Timely filing:
NON-CONTRACTED PROVIDERS:
Initial Claim: 12 months from the date of service.
Corrected Claim: 12 months from the date of service.
Initial Claim: 12 months from the date of service.
Corrected Claim: 12 months from the date of service.
CONTRACTED PROVIDERS:
Initial Claim:6 months from date of service.
Corrected Claim:12 months from the date of service.
Initial Claim:6 months from date of service.
Corrected Claim:12 months from the date of service.
| Timeliness | NON-CONTRACTED | CONTRACTED |
| Claim Submissions | 12 Months from the DOS | 6 Months from DOS |
| Claim Re-submission | 12 Months from the processing date of the original claim Submission | 12 Months from DOS |
| Dispute | 30 Business days to ask for open negotiation | Disputes related to coverage, benefit book exclusions, medical necessity, non-contracted claim denials Within 2 years from date of denial (there is only one level of internal appeal)Payment disputes (Services are covered, provider believes the services weren’t reimbursed correctly/underpaid) One year after denial or other notification, or date of the occurrence if the provider did not receive notification (level one, internal appeal) |
| Second Level Dispute | After open negotiation, 4 business days to seek Federal IDR | Disputes related to coverage, benefit book exclusions, medical necessity, non-contracted claim denials Up to 4 months from date of final internal adverse determination (external)Payment disputes (Services are covered, provider believes the services weren’t reimbursed correctly/underpaid) Within 60 days of Provider’s receipt of Level 1 decision (level two, internal appeal) |