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

Timely filing limit for BBHHF providers

Timely Filing for BBHHF Providers;

Timely Filing Policy under Charity Care To meet timely filing requirements for the BBHHF Charity Care program, claims must be received within 180 days from the date of service. Claims that are 180 days old must have been billed and received within the 180 day filing limit.

The original electronic claim must have had the following valid information:

• Valid Provider Number

• Valid Member Number

• Valid Date of Service

• Valid Bill Type

Claims that are over 180 days must be submitted on paper with a copy of the original remittance advice showing where the claim was initially received PRIOR TO the 180 day limit. Claims with dates of service over 360 days are NOT eligible for reimbursement. This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over 180 days, the replacement claim must be submitted on paper with a copy of the original remittance advice to:

BBHHF Charity Care Program

Timely Filing

PO Box 2002

Charleston, WV 25327-2002.

You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim, and the dates of service are over 180 days, the claim will be denied for timely filing.

Medicare Primary Claims/Secondary Claims

Timely filing requirement for Medicare primary claims is one year from the EOMB date.

Did you know that secondary claims can be submitted electronically? For more infortion, please call our EDI help desk at 888-483-0793, option 6.

TPL Primary Claims

Timely filing requirement for TPL insurance primary claims is one year from the date of service.

Backdated Medicaid Cards

If a member receives a backdated medical card and the provider wishes to accept it and bill Medicaid for services that occurred over a year ago, the claims must be billed within one year of the issuance of the card. Claims must be billed on paper with a copy of the medical card or letter of eligibility and mailed to Provider Relations address at PO Box 2002, Charleston, WV 25327-2002.

MCO’s and Timely Filing

Molina does not reimburse for any services the provider does not bill timely to the MCO. If the MCO denial is due to the member not being covered under the MCO and the provider determines that the member was covered with WV Medicaid at the time services were rendered, Molina may be responsible. In this case, Molina will accept MCO Medicaid remits as proof of timely filing as long as the date of the denial is not over a year from the date of service.

Please Note: The MCO must be one of the MCO’s that are contracted with WV Medicaid and not an MCO that has a private insurance policy for the member.

Time limit for West Virginia Medicaid and MCO

Timely Filing Policy

To meet timely filing requirements for WV Medicaid, claims must be  received within one year from the date of service.

The year is counted from the date of receipt to the “from date” on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit.

(See exceptions below for Medicare primary claims and backdated medical card.) The original claim must have had the following valid information:

• Valid provider number

• Valid member number

• Valid date of service

• Valid type of bill

Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement.

This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV 25327-2002. You are NOT allowed to add additional services to the replacement claim.

If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing

Healthchoice Medicaid HMO Timely filing limit and claim submission address

BILLING INFORMATION

Providers must bill on the CMS-1500. Claims can be submitted in any quantity and at any time within the filing limitation.

Filing Statutes: Claims must be received within 12 months of the date of service. The following statutes are in addition to the initial claim submission.

12 months from the date of the IMA-81 (Notice of Retro-eligibility)

120 days from the date of the Medicare EOB

60 days from the date of Third Party Liability EOB

60 days from the date of Maryland Medicaid Remittance Advice

The Program will not accept computer-generated reports from the provider’s office as proof of timely filing. The only documentation that will be accepted is a remittance advice, Medicare/Third-party EOB, IMA-81 (letter of retro-eligibility) and/or a returned date stamped claim from the Program.

Paper Claims Submission: Once a claim has been received, it may take 30 business days to process your claim. Invoices are processed on a weekly basis. Payments are issued weekly and mailed to provider’s pay-to address. All claims should be mailed to the following address:

Claims Processing

Department of Health and Mental Hygiene

P.O Box 1935

Baltimore, MD 21203

Electronic Claims Submission: Providers must submit claims in the ANSI ASC X12N 837P format, version 5010A. A signed Submitter Identification Form and Trading Partner Agreement must be submitted, as well as testing before transmitting such claims.

