tufts Health Plan follows the guidelines described in the Tufts Health Plan Claims Submission Policy. For professional or outpatient services, Tufts Health Plan must receive claims within 60 days from the date of service for Tufts Medicare Preferred HMO claims. 

For inpatient or institutional services, Tufts Health Plan must receive claims within 60 days from the date of hospital discharge. When a member has multiple insurance plans, the filing deadline for claims submission is 60 days from the date of the primary insurer’s explanation of benefits (EOB).

Filing Deadline Adjustments

To be considered for review, requests for review and adjustment for a claim received over the filing deadline must be submitted within 90 days of the SOA date on which the claim originally denied. Disputes received after 90 days will not be considered.

If the initial claim submission is after the filing deadline and the circumstances for the late submission are beyond the provider’s control, the provider may submit a payment dispute for reconsideration by sending a letter documenting the reason(s) why the claim could not be submitted within the contracted filing deadline and any supporting documentation.

Documented proof of timely submission must be submitted with any request for review and payment of a claim previously denied due to the filing deadline. A completed Provider Request for Claim Review Form must also be sent with the request.

For paper claim submissions, the following are considered acceptable proof of timely submission:

** Copy of patient ledger that shows the date the claim was submitted to Tufts Health Plan.

** Copy of EOB from the primary insurer that shows timely submission from the date that carrier processed the claim.

** Copy of EOB as proof that the member or another carrier had been billed, if the member did not identify him/herself as a Tufts Medicare Preferred HMO member at the time of service.

For EDI claim submissions, the following are considered acceptable proof of timely submission:

** For claims submitted though a clearinghouse or MD On-Line, a copy of the transmission report and rejection report showing that the claim did not reject at the clearinghouse or at Tufts Health Plan (two separate reports).

** For claims submitted directly to Tufts Health Plan, the corresponding report showing that the claim did not reject at Tufts Health Plan

** Copy of EOB from the primary insurer that shows timely submission from the date that carrier processed the claim

** Copy of EOB as proof that the member or another carrier had been billed, if the member did not identify him/herself as a Tufts Medicare Preferred HMO member at the time of service

The following are not considered to be valid proof of timely submission:

** Copy of original claim form

** Copy of transmission report without matching rejection/error reports (EDI)

** Verbal requests

Requests for filing deadline adjustments for Tufts Medicare Preferred HMO claims should be sent to the following address:

Tufts Medicare Preferred HMO Provider Payment Disputes P.O. Box 9162 Watertown, MA 02471-9162

Can we appeal while using GA modifier -Medicare

ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item.

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item.

Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.

Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

Medicare new patient claim edit and how to appeal on denial ?

Medicare E/M claims for new patients

As previously announced with MM8165, Medicare implemented a common working file system edit to  identify claims where more than one new patient visit was billed for the same patient within three years.  Medicare guidelines only allow one new patient visit by the same provider or different providers in the same group with the same specialty, within a three year period.

In addition to this new edit, the common working file has established an additional edit which identifies claims where an established patient visit was billed in advance of a new patient visit within a three year period.  This edit fails when the rendering provider on the claim with the established patient visit is the same as the rendering provider on the claim with the initial patient visit.  As a result of these new edits, you may begin to see services deny on the original claim submission or you may receive an overpayment request.

If you receive this denial on a new patient visit (not an overpayment request) and you determine that the procedure code should have been filed as an established visit, you can simply call the interactive voice response (IVR) system and request a reopening. Additional IVR reopening information can be found by clicking here. If you do not want to use the IVR for this, you have the option of submitting a new claim or writing in for a reopening.

Note:  Submitting a new claim for the revised established E/M visit will not result in a duplicate denial since the original visit code was not paid.CMS has mandated that contractors request overpayments on any claims that were previously paid when either:

An established patient visit was billed prior to an iitial visit within a three year period by the same rendering provider; or

More than one new patient visit was billed within a three-year period by the same provider or different providers in the same group with the same specialty.

Submission of Formal Grievances and Appeals: to simply health care insurance

Providers are encouraged to first communicate any concerns or dissatisfaction about an SHP process or decision verbally through the Provider Relations telephone lines at 1-800-887-6888 ext. 6005 Monday through Friday between 8 AM and 7 PM EST, excluding state holidays. After hours, an electronic voice messaging system will record provider complaints.

