Getting Paid for Late Claims

There it is, that sinking feeling when you realize your claim has been denied (or will be) because you missed the plan’s filing deadline.

Maybe you got busy, forgot, didn’t include a session on a claim, or sent the claim to the wrong address. By the time this comes to light, the “timely filing” deadline has passed. But you may still have a chance to be paid in certain situations if you throw yourself on the plan’s mercy.

When is the “timely filing” deadline?

Check with the plan or your contract. Deadlines may vary by plan, state, and provider status. In California, for example, a plan’s deadline must be at least 90 days from the date of service for contracted providers or 180 days for non-contracted providers.

What can I do if I miss the deadline?

It may be worth filing a dispute (aka appeal) with the plan, since in certain situations where there is “good cause” for the delay, some state laws even require that exceptions be made. For example, California law states “An insurer/plan that denies a claim because it was filed beyond the claim filing deadline, shall, upon provider’s submission of a provider dispute and the demonstration of “good cause” for the delay, accept and adjudicate the claim.”

What might be considered “good cause?”  

While I don’t have data on “successful excuses,” I would consider filing a dispute for reason of illness, injury, hospitalization, caring for an ill family member, significant personal issue (ex. divorce, death), problem with biller/electronic billing, or other unforeseen event. What have you got to lose?

What should I include in my dispute?

According to Catherine Atkins, JD, staff attorney at the California Association of Marriage and Family Therapists, the disputes should include:

  • Client information [ex. Name, plan ID#, date of birth, Social Security #, dates of service]
  • Why the treatment delivered was medically necessary
  • That your delay did not involve willful neglect/misconduct
  • That “good cause” for the delayed filing existed (discuss reason)
  • The amount of money owed to you

What if my dispute fails?  

You can appeal to your state’s Department of Insurance or Department of Managed Care. A plan that I had billed electronically denied receiving it on time, and refused to pay even after I appealed and provided proof of timely filing from the online claims clearinghouse. After filing an online complaint with the state, I was paid.

What can I do to avoid this?

  • Before submitting the claim, be sure you’ve included every session
  • Submit claims as quickly as possible after session
  • Review charts regularly to see if claims haven’t been paid, so you can follow up and have time to resubmit, if needed
  • File electronically, and save filing acknowledgements (non-contracted providers can even file electronically for clients)
  • Review health plan contracts for filing deadlines

For assistance writing dispute letters, contact me to set up a consultation.

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