Primary Care Coding Alert

Question: After getting a denial on a claim for a patient insured by an employment benefit plan, we submitted an appeal. Even though it was submitted within 180 days, we received a timely filing denial from the payer. What should we do?

AAPC Forum Participant

Answer: Start by examining the information you receive with the denial and reviewing the plan and policy details. “If the insurance policy is a result of an employee benefit plan, the federal Employee Retirement Income Security Act [ERISA] law overrides any state laws and contract-imposed timeframes. As a result, for about 80 percent of your non-Medicare/Medicaid-insured patients, the appeal timeframe is 180 days. For Medicare, the timeframe is 120 days, and every state Medicaid has its own specific appeal timeframe, so it’s crucial to examine the information from your state Medicaid program,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPCO, CPC-P, CPC-I, CENTC, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey.

“Keep in mind that the information on your remittances and denials from the payer may be misleading, stating the insurance company appeal deadline… Often, these timely filing denials are invalid because the window being applied by the payer is shorter than the 180-day timely filing window established by ERISA,” says Cobuzzi.

Bottom line: Arbitrary timely filing timeframes established by third-party payers are meaningless for policies that fall under ERISA — only ERISA rules apply: 180-day timeframe for participating providers and 60 days for non-participating providers.

Do this: Even if the denial states that the denial is for timely filing, if you have proof of filing within 180 days of the date of service for a participating provider and the plan is covered by ERISA, the denial is invalid, and the payer should immediately pay the appeal, Cobuzzi advises.

For more information, see the U.S. Department of Labor website.