Most insurance carriers have a rule regarding the filing of insurance claims. Some such as Medicare allow up to 365 days from the date of service and others only allow 30 days. Most allow something in between. Many of our local Blue Cross Blue Shield policies allow 120 days. In any case, as the biller it is our job to make sure the claims are filed timely.
In a perfect world this would be no concern. Claims would be filed, in a timely manner and paid on the first submission. But ahhhh……reality. We try our best to submit claims timely but sometimes there are things that just prevent us from doing so. The patient provides us with the wrong insurance information, or their insurance didn’t change but their id number did and they didn’t give you a copy of the new card. Or maybe they weren’t even aware it had changed! There are many other reasons that can cause delay in submission.
All of these reasons, valid as they may be, can cause delays in getting the claim submitted to the insurance carrier. At least they delay the claim in being submitted CORRECTLY. So often we are faced with denials from the insurance carriers that state that they claim was not filed timely. In most of the cases the claim was at least attempted to be filed, but either failed at a clearing house level or was denied for invalid information. It will depend on what the problem is and how the insurance carrier deals with it.
For our local Blue Cross Blue Shield, if you submit a claim with an invalid id number, or an old id number it will deny at the clearinghouse level stating “subscriber not found”. In this case there is actually no claim ever on file with Excellus since they rejected the electronic submission. So if you were to call they would not even know a claim had been submitted.
So how do you deal with these timely filing denials? Up until recently they were not that difficult to appeal. We would simply print out a patient ledger from our practice management system, attach it to the claim with a generic letter we stapled to the front explaining that we were appealing the timely filing denial. The patient ledger showed the first date submitted, the last date submitted and the number of times the claim was submitted. With that simple system 99.9% of our appeals were reprocessed for payment.
In recent months insurance carriers have been cracking down on timely filing denials and requiring more proof. No longer do they accept the patient ledger as proof of the original submissions. Now they are requiring that you not just show the original submission but that you show what was done in between.
For example, if we submitted a Blue Cross Blue Shield claim with an invalid ID number and then by the time we corrected the id number the claim was past the filing limit. The correct version of the claim is now denied for timely filing. In addition to the patient ledger we also have to submit an insurance aging report that shows not only the first and last submission but actually shows each and every date the claim was submitted. In addition to that, we have to state if the claim was submitted electronically or on paper. If electronically, then we have to include clearinghouse submission reports showing what happened to each claim that was submitted. Was the claim rejected? Did we have ample time to correct the mistake?
Most insurance carriers not only have rules about the time frame a claim must be submitted but also how much time you have to act if a claim is rejected. For example, if you receive an electronic rejection stating subscriber ID invalid, you may only have 120 days from the date of that rejection to take action. So if you get a rejection and then you contact the patient for the correct information, if they do not get back to you quickly you may not be able to appeal the denial.
If the claim was submitted on paper you may have to include a written explanation of all steps that took place involving the claim. For example, you might indicate that the claim was submitted on January 5th on paper and you received a denial on February 8th stating “patient not covered under policy”. So you send the patient a bill asking them for the correct insurance information. Maybe the patient is in Florida for the winter and they don’t respond to you until April. You would need to write up an explanation to submit with your proof of the original submission. You would also want to include a copy of the original denial.
The point is that insurance carriers are getting tougher with their timely filing guidelines. The best option is to get all claims in timely. But for those few that you just can’t seem to avoid, make sure you clearly show your proof with all evidence that you have available. Otherwise most likely they will uphold the denial of timely filing.