1. All SHP providers have the right to submit a formal written appeal to SHP:

* within 45 calendar days from the denial disposition on a referral/authorizations/grievance

adverse determination;

* within 365 calendar days from the date of service for a claim adverse decision

2. A provider’s written grievance and/or appeal must be forwarded to the SHP Provider Appeals

Coordinator at the following address:

Simply Healthcare Plans, Inc.

1701 Ponce De Leon Blvd, Suite 300

Coral Gables, Fl 33134-4414

Toll Free Number: 1-800-213-1133

Attn: Provider Appeals Coordinator

3. Provider grievances and appeals are handled by the Provider Appeals Coordinator and are reviewed with the corresponding and designated department head.

4. All provider complaints are investigated using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Plan’s written policies and procedures.

5. SHP’s Director of Provider Relations, and the Chief Operating Officer and/or Chief Medical  Officer if appropriate, are involved in the provider complaint process, and have authority to require corrective action plans.

6. Upon the receipt of the provider grievance/appeal letter, a provider grievance acknowledgement letter will be forwarded to the provider within five (5) working days from the receipt of the document.

7. A resolution to the provider’s appeal will be rendered and communicated to the provider in writing within a sixty (60)-day period from the receipt of the provider appeal or grievance. The letter will include information on filing a Level II appeal, should the provider not be satisfied with the decision.

8. Grievance extensions: If the review of the grievance (excluding appeals) involves the collection of

information outside the service area or from a non-participating provider, an additional 30 days extension is allowed, with prior notification to the provider.

9. The time limitations requiring completion of the grievance review shall be tolled after SHP has notified the provider in writing that additional information is required. Upon the receipt of the additional information required, the time frame for completion of the grievance process shall resume.

10. For appeals/grievances requiring a re-review of clinical records, a Medical Director or consultant other than the one who made the initial review will process the appeal and corresponding documents and render a determination.

Tips for Filing Inquiries, Corrected Claims and Provider Appeals from BCBS

Inquiries

When submitting an inquiry regarding corrected claims, questions about late charges, medical records or other situations, remember to complete the Provider Claim Inquiry Form and attach it to your claim. You should use this form for claims that denied with reason code CADEV (contest/additional information) and INFNR (claim denied, requested information not received or incomplete.) Please do not submit these denials with a Provider Appeal form.

A corrected claim is a claim that has already been processed, whether paid or denied, and is resubmitted with additional charges, different procedure or diagnosis codes or any information that would change the way the claim originally processed.

For a copy of the Provider Claim Inquiry Form Click Here, or visit our website at www.floridablue.com, select the Providers tab, then Tools & Resources.

Filing Corrected Claims

When submitting a corrected claim, follow these steps:

• Submit a copy of the remittance advice with the correction clearly noted.

• If necessary, attach requested documentation (e.g., nurses’ notes, pathology report) along with the copy of the remittance advice. To ensure documents are readable, do not send colored paper or double-sided copies.

• Boldly and clearly mark the claim as “Corrected Claim.” Failure to mark your claim appropriately may result in rejection as a duplicate.

• Attach the completed Provider Claim Inquiry Form with your corrected claim.

• If a modifier 25 or 59 is being appended to a procedure code that was on the original claim, do not submit as a "Corrected Claim." Instead, submit as a coding and payment rule appeal with the completed Provider Appeal Form and supporting medical documentation (e.g., operative report, physician orders, history and physical).

Who can appeal against insurance denial claims

Proper Appealing Parties

•     The TRICARE beneficiary (including minors)

•     The non-network participating (accepts  assignment) provider of services

•     A non-network participating (accepts assignment) provider appealing a readmission/preprocedure denial (when services have not been rendered)

•     A provider who has been denied approval as a TRICARE-authorized provider or who has been terminated, excluded, suspended, or otherwise sanctioned

•     A person who has been appointed in writing by the beneficiary to represent them in the appeal

•     An attorney filing on behalf of a beneficiary

Adverse Determination External Review Process

 The Adverse Determination External Review process will provide for an Independent Review Organization (IRO), to resolve disputes with physicians and physician groups arising from BCBSF’s determination that certain services provided to BCBSF’s members are not covered services because they are not medically necessary, experimental or investigational in nature, supportive of an experimental or investigational procedure, or supportive of a not medically necessary procedure (“Adverse Determination Disputes”). The external review process is only available if BCBSF makes the Adverse Determination and administers its Plan Member appeals and/or external review process. Additionally, the Adverse Determination External Review Process is only available if BCBSF upholds its initial Adverse Determination through the internal Post-Service Appeals process and the cost of the service at issue exceeds the threshold amount, if any, the BCBSF’s Plan member would need to satisfy in order to seek external review under the terms of the applicable health benefit plan. 

