Timely Filing for Claims and Appeals | Medical Billing Tips

As I said before, this is a question that
comes up all the time in coding, billing and the practice management courses that I work
with, so I just thought I’d go over it one more time for students that had never heard
me talk about it before. Q: “Please explain filing limits with insurance
claim processing” for the initial claim as well as the appeal process. A: Basically, we’ll be covering information
about how all insurance companies do enforce filing limits for both initial claim submission,
as well as for appealing claims. So, you really need to know your payer filing
limits and create a cheat sheet for your demographic area. When filing or appealing a claim, you want
to be absolutely sure that you get those claims in early because there were always technical
problems or if you’re using snail mail, things get lost in the mail. It happens more often than not, so if a doctor
gives you a charge today and expects you to transmit it tonight and thinks it’s going
to be OK because the cutoff is tomorrow, I can bet you that it didn’t go through for
some reason. There’s always a delay and the insurance
companies do look for specific proof of when they received it in order for you to get paid. You want to pay also attention to notifications
of changes regarding time constraints. For years, we were dealing with a year and
a half with Medicare and then they changed to one year submission, so pay attention to
any of your payer’s notifications because they will send them to you via email if you
sign up on their website. Lastly, when you do your aging, the follow-up
– I can’t say it enough, just pay attention to your follow-up because you can see trends
there, as far as claims not being paid and you can see “Gee, if this whole bunch didn’t
get paid, there might be a problem,” and so forth. Filing limit – I can’t stress enough. Below (on the answer sheet) is an example
of how this particular payer, which is TRICARE, allows 90 days from the date of service to
bill out claim but the biller really has to know all the filing rules! In this particular case, we see at the top
that the date of the notice when the doctor got paid was May 15, 2006 and below where
the other red arrow is, it shows date of service is April 08, 2006, and it was paid; so it
clearly is showing me that the biller had the work and transmitted it right away and
TRICARE paid it. What I do want to point out is that for any
reason this claim is denied or there was any type of issue with it, if you were appealing
to TRICARE, you would have 90 days to appeal from the date that the explanation of benefit
was dated; so you’re not going to go 90 days from the date of service but from the
actual notice or EOB. So, the May 15 th , you would tap on 90 days,
and if it’s a secondary insurance, it might be 60 days, it could be a year, and whatever
it is, you have that amount of time from the date of the original either payment or denial
of an EOB. What I did just so that you all understand
is that Google is a wonderful thing, and I just wanted to point out that when you know,
when you’re working for a practice, what payers are dealing with, whether it’s California
or Massachusetts, go into those payer websites. This example was TRICARE because I showed
you that Explanation of Benefits, I just happened to find these guidelines and they were current. It basically said that: TRICARE network providers
must file all claims within 90 days of the date of service. Where TRICARE is the secondary payer, the
90 days will begin after the first initial claim paid. If Medicare was primary and they paid today’s
date, you would have 90 days from today’s date to bill out TRICARE. If TRICARE denied you would have 90 days from
this denial to appeal. Also, non-network providers may file claims
up to one year after the date of service. That really is up to the biller to find out
because a lot of doctors that are in networks of particular payers, they are usually affiliated
with hospitals that are either involved in the network or not. Only you will know best and that’s why I
really stress you have to check it out. Another example here just to show you very
quickly is the Basic Claims Processing Times and the different guidelines with TRICARE. Most clean claims will process within 30 days
and generally, if a clean claim goes over the 30 days, they will pay you interest. That’s pretty standard with most insurances. Then they give you the criteria for clean
claims: complying with the billing guidelines and requirements. Having no defects or improprieties on a claim,
including documentation if it’s applicable, and also do not require a special processing
that would prevent timely payment. If you have any problems with your EOBs, whether
you don’t think they paid enough or anything, TRICARE gives you a website that you can register
on and you get a username and password and you can access all your doctor’s information,
or you can call voice recognition and call a number and speak to someone. That’s just telling you a little bit more
