CurrentFallon Community Health Plan IncPolicy N/A

Adjustments and Provider Appeals

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Governs timely filing limits, adjustment and appeal submission timeframes, prompt payment practices, and billing/coding guidance for providers submitting claims to Fallon Community Health Plan Inc. Affects providers contracting with the Plan and submitting claims or appeals.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyAdjustments and Provider Appeals

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewApr 1, 2021

Next Review DateN/A

Key ActionSubmit adjustment requests and provider appeals in writing within 120 days from the date of the initial claim denial/RAS and follow the Plan Provider Manual guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 daysfiling limit

120 daysappeal window

All settingsplace of service

Post-payment auditspayments subject to

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CurrentFallon Community Health Plan IncPolicy N/A

Adjustments and Provider Appeals

Customize your policy alerts

Sign up for all fallon_community_health_plan_inc policy alerts

Know when fallon_community_health_plan_inc releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerFallon Community Health Plan Inc

PolicyAdjustments and Provider Appeals

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewApr 1, 2021

Next Review DateN/A

Key ActionSubmit adjustment requests and provider appeals in writing within 120 days from the date of the initial claim denial/RAS and follow the Plan Provider Manual guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 daysfiling limit

120 daysappeal window

All settingsplace of service

Post-payment auditspayments subject to

Operational Coverage and Administrative Criteria

Operational rules and administrative requirements for claim submission, timely filing, adjustments/appeals, prompt payment, billing/coding, place of service, and post-payment audits.

ALL of the following

Claim filing deadline: Submit claims to the Plan within 120 days from the date of service unless a different contract-specific limit applies; follow the Plan Provider Manual Claims Guidelines and Submission sections.
Adjustment and appeal submission: All adjustment requests and provider appeals must be received in writing within 120 days from the date of the initial claim denial/Remittance Advice Summary (RAS) to be considered for review; follow the Plan Provider Manual Adjustments and Provider Appeals section.
Prompt payment: The Plan will make payment or notify the provider in writing of the reason for nonpayment within the timeframes required by applicable regulations (e.g., CMS, Massachusetts Division of Insurance, Federal Department of Labor, Managed Care Act); for fully insured products, legislated interest will be paid for claims paid outside mandated timeframes.
Billing and coding guidance: Follow billing/coding guidelines as outlined in the Plan Provider Manual, Claims Submission section.
Place of service: This policy applies to services rendered in all settings.
Post‑payment audits and overpayment recovery: Payments are subject to post-payment audits and retraction/recoupment of overpayments where appropriate.

Operational notes

When a provider contract specifies a different timely filing limit, the contract-specific limit supersedes the 120-day Plan default.
Follow the Plan Provider Manual for procedural details on submitting clean claims, adjustments, and appeals and for documentation requirements to avoid delays or denials.

Billing and Coding Guidance

Billing/Coding Guidancemixed

Follow the guidelines as outlined in the Plan Provider Manual, Claims Submission section.

Provider Submission Timeframes and Actions

Prior Authorization

Submit adjustment requests and provider appeals in writing within 120 days

All adjustment requests and provider appeals must be submitted in writing within 120 days from the date of the initial claim denial/Remittance Advice Summary (RAS). Follow the Plan Provider Manual guidelines for Adjustments and Provider Appeals when preparing submissions.

Written submission required
120-day deadline from date of initial denial/RAS
Follow Plan Provider Manual: Adjustments and Provider Appeals section

Billing Rule

File claims within 120 days of service (unless contract specifies otherwise)

Submit claims to the Plan within 120 days from the date of service unless a different contract-specific limit applies. Adhere to the Plan Provider Manual Claims Guidelines and Submission sections for filing instructions.

Key Definitions

inv-05: clean claim

DefinitionA 'clean claim' is a claim that has no defect, impropriety, lack of any required substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment.

Operational noteA clean claim must contain all required documentation and have no defects or improprieties that would delay timely payment by the Plan.

Implication for providersOnly claims meeting the clean claim definition will be eligible for prompt processing under the Plan's payment policies.

Relation to timely filingClean claim status affects the Plan's ability to make timely payment; claims with defects may not be processed within standard timelines.

Documentation expectationProviders should include all substantiating documentation at submission to avoid classification as anything other than a clean claim.