Wiki Medicare exceed timely filing

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JesseL

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I have a claim that was filed through our PMS. I did not find out until recently that the claim never actually made it to the clearing house and was just stuck on "filed" status. I only found out now because recently a whole bunch of claims I submitted through that PMS were stuck on the "filed" status glitch and the system never actually sent the claim to the clearing house. Thankfully I caught those on time except for one. It was a September 2015 claim. I tried mailing the claim to our Medicare contractor including letter stating what happened and proof of filing attempt generated from our probably the WORST PMS on the market, but they still denied the claim as exceeded timely filing.

I think I've exhausted what I could do about that one claim. Since the claim never actually made it to the clearing house and was just stuck forever in the PMS, I'm probably out of luck but hope someone has a solution.
 
Likely not in the case of provider office failure to working EDI fails. Now you know what to watch for. I mean you can always try under Administrative Error "This is where the failure to meet the filing deadlinewas caused by error or misrepresentation of an employee" but it doesn't seem to fit under the full description under

70.7.1 - Administrative Error.

Medicare Claims Processing Manual
Chapter 1 - General Billing Requirements
 
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CodingKing said:
Likely not in the case of provider office failure to working EDI fails. Now you know what to watch for. I mean you can always try under Administrative Error "This is where the failure to meet the filing deadlinewas caused by error or misrepresentation of an employee" but it doesn't seem to fit under the full description under

70.7.1 - Administrative Error.

Medicare Claims Processing Manual
Chapter 1 - General Billing Requirements
Click to expand...

They denied the claim with "you may not appeal." Sucks how unsympathetic they are.
 
JesseL said:
They denied the claim with "you may not appeal." Sucks how unsympathetic they are.
Click to expand...

Well there really isn't an excuse for not having timely filing on an EDI claims since there are so many reports available to keep track of failed submissions and AR should be worked in a timely manner. They were many chances to catch it so payers have no sympathy.
 
CodingKing said:
Well there really isn't an excuse for not having timely filing on an EDI claims since there are so many reports available to keep track of failed submissions and AR should be worked in a timely manner. They were many chances to catch it so payers have no sympathy.
Click to expand...

The way I tracked failed submissions was if the the claim ever got rejected by the clearing house. I never saw any rejection from the clearing house and did not expect the PMS itself would ever fail to send the claim to the clearing house and the PMS has no way of alerting me that they failed to send the claim (other than seeing that the claim is stuck on "filed" status which I know now). I would have caught it had I looked at the aging but due to large number of payments without ERA's I have to post manually, I haven't been able to keep up with it and just prioritized denied claims I see physically. But yes, there's no sympathy for billers that have to do everything on their own.
 
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You MIGHT be able to fight the clearinghouse to have them reimburse for the claim, IF the reason it was "stuck" truly their fault. There would have to be no reason the claim would have been denied...everything thing would have to be completely accurate. If they scrubbed it for ANY reason (incorrect HIC#, invalid CPT or dx code, incorrect DOS, etc) they will deny your request. You will have to indicate the NEIC (EP id#) claim # on your request. This will be the first thing they research to verify when the claim hit their system. I've had to do this for a commercial insurance but never Medicare.
 
ldstallmann said:
You MIGHT be able to fight the clearinghouse to have them reimburse for the claim, IF the reason it was "stuck" truly their fault. There would have to be no reason the claim would have been denied...everything thing would have to be completely accurate. If they scrubbed it for ANY reason (incorrect HIC#, invalid CPT or dx code, incorrect DOS, etc) they will deny your request. You will have to indicate the NEIC (EP id#) claim # on your request. This will be the first thing they research to verify when the claim hit their system. I've had to do this for a commercial insurance but never Medicare.
Click to expand...

It wasn't that it got stuck in the clearing house. It got stuck in the PMS, when I submitted the claim through the PMS, it never actually transmitted the claim even though I click submit, so it's the PMS's fault. I only happen to caught it because it happened to multiple claims recently because at the time they did some sort of system update that screwed up everything. I submitted the proof of filing from the PMS to Medicare but I guess they didn't accept it. Most payers don't accept proof of filing generated by the PMS. Most payers only accept proof of filing from the clearing house but that claim never made it there because of the expensive for nothing PMS we use.
 
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