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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyHealth New England Filing Policy Update | OpenPaye…
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    CurrentHealth-New-EnglandPolicy PP045POL

    Timely Filing Limit

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    Governs claim filing deadlines and submission requirements for network and non-network providers across commercial, Medicare Advantage, and Be Healthy Partnership plans, subject to applicable contracts and benefit documents.

    Policy Summary
    PayerHealth-New-England
    PolicyTimely Filing Limit
    Policy CodePolicy PP045POL
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateNovember 1, 2023
    Next Review DateNot specified
    Key ActionSubmit claims within the applicable filing limit and do not bill members for denials caused by untimely filing.
    SourceLink
    POLICY UPDATE CHANGES

    The policy history records an update to the Medicare participating and non-participating provider section.

    The policy history records a template update and updated resource links.

    90 daysCommercial filing limit
    365 daysMedicare filing limit
    90 daysBe Healthy and self-funded limit
    4Applicable plan categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Prohibited
    Member billing after untimely denial

    Claim Filing Criteria

    Commercial Providers — Participating and Non-Participating

    Claim submission requirements for participating and non-participating commercial providers. Contracts may differ and supersede these requirements.

    ALL of the following

    • Submit commercial claims within 90 days from the date of service or date of discharge.<= 90 days
    • For coordination of benefits (COB), submit the claim within 90 days from the date the primary insurer processed the claim.<= 90 days

      The primary insurer's process date must be indicated on the Explanation of Benefits (EOB), and the EOB must be included with the claim submission.

    Medicare Providers — Participating and Non-Participating

    Claim submission requirements for participating and non-participating Medicare providers. Contracts may differ and supersede these requirements.

    ALL of the following

    • Submit Medicare claims within 365 days from the date of service.<= 365 days
    • For inpatient admissions, submit the claim within 365 days from the date of discharge.<= 365 days
    • For coordination of benefits (COB), submit the claim within 365 days from the date the primary insurer processed the claim.<= 365 days

      The primary insurer's process date must be indicated on the Explanation of Benefits (EOB), and the EOB must be included with the claim submission.

    Be Healthy Partnership and Self-Funded Providers

    Applicable filing requirements for Be Healthy Partnership and self-funded claims. Contracts may differ and supersede these requirements.

    Be Healthy Partnership

    • Submit claims within 90 days from the date of service.<= 90 days
    • For inpatient admissions, submit the claim within 90 days from the date of discharge.<= 90 days
    • For coordination of benefits (COB), submit the claim within 90 days from the date the primary insurer processed the claim.<= 90 days

      The primary insurer's process date must be indicated on the Explanation of Benefits (EOB), and the EOB must be included with the claim submission.

    Commercial Self-Funded

    Untimely Claims — Member Billing Restriction

    The filing limits apply to claims submitted to HNE. A claim denied because the filing limit was exceeded cannot be transferred to the member for billing.

    ALL of the following

    • The claim was denied because it exceeded the applicable filing limit.
    • The provider does not bill the member for the denied services.

      Members cannot be billed for services denied because the filing limit was exceeded.

    Filing Limit Reference

    Commercial claim filing limit
    Filing period90 days
    Starting pointDate of service or date of discharge
    Applicable claimsIn-network fully insured, in-network self-funded, and commercial out-of-network claims
    Commercial COB claim filing limit
    Filing period90 days
    Starting pointDate the primary insurer processed the claim
    Required documentationThe primary insurer's Explanation of Benefits (EOB) must show the processing date and accompany the HNE claim

    Submission and Billing Requirements

    Prior Authorization

    Prior Authorization

    Prior authorization requirements are not applicable under this policy.

    Documentation Required

    Accurate Claims and Audit Compliance

    Submit accurate claims for all services. HNE reserves the right to audit providers and facilities for compliance with the guidelines in this payment policy and its provider review policy.

    Documentation Required

    Coordination-of-Benefits Documentation

    When coordinating benefits with a primary insurer, submit the primary insurer’s Explanation of Benefits (EOB) with the claim. The EOB must indicate the date the primary insurer processed the claim; that processing date determines the applicable filing period.

    Key Terms and Applicability

    Coordination of benefits (COB)
    MeaningCoordination of benefits is the process of submitting a claim to HNE after a primary insurance carrier has processed the claim
    Primary insurer requirementThe primary insurer must process the claim before it is submitted to HNE
    Evidence requiredThe primary insurer's Explanation of Benefits (EOB), showing the processing date, must accompany the HNE claim
    Contract precedence
    General ruleThe policy provides general claim filing limits for providers
    Contract termsApplicable provider contracts may establish requirements that differ from the policy filing limits
    Policy Summary
    PayerHealth-New-England
    PolicyTimely Filing Limit
    Policy CodePolicy PP045POL
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateNovember 1, 2023
    Next Review DateNot specified
    Key ActionSubmit claims within the applicable filing limit and do not bill members for denials caused by untimely filing.
    SourceLink
    On This Page
    Claim Filing CriteriaFiling Limit ReferenceSubmission and Billing RequirementsKey Terms and Applicability
    • Submit claims within 90 days from the date of service or date of discharge.<= 90 days
    Medicare claim filing limit
    Filing period365 days
    Outpatient claimsMeasured from the date of service
    Inpatient claimsMeasured from the date of discharge
    Medicare COB claim filing limit
    Filing period365 days
    Starting pointDate the primary insurer processed the claim
    Required documentationThe primary insurer's Explanation of Benefits (EOB) must show the processing date and accompany the HNE claim
    Be Healthy Partnership claim filing limit
    Filing period90 days
    Outpatient claimsMeasured from the date of service
    Inpatient claimsMeasured from the date of discharge
    Be Healthy Partnership COB claim filing limit
    Filing period90 days
    Starting pointDate the primary insurer processed the claim
    Required documentationThe primary insurer's Explanation of Benefits (EOB) must show the processing date and accompany the HNE claim
    Self-funded claim filing limit
    Filing period90 days
    Outpatient claimsMeasured from the date of service
    Inpatient claimsMeasured from the date of discharge
    Self-funded COB claim filing limit
    Filing period90 days
    Starting pointDate the primary insurer processed the claim
    Required documentationThe primary insurer's Explanation of Benefits (EOB) must show the processing date and accompany the HNE claim
    • Commercial: Submit the claim within 90 days of the primary insurer’s processing date.
    • Medicare: Submit the claim within 365 days of the primary insurer’s processing date.
    • Be Healthy Partnership and other applicable plans: Submit the claim within 90 days of the primary insurer’s processing date.
    Denial Risk

    Do Not Bill Members for Untimely Claims

    Do not bill members for services denied because the claim was submitted after the applicable filing limit.

    Billing Rule

    Verify Contractual Requirements

    Verify the applicable provider contract before submitting claims. Contractual terms may differ from or supersede the filing limits and other information in this policy.

    • Commercial participating and non-participating providers: confirm contract-specific requirements.
    • Medicare participating and non-participating providers: confirm contract-specific requirements.
    • Be Healthy Partnership participating and non-participating providers: confirm contract-specific requirements.
    Precedence
    Applicable provider contract terms supersede the general filing limits stated in this policy
    Applicable plans
    Commercial Self-FundedApplicable plan category
    Commercial Fully FundedApplicable plan category
    Medicare AdvantageApplicable plan category
    BeHealthy PartnershipApplicable plan category