Monday, June 7, 2010

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.


Your Name

Timely filing Claims Guidelines

Timely filing within 180 days of date of service. Reconsidered claims within 90 days of timely filing adjudication.

Claims for covered service must be filed within 12 months from the through/ending dates of service.

Claims filed within the first 12 months and denied can be resubmitted with the original transaction control number (TCN).

**Claims over 12 months can be processed if the beneficiary’s Medicaid has  been retroactively approved by DOM or Social Security Administration.

**The 12 month filing limit for newly enrolled provider begins with the date  of issuance of the provider’s Welcome Letter.

**Medicare crossover claims for co-insurance and/or deductible must be filed with  the Division of Medicaid within 180 days of the Medicare paid date. This is  also applicable to Medicare Part C claims.

NOTE: Claims filed after the 180 day limit will be denied.

**Crossover claims over 180 days old can be processed if the beneficiary’s Medicaid  eligibility is retroactive. Paper crossovers must be filed within 180 days of the Medicaid retroactive eligibility determination date.

Timely Filing

• MississippiCAN: Effective July 1, 2014, claims must be filed within six months from the date of service.

• Mississippi CHIP: Effective Jan. 1, 2015, claims must be filed within six months from the date of service.

• All claims for Magnolia Health for the MississippiCAN and Mississippi CHIP products must be filed within 180 days from the date of service (DOS)

• Options are available to file claims electronically through a clearinghouse, the Magnolia secure portal, or via paper submission

• All claims must be completed in accordance with accepted billing guidelines

• All member and provider information must be complete and accurate

Updated Timely Filing Policy

The following is important information regarding recent New York State Managed Care regulations.

Effective April 1, 2010, New York State Managed Care regulations stipulate that health care claims must be submitted by health care providers within 120 days of the date of service. If a health care provider demonstrates that an untimely claim submission was the result of an unusual occurrence and the provider has a history of timely claim submissions, HealthNow New York is required to reconsider the denied payment. We understand that every provider office has occasional claims (with total charges under $5,000) that are not submitted in a timely manner due to system errors, delivery problems, incorrect member data, etc., therefore, HealthNow has adopted the following policy.

Provider Service may override and adjust these claims to pay if the following documentation is submitted to verify attempt of timely submission:

• Legitimate/non-altered provider computer printouts.
• A copy of the provider’s electronic acceptance report supporting that the claim was submitted in a timely manner.
• Clearinghouse edit.
• Documentation from the EDI help desk.
• CMS 1500/UB92/04 form showing the date of submission in lower left field or at top of claim form is timely; this must be a non-altered date. We also understand the difficulty a provider encounters obtaining correct insurance information once the patient leaves the office, therefore, a copy of an EOB/remittance showing timely submission to another insurance plan, including Medicare, will be considered proof of timely filing, regardless of when the initial denial from the other carrier was received.

If the Provider Service Department is unable to determine if a timely filing override is warranted, or if the total charges on the claim(s) are over $5,000, the case will be referred to the Provider Relations Department.

Provider Relations will determine whether the documentation supplied by the provider is acceptable proof of timely filing, or if the situation represents a true unusual occurrence. The following reasons constitute an unusual occurrence:

• Billing system/software malfunction

• Billing personnel/billing company problem (e.g., employees or billing company not filing claims appropriately)

• Problems encountered obtaining medical records and/or patient information from another practice or facility needed for claim submission Anything other than the situations listed will be considered on a case-by-case basis.

A timely filing override based on the criteria listed will be granted for each provider/provider group once every 2 years. Additional “unusual occurrences” within the rolling 2-year period that result in claim submission delays will be considered on a case-by-case basis. Claims will be adjusted to pay without interest.

If the provider/provider group notifies HealthNow prior to implementing a system upgrade, billing staff/billing service change, or any other change that could result in claim filing delays, any related late claim submissions will be approved for payment (without interest) and will not count against the “once every 2 years” unusual occurrence limit.

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