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Tuesday, May 25, 2010

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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