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. If TRICARE denied you would have 90 days from this denial to appeal.Īlso, non-network providers may file claims up to one year after the date of service. If Medicare was primary and they paid today’s date, you would have 90 days from today’s date to bill out TRICARE. Where TRICARE is the secondary payer, the 90 days will begin after the first initial claim paid. It basically said that: TRICARE network providers must file all claims within 90 days of the date of service. This example was TRICARE because I showed you that Explanation of Benefits, I just happened to find these guidelines and they were current. 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. 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 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.

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 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. VIDEO: Timely Filing for Claims and Appeals | Medical Billing Tipsįiling limit – I can’t stress enough. 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. 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. You want to pay also attention to notifications of changes regarding time constraints.

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. 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. 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. So, you really need to know your payer filing limits and create a cheat sheet for your demographic area. Q: Timely Filing for Claims and Appeals - “Please explain filing limits with insurance claim processing” for the initial claim as well as the appeal process.Ī: 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.

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