Insurance claims timely filing limit for all major insurance - TFL Denial - required documents

1) Aetna: 120 days. 90 Days

2) Amerigroup: 180 days.

3) Bcbs: 1yr. 180 days updated.

4) Cigna: 180 days.

5) Humana: 15 months.

6) Greatwest: 1 year.

7) Medicare: 1 - 2 Year.

8) Medicaid: 1 year

9) Rail Road Medicare: 1 year.

10) United Healthcare: 90 days.

11) Universal Healthcare: Depends upon the provider’s contract.

12) Polk Healthcare (Community Healthplan): 180 days.

13) Medicare Complete: 180 days.

14) Ever care: 180 days.

15) Quality Health Plan: 180 days.


Abrazo 180 days 

Arizona BCBS 365 days 

Arizona Physicians IPA 120 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

Health Net 120 days

foundation 1 yr

Tricare 1yr

Pacificare 90 days



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. 

I have listed the some common insurance timely filing limit. If you know some other insurance please use the comments section to help others.

BCBS Timely Filing

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. 

Documentation needed to qualify for timely filing limit exceptions

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 involving state Medicaid agencies
• Retroactive disenrollment from a Medicare Advantage plan or program of all-inclusive care for the elderly (PACE) provider organization

Retroactive Medicare entitlement

• An official letter notifying the beneficiary of Medicare entitlement and the effective date of the entitlement, and
• Documentation describing the service(s) furnished to the beneficiary and the date of the furnished service(s), or
• If an official Social Security Administration (SSA) letter cannot be provided, First Coast Service Options, Inc. (First Coast) will check the Common Working File (CWF) database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify retroactive Medicare entitlement.


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
• Evidence that the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization, and
• The effective date of the disenrollment; and
• Documentation showing the date the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

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:
• Medicare providers must complete the Request for Telephone Claim Override Timeliness Form for Part A, attach the appropriate documentation and a brief explanation of the reason for delayed filing. A limit of one form can be submitted per fax request. Fax the request to 904-361-0693. Click here to access the form pdf file. Note: If any part of the form is not legible, the timely filing limit for your claim(s) will not be overridden.

• 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. 


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.

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


There are always some times when you will fall outside a company’s timely filing deadline. By reviewing your accounts receivable aging report every single month, by ensuring that your review all electronic submission reports (both from your clearinghouse and from the insurance company), and by setting up accounts correctly from the start, you minimize these problems.

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.


In order to be considered timely, the claim must be received by UnitedHealthcare within the timely filing period from the date on the other carrier’s correspondence. If the claim is received after the timely filing period, it will not meet timely filing criteria. 



16 comments:

Anonymous said...

Health Net 120 days
foundation 1 yr
Tricare 1yr
Pacificare 90 days

Anonymous said...

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

Mahesh Rajamani said...

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).

Anonymous said...

BCBS Timely Filing is 180 days, not 365. ~Ben

Anonymous said...

IT IS 1 YR FROM DOS

Anonymous said...

Medicaid Is 95-Days Effective 01/01/2010.

Anonymous said...

BCBS is 180 days for initial clean claim submission - 365 days to submit an appeal.

Anonymous said...

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.

Anonymous said...

Aetna is also now 90 days.

Anonymous said...

Sam Jones sd All of the above is incorrect .... im telling is correct...SU

Anonymous said...

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.

Anonymous said...

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?

Anonymous said...

why timely filing limit is different for each insurance

Sarah Jasson said...

Great information, you have a wonderful blog and an excellent article.
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Anonymous said...

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?

Anonymous said...

Does anyone know timely filing for WC in MAryland?

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