Are You Aware of Medicare Advantage Plans Timely Filing Rules?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Aug 20th, 2019

The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.

As any company who has billed Medicare services can attest, the one-year timely filing rule allows time to reconcile the many peculiar situations that arise when dealing with some Medicare beneficiaries who are unsure of the details of their coverage such as:

• Which payer is primary and which is secondary
• Whether they have the right insurance card
• They think they switched to a Medicare Advantage Plan but cannot remember 
• They are unsure of coverage dates
• They don't have (or cannot locate) their MA plan card but instead provide their original Medicare FFS card

Some providers and/or coding and billing staff may be unaware that, although the original or traditional Medicare Fee For Service plan has a one-year timely filing rule, patients who transfer their Medicare benefits over and join a Medicare Advantage Plan are required to follow the timely filing rules for their particular MA plan; and most often, that filing requirement is significantly shorter than one year.

As an example, on June 21, 2019, Anthem Blue Cross sent a notification to their network and contracted providers informing them that their new timely filing rule will become effective as of October 1, 2019, and the time for submitting a claim will be limited to 90 days from the date of service. They state this change is done in an effort to, "simplify our processes, align with industry standards, and better support coordination of care."

Upon review of a CGS Medicare FAQ on timely filing for Medicare Advantage plans, the following question and answer was received, 

"Question: Do Medicare replacement plans (Medicare Advantage (MA) Plans) generally follow Medicare guidelines for timely filing? 

Answer: We do not know about the timely filing guidelines for MA Plans. Providers should check with the individual MA Plan to determine their timely claim filing requirements.

In short, be sure to review all MA plan contracts or speak with an MA plan representative to be certain of the timely filing dates and educate all staff who may be involved with patient documentation and claims. The loss of reimbursement for claims due to timely filing errors can be significant, and while some payers may allow an appeal, some are becoming very strict about the rules for overturning a timely filing denial. 

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.