about how to process a claim. Next page, what I did is just showed you an
example. There are multiple contractors that process
Medicare claims. In my area and another areas in the United
States, NGS is one of the contractors. What I wanted to do is just show you that
not only do they give you information about where you have to file how many days you have,
but if you look here, it gives you all the information on how to appeal a claim and if
you look to the left it will say: Who May File An Appeal, Levels of Appeals and Time
Limits for Filing, and it even explains Reopening and Redetermination. Reopening is very basic, you messed up on
a diagnosis code, you forgot a modifier, something very basic. Redetermination – you may feel that obstetrical
procedure that’s not typically bundled into another procedure, should have been paid or
something, and it gives you all the guidelines. If you look to the right of this, you’ll
see this in Appeals Timeliness Calculator, which I’ll show you next, as well as appeal
forms. That is with any Medicare website and pretty
much every other insurance company, it may look different but the information is the
same. The next page has to do with just basically
the appeals calculator. Again, I won’t go into big detail, but you
have your option of picking if it’s a reopening, redetermination, and it tells you the amount
of days that you have to appeal, like, 120 days or whatever. Again, all your carriers will give you this
information. This is just an example of what’s available
on the websites. The next one is just a very simple explanation
of what a redetermination is, and it’s just giving you the filing limits again, how many
days, time limit to initiate a redetermination, you have 120 days from the date of receipt
of the initial determination, which is the EOB. Once they come up with the determination,
you are not happy with it, you have 60 days to apply again, and it just gives you more
information. It also tells you, a little bit below on this
page, that you just submit your redeterminations online but you can do them on mail. The next page, you’ll actually see a copy
of a form just as an example. I won’t go through it, but it’s basically
the beneficiary’s name, ID number, the reason why you are appealing, and so forth. Laureen: Jo-Anne, Tamika had a question, she
said: “Does timely filing policies apply even if you’re not contracted with the payer?” Jo-Anne: Yes, they do. And I’ve had first-hand experience with
that, so yes. Laureen: Then another related question: “Do
coders or billers process claims?” Jo-Anne: It really depends. In my billing service, all the billers always
coded or make sure the coding was appropriate and then they bill it out. When you’re in a big practice management
within a hospital setting usually all roles are broken down, so a coder would actually
be coding, but the biller they’ll have one that registers, one that does keypunching,
one that does coding, one that does payment posting, and one that does problem resolution. My mindset is I like to do it all because
oftentimes the left hand doesn’t know what the right hand is doing, and I like to have
control when I used to bill all the time, of knowing when my claims went out, that I
was responsible to leave notes against the patient’s account. But typically, the coders don’t have anything
to do with the appeals process unless there’s an issue with the code that the biller may
approach the coder. But that’s why a lot of billers are already
coders because you will find out fast enough that you have to understand coding to a certain
extent in order to understand why some of the claims are denied. Laureen: Then we had one more, Charity wants
to know: “If Medicare does not pay a clean claim within 30-46 days, what would you suggest
doing at that point to get them to pay the interest?” Jo-Anne: I’ve never run into a time where
they haven’t paid the interest, but sometimes depending, like, when we went through ICD-10,
major changes where we anticipated and they tell us ahead of time that there will be delays,
I’m not sure if we’ve seen interest on that. But a typical delay in payment I’ve always
seen the interest given to the doctor, but again if they haven’t been paid, first of
all, you want to make absolutely sure that they’re even in the system and so you can
check online one or two just to make they’re there, because if they’re not there and
you have a whole list of Medicare claims sitting there, then something may have happened between
your office and the clearing house, or the clearing house and the payer, and that’s
where I really stress to follow-up and staying on top of your work because the filing limits
really do come into play and they’re not as lenient as they were even a year ago. They’re so strict, so you want to make sure
that you understand. The next slide is a cheat sheet and whatever
you do, do not go by my numbers, this is strictly an example, but this is what my staff always
