# Medicare Advantage plans/timely filing



## kparkhurst

I am running into a problem with timely filing for one of our medicare advantage plans. The company is stating 90 days but shouldn't they have to follow Medicare filing rules? Does anyone know of any documentation I could use to try and appeal?


----------



## Deana Banks

Yes, they can do this check your contract the provider has with this insurance plan.  It is a very deceiving underhanded move. I ran into the same problem and when I questioned the Ins. co. they stated our contracted we had with them only allowed 90 days for claims. Have the office manager review the contract. You can try to appeal If the patient did not give you the correct insurance in the first place, state in your appeal letter that even though as a provider you are obligated to follow the timely filling guidelines but the policy holder is also obliagated to give correct ins in a timely fashion.  This usuallys works for me.  Good Luck.
Deana Banks CMA, medical billing specialist 
Easton Pa


----------



## Dani_k_83

I am making the assumption that you are not contracted with this MCO plan.  MCO's have to provide the same benefits or greater to their patients as Traditional MCR. LCD policies, covered drugs and CPT codes must be covered as if the patient had traditional MCR.  However, they can implement their own guidelines on appeal processes, timely filing, documentation requirements etc. Many MCO's have provider reps you can utilize even if you are not contracted. Refer to Ch 13 of the Managed Care Manual at the CMS website.


----------



## Deana Banks

daniellemiller said:


> I am making the assumption that you are not contracted with this MCO plan.  MCO's have to provide the same benefits or greater to their patients as Traditional MCR. LCD policies, covered drugs and CPT codes must be covered as if the patient had traditional MCR.  However, they can implement their own guidelines on appeal processes, timely filing, documentation requirements etc. Many MCO's have provider reps you can utilize even if you are not contracted. Refer to Ch 13 of the Managed Care Manual at the CMS website.



Our provider is actually contracted with one specific Advantage plan and their commercial plan that is offered and this certain insurance company actually had a time frame of less than 1 year for claims filling for, when I questioned them they stated as per our contract with them they are only allowing 6 months claims filing. After this our provider is reviewing this contract for re- negotiation.  And yes the Medicare Advantage/replacement plans are to follow Medicare quidelines but as above, I would encourage all providers to review their contracts.


----------



## ajb1986

If you have a contract stating that you need to get the claim there within 90 days thats one thing. If not then you have a year from the date of service to get it in. 

As for documentation figure out how to print out when you filed the claim. If it went electronically that should be easy. Then you can prove that you filed it within a timely manner.


----------



## airart

*timely filing issues with MAs Part C*

I found this info on this topic for beneficiaries regarding claims and timely filings.  

Link: http://www.medicare.gov/claims-and-appeals/file-a-claim/file-a-claim.html
How do I file a claim?

If you're in Original Medicare, doctors, and suppliers are required by law to file Medicare claims for covered services and supplies you get. Find out which doctors in your area accept assignment.

If you have a Medicare Advantage Plan (Part C), these plans don't have to file claims because Medicare pays these private insurance companies a set amount each month.
When do I need to file a claim?

You should only need to file a claim in very rare cases.

Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't pay its share. 

For example, if you see your doctor on March 22, 2012, the Medicare claim for that visit must be filed no later than March 22, 2013. Check the "Medicare Summary Notice" (MSN) you get in the mail every 3 months or on MyMedicare.gov to make sure claims are being filed timely. 

If the claims aren't being filed timely:
1.	Contact your doctor or supplier, and ask them to file a claim.
2.	If they don't file a claim, call 1-800-MEDICARE. Ask for the exact time limit for filing a Medicare claim for the service or supply you got. If it's close to the end of the time limit and your doctor or supplier still hasn't filed the claim, you should file the claim.
How do I file a claim?

Fill out the Patient Request for Medical Payment form (CMS-1490S). Follow the instructions on the second page to submit the form to your carrier. If you don't know the address for your carrier, you can find it here. Get this form in Spanish.

If you want someone to be able to call 1-800-MEDICARE on your behalf or you want Medicare to give your personal information to someone other than you, you need to fill out an "Authorization to Disclose Personal Health Information."


----------



## karansinghchauhan

*Medicare claims filing*

If you file Medicare claims electronically, as most ophthalmologists do, you know that you can't get more than two modifiers in the modifier field. This presents a problem for ophthalmologists who must use more than two modifiers. 

This comes up frequently in the following situation: An ophthalmologist co-manages cataract surgery with an optometrist. The ophthalmologist performs the surgery, and the optometrist follows the patient through the post-operative period. The global fee for postoperative care must therefore be prorated, with the ophthalmologist only getting paid up until the optometrist takes over. But how can you convey the many modifiers that apply when you are filing the claim?

You can get more information here: 

http://www.supercoder.com/coding-ne...ce=content&utm_medium=text&utm_campaign=forum


----------

