Monday, June 7, 2010

Insurance denial for timely filing - CO 29

Timely Filing Denial and Solution -Denial Code -CO 29 The time limit for filing has expired.

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 other insurance like UHC, Aetna, 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 consumer relations to make the patient pay for your office’s failure to submit the claim.

Reason for Denial and checking process

Claim Submission Window Exceeded  

Verify the DOS which has been billed

Check whether it has been billed within TFL period (One year from DOS)

If DOS has been wrong, resubmit with correct DOS

If the claim has been submitted within the TFL period, call customer care and request for Reopening 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.

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

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.  

0308  Your payment request was filed past the filing time limit without acceptable documentation

Virginia Medicaid is mandated by federal regulations to require the initial submission of all claims (including accident cases) within 12 months from the date of service. Medicaid is not authorized to make payment on claims submitted after the 12 month timely filing limit

0026  Covered Days Missing or Invalid

UB 04 – Value code 80, enter the number of covered days for inpatient hospitalization or the number of days for re-occurring out-patient claims. The format for value code is digit: do not format the number of covered or non-covered days as dollar and cents.

0734  Covered Days Entered is greater than the Statement Period

The covered days entered cannot exceed the difference between the from and thru dates.

Claim Filing With Wrong Plan

If you file a claim with the wrong insurance carrier and provide documentation verifying the initial timely claims filing within 95 days of the date of the other carrier’s denial letter or RA form, BCBSTX processes your claim without denying it for failure to file within filing time limits.

Acceptable Proof of Timely Filing

Acceptable proof of timely filing includes, but is not limited to any one item or combination of:

* EOB issued by Molina Healthcare;
* Practitioner/provider statements/ledgers indicating the original submission date as well as all follow-up attempts;
* Dated copy of Molina Healthcare correspondence referencing the claim (correspondence must be specific to the referenced claim);
* Other carrier’s EOB when Molina Healthcare is the secondary payor (one [1] year from the date of service);
* Other carrier’s EOB when submitted to the wrong carrier (ninety [90] days); and
* Documentation of inquiries (calls or correspondence) made to Molina Healthcare for follow-up that can be verified by Molina Healthcare.

Submitting COB Claims

When submitting claims for Members for which Molina Healthcare is not the primary insurance, you must attach a copy of the primary payor’s EOB with the exception of home services billed by Early, Periodic Screening, and Diagnostic Treatment (EPSDT) providers for waiver children. The primary payor’s EOB must match the submitted claim, and include descriptions of all associated remit messages so that Molina Healthcare may appropriately consider the charges.

Key to EOB Messages

Explanation of benefits (EOB) is defined on the EOB document sent with claims (i.e. payments, adjustments, denials, etc). Please call Member Services if additional information is needed. The EOB is a single document with pages clearly and consecutively numbered.

The EOB includes:

* The check, if applicable, is printed on the lower third of the first page;

* All settled claims within the Remittance Advice (RA) run cycle appear in alphabetical order first by rendering practitioner/provider, then by patient last name, first name, and middle initial. If there are multiple claims for the same patient, they are presented in the order they were processed;

* Reason codes are conveniently displayed at the charge line or summarized at the end of the remittance advice or directly below the explanation of payment for the specified claim; and
* Each claim has a heading, which includes the practitioner/provider internal patient account number (control number). 

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

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.

Timely Filing Reminders

Following these reminders can reduce the number of denied claims:
• Claims with dates of service over the filing limit must be submitted on paper with proof of timely filing to:
PO Box 2002, Charleston WV 25327-2002.
• Reversal/Replacement and claims with dates of service over the filing limit should also be sent to:
PO Box 2002, Charleston WV 25327-2002.
• It is not necessary to submit all remittance advices related to a claim. Only one remittance advice that
documents proof of filing is required.


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