Pre service and post service Adverse Determination Appeals

 Adverse Determination Appeals

A provider may file a written request with BCBSF for reconsideration of a denial of payment because a proposed, or actual, health care service or supply was not medically necessary, was experimental or investigational, was supportive of an experimental or investigational, or was supportive of a not medically

necessary procedure (“Adverse Determination Appeal”). An Adverse Determination Appeal can be of pre-service claims or a post-service claim if the requirements outlined below are met. An Adverse Determination appeal must be in writing and is not triggered by claim status requests or telephone inquiries regarding the application of benefits or allowed amount.

Pre-Service Adverse Determination Appeals

A physician (i.e., Medical Doctor or Doctor of Osteopathy) or physician group can appeal a pre-service

Adverse Determination (Pre-Service Appeals), if they are appealing on behalf of a BCBSF member. Except for urgent Pre-Service Appeals, authorization must be obtained from the BCBSF member in writing. Pre-Service appeals will be handled by BCBSF under the appeal process available to its member based on the terms of that member’s contract or policy and the applicable state and federal laws and regulations.

Utilization Management Appeals - bcbs

A Utilization Management (UM) Appeal is defined as a written request from a provider to review a claim that required an authorization or precertification affecting a claim’s payment. This does not include provider appeals of pre-service determinations (unless required under ERISA), claims status requests, telephone inquiries or post-service claims review regarding the application of benefits or allowed amounts.

UM appeals must be filed pursuant to the timeliness requirements of the applicable Agreement with BCBSF or within five years from payment date. BCBSF will not overturn administrative claim denials based on the provider’s failure to comply with required procedures and time frames. UM appeals should be sent to the address below with the following information:

• The completed Provider Appeal Form (available at www.bcbsfl.com).

• A copy of the remittance advice.

• The necessary medical documentation (e.g., operative report, physician orders, etc.) as indicated by the reason for the reduction or the denial on the remittance advice.

Billing Dispute External Review Process

The Billing Dispute External Review Process (BDERP) will provide for a Billing Dispute External Reviewer

(BDER), to resolve disputes with physicians and physician groups arising from covered services provided

to BCBSF’s members by such physicians and/or physician groups concerning:

• For Coding and Payment Rule appeals finally adjudicated on or after August 21, 2008, BCBSF’s application of BCBSF’s coding and payment rules and methodologies for covered fee for service

claims (including any bundling, downcoding, application of a CPT modifier, and/or other reassignment of a code by BCBSF) to patient specific factual situations, including without limitation the appropriate  payment when two or more CPT codes are billed together, or whether a payment enhancing modifier is appropriate. All such Billing Disputes must be submitted to the BDER no more than 90 calendar days after a physician or physician group exhausts the internal appeal process, except the parties have agreed that for appeals finally adjudicated after August 21, 2008 and before November 21, 2008, the date the BDERP will start accepting claims, the physicians and physician groups will have until December 20, 2008 to submit their eligible billing disputes. For calculation purposes, the start date will be the date on the appeal letter and the ending date will be when a Billing Dispute is received by the BDER.

BCBS Coding and Payment Rule Appeals

Coding and Payment Rule Appeals

A Coding and Payment Rule Appeal is a written request from a licensed health care practitioner for

reconsideration of a health care claim based on BCBSF’s application of its coding and payment rules and

methodologies (including without limitation any bundling, downcoding, application of a CPT modifier,

and/or other reassignment of a code by BCBSF). These appeals apply to claims filed by M.D.s and D.O.s

in connection with health care services rendered to a specific individual covered under a policy or plan

insured or administered by BCBSF. A Coding and Payment Rule Appeal does not refer to pre-service

review, concurrent review, claim status requests, and other types of provider communication, such as

telephone inquiries.

Claims processed after the implementation date, regardless of service date(s), will process according to

the updated version. No retrospective claim payment changes are made for processing changes that are

the result of new code editing rules.

When provider can appeal and four type of appeal

Provider Appeals

Providers may request reconsideration of how a claim processed, paid or denied. These requests are

referred to as appeals.

There are four different types of appeals:

• Coding and Payment Rule Appeals

• Utilization Management Appeals

• Adverse Determination Appeals

• All Others