November 09, 2016
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
CMA’s “Know Your Rights” series summarizes vital protections under state and federal law that physicians should be aware of in their dealings with payors.
Health plans typically impose claim filing deadlines, which require physicians to submit claims within a certain time period after the date of service. If the physician fails to meet the deadline, the health plan will not pay for the service provided. However, California law prohibits commercial health plans and insurers from imposing claim filing deadlines that are less than 90 days after the date of service for contracted physicians or 180 days for non-contracted physicians. If the payor is not the primary payor under coordination of benefits (COB), the payor cannot impose a deadline for submitting a COB claim that is less than 90 days from the date of payment or date of denial from the primary payor.
Even if the physician fails to submit a claim on time, California law provides a “good cause” exception that requires payors to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay.
Below are steps you can take to prevent timely filing denials:
- Submit claims as quickly as possible after services are rendered.
- Where possible, file claims electronically. Retain payor acknowledgement of receipt of claim as proof of timely filing. California law requires health plans to acknowledge receipt of an electronic claim within two days and a paper claim within 15 days of receipt. (Note: An acknowledgement of transmission of a claim from a clearinghouse is not an acknowledgement that the claim has been received by the payor. Check with your clearinghouse to determine its process for tracking health plan receipt of claims.)
- Appeal in writing all claims that have been incorrectly denied for timely filing. Include a copy of the payor's acknowledgment of receipt of the claim with your appeal.
- Review health plan contracts to ensure that deadlines for filing claims are no less than 90 days.
- Report health plan violations of the timely filing laws to the appropriate regulator and to the California Medical Association (CMA) at (800) 786-4262.
For a summary of California's unfair payment practices law, see "Know Your Rights: Identify and Report Unfair Payment Practices." More information on timeframes for claim submission can be found in “Know Your Rights: Timely Filing Limitations” or in CMA On-Call document #7511, “Payment Denials by Managed Care Plans and IPAs,” available free to members on the Reimbursement Assistance page.