Humana claims , overpayment, appeal address - time limit

Claim and encounter addresses

To decrease administrative costs and improve cash flow, clinicians and facilities are encouraged to use electronic claim submission whenever possible.

When it is necessary to submit paper claims, you can use the addresses below. Please keep in mind, however, that the claim or encounter mailing address on the member’s identification card is always the most appropriate to use.

Valid National Provider Identifiers (NPIs) are required on all electronic claims and strongly encouraged on paper claims.

Paper claim and encounter submission addresses

Humana medical claims:

Humana Claims

P.O. Box 14601

Lexington, KY 40512-4601

HumanaDental® claims:

HumanaDental Claims

P.O. Box 14611

Lexington, KY 40512-4611

Humana encounters:

Humana Claims/Encounters

P.O. Box 14605

Lexington, KY 40512-4605

Claim overpayments:

Humana

P.O. Box 931655

Atlanta, GA 31193-1655

HumanaOne® claim submissions:

HumanaOne

P.O. Box 14635

Lexington, KY 40512-4635

Claims submission time frames

Health care providers are encouraged to take note of the following claims submission time frames:

Medicare Advantage: Claims must be submitted within one calendar year from the date of service.

claim timely filing denial exceptions.

The following scenario, claim will not be denied as timely filing limit exceeded.
Exceptions to the 12-Month Time Limit
Exceptions to the 12-month claim submission time limit may be allowed if the claim meets one or more of the following conditions:

·  New clean claim submitted within six months of the date of the void of the original claim payment date;
·  Court or hearing decision;
·  Delay in recipient eligibility determination;
·  Medicaid delay in updating eligibility file;
·  Court ordered or statutory action; or 

·  System error on a claim that was originally filed within 12 months from the date of service.


Any claim filed more than 12 months from the date of service that meets an exception must be sent to the area Medicaid office for processing, not to the fiscal agent.

Each of these exceptions is discussed below.
Original Payment is Voided
When an original Medicaid claim is voided, the provider may submit a new claim and a written request for assistance to the area Medicaid office no later than six months from the void date.


Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court decision, there is no time limit for the submission of a claim.


Delay in Recipient Eligibility Determination
An exception may be granted when there is a delay in the determination of an individual’s Medicaid eligibility by the Department of Children and Families or the Social Security Administration. The provider must send in specific documentation to the area Medicaid office no later than 12 months from the date the recipient’s eligibility is updated on FMMIS. The claim submission must include:
·  A clean claim,
·  A copy of the recipient’s proof of eligibility, and
·  Documentation of the reason for late submission.

Medicaid Delay in Updating Eligibility File
If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid Management Information System (FMMIS), an exception may be granted. The provider must submit the related clean claims to the area Medicaid office no later than 12 months from the date the recipient’s eligibility file was updated.

Medicaid claim submission time limit - primary and secondary claims

Timely Claim Submission
Medicaid providers should submit claims immediately after providing services so that any problems with a claim can be corrected and the claim resubmittedbefore the filing deadline.

Clean Claim 
In order for a claim to be paid, it must be a clean claim. A clean claim is a Medicaid claim that:
·  Has been accurately and fully completed according to Medicaid billing guidelines.
·  Is accompanied by all necessary documentation.
·  Can be processed and adjudicated by the fiscal agent without obtaining additional information from the provider.


12-Month Filing Limit
A clean claim for services rendered must be received by the Medicaid office or its fiscal agent no later than 12 months from the date of service.

Date Received Determined

The date stamped on the claim by any Medicaid office or by the Medicaid fiscal agent is the recorded date of receipt for a paper claim. The fiscal agent date stamps the claim the date that it is received in the fiscal agent’s mail room.
The date electronically coded on the provider’s electronic transmission by the Medicaid fiscal agent is the recorded date of receipt for an electronic claim.