Optometry Coding & Billing Alert

Question: I sent a claim to the insurance company and have proof that the claim was sent, but the insurer hasn't paid. I followed up with a tracer, but the insurance company said my claim was denied on the grounds of "untimely filing." Should I appeal this claim, and if so, how?
     
California Subscriber

Answer: Whether you can successfully appeal the untimely filing depends on your state laws. You need to contact your court systems, legislature, or medical association, or check the Internet to find out the "untimely filing" statutes for insurers, says Victoria Jackson, administrator and chief executive officer of Southern Orange County Pediatric Associates in Southern California.
 
In California, for example, you can successfully appeal "untimely filing" denials if you have proof that you filed your claims on time, Jackson says.
 
The California state statute says that if you've submitted within the proper time, insurers can't deny you payment because of untimely filing.
 
A common "untimely filing" excuse that Jackson appeals is when the patient's insurance eligibility runs out. According to the California statute, if the patient had insurance at the time of service, you saw the patient "in good faith that she had insurance," and you billed appropriately, then the insurance companies cannot deny your claims based on untimely filing, Jackson says.
 
Your filing time does not have to coincide with the patient's insurance-plan expiration. You are billing for the time of service.
 If you have proof of timely filing, and your state does have a statute, send letters to the insurance company telling it "Thank you, but no thank you," Jackson says. Send the insurer a copy of the state statute, a copy of the EOB, and the proof of your timely filing. Following these steps, "We've never had an insurance company not pay us," Jackson says.
 
If you're not as lucky as Jackson, and the insurer continues to refuse your payment despite your documents, consider filing suit. "Depending on the dollar volume and the insurance company, take it to court," Jackson says. Or take the insurer to small-claims court and get a judgment against it, she adds.
 
Remember, not all states have the statute in place. You'll have less success in court if there is no explicit mandate requiring the insurer to pay.