had and I used to have in a day. I would list all my key insurance companies
(Medicare, BlueCross BlueShield, HMO, PPO, Medicare Advantage, one of their plans, Tufts
Medicare Preferred). As you can see, the initial claims vary. At one point, BlueCross BlueShield, HMOs we
only had 90 days, but their PPOs and indemnities we had a year. Now, everything is 90 days. And, their appeals vary from 90 days to 120
days, 180 days. You really have to go into the insurance companies
that your providers are contracted with. If you have any plans, and I know in Massachusetts
we have a few, that a 60 days you stay on those because by the time you get it and it’s
transmitted and you get your EOB back, if you get it back, you don’t have a whole
lot of time to play there; so those 60 days, make those a priority. Allow Time for Technical Problems When Filing You just want to allow time for technical
problems. I would never submit a claim 1-5 days prior
to the filing limit. Clearinghouses and payers have maintenance
downtimes when no work can be transmitted. Databases crash, whether it’s the software,
the clearinghouses, or the insurance companies. Regardless of when you transmit, payers consider
when the claim was received. It does not matter if you sent it one day
before; if there was a delay – trust me, there’s plenty of them. Things get lost in cyberspace so there’re
problems; claims will be delivered late and they will deny it for over the filing limit. Billers oftentimes can appeal, but like I
said, it’s very rare that they pay. If the insurance doesn’t have an electronic
acknowledgement saying that they have that claim, they don’t usually work with you. As far as problems where your claim is denied
and you have to file, you have to first ask yourself: Was it the front desk? Was it the patient’s fault? If the patient gave the information but the
front desk was negligent, then the practice is liable if we didn’t get the information
on time, so you can’t bill the patient. But if the patient came in and did not give
updated information and billing companies, office will call the patient, will try to
get the office to call the patient, and they finally get around to calling you four months
after four bills have gone out, they’re liable. Again, your office should develop a protocol
and stick to it for all your filing limit scenarios because front desk sometimes does
not update their files by the time the biller gets the work, and that’s a bad practice
to get into. And follow-up on claims is IMPERATIVE. Problems will jump out when you examine the
dates of the outstanding claims. A lot of times you’ll see that the transmissions,
even though they said they were sent weren’t, so that will keep you in line as well. That will keep you in line as well. In summary, just know your clean claim submission
filing limits, as well as the filing limits for your claim appeals. Use designated payer forms, phone calls or
online access to appeal claims. Definitely use a cheat sheet for the initial
and appeal file limits. Allow time for technical problems and delays
and file clean and appealed claims ASAP. Don’t let them sit there. And, monitor your ageing to see if any claims
are old- do not allow this to occur after the filing limit because it’s really tough
to get that money. And if your billing [or coded] for a surgeon,
it’s not $50, you may be talking $2500 and they won’t be happy with you. And that’s it! Laureen: Very good. I really like the graphics and showing those
examples. One thing I wanted to clarify that came up
because we do have a lot of newbies on the call, to do coding, you don’t have to do
billing and vice versa. They do complement each other, coding is a
part of billing; but we don’t normally do a lot of billing topics but we’re starting
to because we have a lot more billing students than we ever had and a lot of people want
to have multiple skills and even though they might not actually do billing as part of their
job. They want to understand all of the pieces
because it makes them a more valuable employee. Some people do coding with auditing or coding
and they get into risk adjustment, so there are multiple things that you can do in this
industry. And because this call is kind of a hodgepodge
of everything, we try and answer questions in all different areas, so for those who are
currently taking our coding course and are freaking out thinking now they got to do billing,
no you don’t have to. You can, if you want to have multiple certifications,
they do complement each other, and it’s neat to know when you code things and off
it goes to get paid, all the work that has to be done on the end of that. You’re doing the coding upfront, but then
billing has to take over and get it processed and post the payments and all that fun stuff.

1 thought on “Timely Filing for Claims and Appeals | Medical Billing Tips

  1. Nice explaination….Could you please explain what is difference between first leval fo appeal and second leval of appeal?

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