Timely filing of claims for covered services in healthcare is the most appropriate way of facilitating prompt payment. However, insurers have their terms and conditions guiding the processing of claims. In this regard, claims may be denied as a result of claim filing limits violations. Thus, it is vital to consider an insurer’s claim filing procedures. Notably, insurers such as Medicare, Medicaid, Blue Shield and Aetna have varying claim filing limits which impact the settling of claims differently. Nevertheless, best practice recommendations can be essential in enhancing improved service delivery.
Medicare Claim Filing Limits
Medicare beneficiaries can either have an Original Medicare or Medicare Advantage Plan (Part C). Doctors and suppliers are required by law (Patient Protection and Affordable Care Act) to file Medicare claims for the rendered services. On the other hand, Medicare Advantage Plan does not require the filing of claims since the insurer remits a set amount to private insurance companies monthly (Centers for Medicare & Medicaid Services (U.S.), 2018). Consequently, Medicare claims should be filed no later than twelve months after delivery of the covered services. If claims are not filed within the stipulated time frame, the insurer is obliged not to pay for the provided services. In some rare cases, Medicare provides for an exception to the one year claim filing limit. As such, administrative errors, retroactive Medicare entitlement, disenrollment from Medicare Advantage Plans and Medicare entitlement involving state agencies are cases where filing claim limits can be extended.
Medicaid Claim Filing Limits
Medicaid has a vast reimbursed plan, and its claim filing limits are comprehensive. Conversely, the insurer classification of claims comprises of claims under straight Medicare, KIDMED, recipients with Medicare and Medicaid, hard copy claims and third-party payment. Essentially, while all straight Medicaid and third-party payment claims are being filed in less than 12 months after delivery of a covered service, KIDMED requires the service provider to file a claim within 60 days. On the other hand, recipients with both Medicare and Medicaid coverage should also file their claims within one year. Consequently, if a claim is not electronically filed, it must be presented to Medicaid in less than six months. With regard to exceptions, Medicaid provision for an extended claim filing is identical to Medicare.
Blue Cross/ Blue Shield Claim Filing Limit
Blue Cross/Blue Shield insurer consists of facility providers and preferred provider organization (PPO) who are contracted providers. For the facility providers, all the claims are supposed to be filed on or before 31st December of a given year in which the services were rendered. On the contrary, services furnished within the last quarter of a year are considered to be furnished in the following year. Claims that are not filed within the stipulated time would be denied. On the other hand, contracted providers are supposed to submit claims within 180 days after delivery of service, failure to do so will lead to denial of reimbursement. However, there are exceptions which apply to particular cases. In principle, if a Blue Cross administrative error occurred, then, the claim restrictions are lifted. Errors can occur as a result of erroneous written instructions from providers or failure of a Blue Cross staff to enter authorization code in the system. On the other hand, if a Medicaid beneficiary eligibility was established retroactively, then this will also be an exception. Additionally, if primary insurance takes back payment after timely filing of a claim, then the claim limits will not apply in this case.
Aeta Claim Filing Limit
Aetna terms and conditions require providers to submit claims within 180 days from the time a service was rendered unless stipulated otherwise by the provider contract. Consequently, Aeta has other packages such as Aeta Better Health where claim resubmissions should be done within 365 days from the date a service was provided. Additionally, Aeta requires provider appeals to be submitted within 60 days from the date a claim was denied. Just like other insurers, Aeta has exceptions in which restrictions can be reclassified to prevent denial of claims. As such,
in cases where there is a coordination of benefits/subrogation, the new time frame required for a claim will start from the date the third party submits an explanation of the benefits (Hall, 2015). On the hand, if a member has a retroactive eligibility, the stipulated time frame for the filing of a claim usually begins after the insurer receives a notification from the enrollment broker.
Comparison and Contrast
All of the four insurers have some similarities, especially after the Affordable Care Act was enacted in 2010 and signed into law by President Barrack Obama. In the law perspective, at least each of the insurers provides plans to process claims filed within a year after the provision of service. Additionally, Medicare, Medicaid, Blue Cross/ Blue Shield and Aeta have some similar exceptions such as the occurrence of administrative errors that lead to an extension of the restrictions defined by the insurance companies. Further, all of the insurers have different plans that members can subscribe to based on their needs. For instance, Medicaid has plans such as KIDMED plan which covers children. Similarly, there are contrasting features that clearly define service delivery and reimbursement by the insurers. In particular, while Aeta has a comprehensive plan for assessing and processing appeals to denial of claims, the other insurers are reluctant in providing specific means of covering disputed claims.
Implementing best practices in claim filing limits can be a breakthrough, especially in realizing improved care and service delivery. Some of the root causes of limitations in claim filing limits are attributed to the complexity of data and communication between healthcare providers and insurers. As such, service providers can either file claims after the expiry of the stated limit or incur gross errors that negatively impact patients because the claim review is also time-consuming. Hence, claims should be reviewed both at the mid-cycle stage and before the claim is sent to the appropriate payer. Mid-cycle checks will enable administrators to verify authorization and correct errors; thus avoiding major drawbacks in filing claims. Additionally, hospitals, service providers and insurers should ensure that they have accurate, complete and consistent data to establish a workflow that is devoid of errors. This way, irrespective of claim filing limits of the insurers, there will be improved service delivery.
Claim filing limits affected by health insurers determine whether or not a claim will be processed. In principle, insurers such as Medicare, Medicaid, Blue Cross/Blue Shield and Aeta claim filing limits vary depending on the subscriptions entitled to patients. Laws passed by the government to implement affordable care have in one way or another shaped the claim filing procedures of the insurers. However, some loopholes that lead to claim denial can be mitigated by implementing best practices such as mid-cycle checks and capturing accurate and consistent data among hospitals, service providers and health insurance companies.
Centers for Medicare & Medicaid Services (U.S.),. (2018). The Health Insurance Marketplace.
Hall, M. A. (2015). Reforming private health insurance. Washington, D.C: AEI Press.