A sample appeal process and letter based on a timely filing denial.
Now that you know more about timely filing and how important it is to send your claims within the right timeframe, what do you do if some of your claims are returned because of timely filing?
If you've made sure that you have really sent your claims all within their timely filing limits, then you can send a timely filing appeal, and get your claims paid!
In order to send a timely filing appeal, you have to have evidence to support your statement that the claim was sent within the timely filing deadline. This means two things:
Typically, when you send claims through any type of practice management system, an internal report is generated. This says which claims were sent and on which day.
Many of your claims will go out electronically to a claims clearinghouse, which is like a middleman between your office and the insurance company. This clearinghouse checks your claims for errors and then sends them to the insurance company.
See this article on medical billing clearinghouses for more on these services
If there are errors, the clearinghouse will send you a report to let you know what was wrong with your claims so you can fix and resend them.
Checking your claims at the clearinghouse will help you make sure that all your claims are actually going out to the insurance companies, not just getting stopped at the clearinghouse.
The clearinghouse that you use may also generate reports that state which claims went out on which days, and to which insurance companies they were sent. The clearinghouse reports as well as your internal claims reports can both be sent as proof of timely filing.
Lets say that you have sent a batch of claims, checked them at the clearinghouse, and they have all gone out correctly.
Unfortunately, however, some claims simply get lost. This means that even though you sent them to the right place and within the right time frame, they are lost in your electronic system and you never get a response from the insurance company.
By the time you have noticed and resent the claim, it was past the timely filing deadline, and your claim was denied for timely filing.
Usually the entire claim will be completely denied, with a reason stating something like: "This claim has been received past the timely filing deadline. You may not bill the patient for this balance."
This means that you have to write off the claim as denied for timely filing.
You have proof that you really did send the claim within the timely filing deadline in the first place.
When you send claims via your practice management system, make sure you print out your claims report, which says which claims went out on which days. You can use this report to support your timely filing appeal.
Once you receive a denial for timely filing, there is an important process to follow to send a timely filing appeal:
The first thing you have to do is make sure that you really did send the claim within the timeframe.
If you didn't then you have no reason for appeal, and you cannot appeal the claim. This means you have to write it off as a direct loss to your office!
If, on the other hand, you really did send the claim within the timeframe, the next thing to do is make a copy of the report which says that you sent the claim, including the date that the claim was sent.
If this report doesn't have any type of date on it, you can't use it for your timely filing appeal.
Once you have your claims report, which contains the claims that were denied for timely filing, you can use this page as a means of support for your timely filing appeal.
The next thing you need to do is write an appeal letter, which explains to the insurance company that you really did send the claim before the timely filing deadline, and that they need to pay the claim.
(click here to skip to the sample appeal letter at the end of this article)
After you have printed out your appeal letter, you'll need to print out a paper version of the claim that was denied on an official CMS-1500 claim form. This is so the insurance company knows the specifics of the claim, and so that they can process it directly.
You may find this tutorial on filling out the CMS-1500 claim form useful.
You may also want to make a copy of the Explanation of Benefits or Remittance Advice, on which your claim was denied for timely filing.
Sometimes it helps to send this along with the appeal so that the insurance company can locate your claim. The easier it is for the insurance company to process your appeal, the more likely it is that they will pay it!
Staple all of your paperwork together, with the appeal letter on top, and send it to the claims processing department of the insurance company.
Many, but not all, insurance companies have specific appeals processing departments, to which to have to mail appeals directly, so make sure you are sending the appeal of your claim to the right address. If you don't send your appeal to the right address, it won't be processed correctly!
Most appeals take anywhere from 30 to 45 days to process, so make sure you keep a copy of the appeal for your own records and check the appeal in 30-45 days to see if it has been paid.
If, after 45 days, you have received no response from the insurance company, you will need to call the claims department to make sure they have received the appeal and are processing it for payment.
The following is a simple sample timely filing appeal letter:
(Your practice name and address)
(Insurance Company name and address)
(Date of appeal)
Patient Identification Number:
Date of service:
Total claim amount:
To Whom It May Concern;
The above claim has been denied due to timely filing. However, this claim was originally sent within the timely filing limits. Please see attached claims report, stating that this claim was originally sent (electronically/paper) to the correct insurance company on (date). This date was within the timely filing limits and the claim should have been paid upon receipt. It has been incorrectly denied due to timely filing.
Please see all attached documentation in support of this appeal. If you have any questions or concerns, please feel free to contact me at the below contact number.
Thank you for your prompt attention to this matter.
(Your contact phone number)
See more on appealing a denied insurance claim.
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