One major problem medical billers encounter is when claims are denied for timely filing because each insurance carrier has its own guidelines for filing claims in a timely fashion.
Some are as short as 30 days and some can be as long as two years. It is important to follow these guidelines or your claims may be denied for timely filing.
Claims are often denied for timely filing when the claim was actually submitted in a timely fashion but not received by the insurance carrier. There are many reasons this can happen, but the important part of the equation is how the biller responds to the denial.
Other times, claims are denied for timely filing when they were not filed within the timely filing period due to initial mistakes.
Reasons for Claim Denials
One reason for a denial is when a claim is initially submitted with incorrect information.
It may be a variety of things such as a typo on the part of the biller, it may be that the patient offered the wrong insurance card at the medical office, or it may be that when the information was transferred from the person who took the info to the person who is doing the medical billing and coding it wasn’t copied correctly. Lots of things can go wrong.
At any rate, it doesn’t necessarily mean you won’t get paid for the services denied for timely filing, but you do need to know how to handle them.
It is best to work out a system for handling claim denials for timely filing and just follow that system every time you encounter this problem.
Handling Timely Filing Claim Denials
For example, you may have submitted a claim in the proper time frame and it was denied for a reason such as incorrect ID#, patient’s name was misspelled, or it was originally sent to the wrong insurance carrier.
Now, you have fixed the problem and resubmitted it with the correct info, but the carrier denies it for timely filing. The denial must be appealed.
Some carriers have special forms you must use, others don’t. Whether you are using their form, or making your own, you should attach a copy of the claim, and your proof of timely filing to that form.
The proof needs to be something that shows when the claim was originally submitted or when and how many times it was resubmitted.
If the claim was submitted electronically then you can print an electronic report showing the original submission. If the claim was denied electronically you may even have that electronic denial, so that you can show what information was incorrect and that the claim was corrected and resubmitted.
If the claim was submitted on paper, your practice management system should provide you with some report showing the original submission date, and if the claim was submitted multiple times it should show each time submitted.
Our system provides a patient ledger which shows the original date billed, the most recent date billed and how many times the claim was submitted in total.
It cannot just be a handwritten note stating, “We submitted the claim on 1/1/2011.” It must be something that was electronically generated.
Reports generated from practice management systems generally cannot be altered and are accepted as proof by most insurance carriers.
Appealing Timely Filing Denials
If your claim was denied for timely filing, and it was not ever submitted in the timeframe allowed, then it is more difficult to appeal. If you have a valid reason for not submitting the claim, you can appeal based on that.
For example, if the patient stated that they didn’t have insurance because they thought that they were not covered at that time but then found out later that they actually were covered, and the claim is then submitted but after the filing deadline, you can try to appeal.
Write up a letter explaining exactly what happened, why the patient didn’t think they were covered, and what made them realize that they were. You’ve got a 50/50 chance, but it’s worth appealing.
Basically, if you feel that you have an explainable and valid reason that the claim was not submitted in time, you can submit an appeal.
If there was any way that the claim could have been submitted in the timeframe, it will most likely be denied. But if you have a valid reason, it will most likely be overturned and allowed.
It is important to file claims as quickly and timely as possible. But there are always things that come up that cause delays and timely filing denials do happen.
If you have good systems in place, you will be able to appeal them quickly and efficiently and most will eventually get paid.
Alice Scott and Michele Redmond are medical billing experts, co-owners of Solutions Medical Billing Inc in Rome, N Y., and coauthors of 14 books on medical billing and medical credentialing. This mother-and-daughter team maintains two medical billing websites, a free newsletter and an active forum. Alice and Michele are on the editorial staff of BC Advantage and are regular contributors to the magazine. Their books are available at www.medicalbillinglive.com