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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyHealth New England Timely Filing Appeal | Policy U…
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    CurrentHealth-New-EnglandPolicy PA03POL

    Provider Appeal Claim Past Filing Time Limit Denial

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    Governs how in-network and out-of-network providers may request reconsideration of Health New England claim payment denials caused by filing past the applicable time limit.

    Policy Summary
    PayerHealth-New-England
    PolicyProvider Appeal Claim Past Filing Time Limit Denial
    Policy CodePolicy PA03POL
    Change TypeNo material change
    Effective DateOctober 1, 2022
    Next Review DateN/A
    Key ActionSubmit complete appeal documentation, including the Request for Claim Review Form and 12-digit control number, within the applicable filing limit.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 daysFinal determination timeframe
    12 monthsStandard appeal deadline
    6 monthsAlternate-payer deadline
    12 digitsRequired EOP control number
    4

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    Applicable plan categories

    Appeal Eligibility and Exceptions

    Standard provider appeal eligibility

    An appeal may be reviewed when the provider meets all standard request, filing, and documentation requirements.

    ALL of the following

    • ALL of the following

      • The request is made by an in-network or out-of-network provider seeking reconsideration of an HNE claim payment denial based on untimely filing.
      • Complete and accurate paperwork is submitted within 12 months of the date of service or date of discharge, unless an exception applies.Within 12 months of the date of service or date of discharge

      • ALL of the following

        • A completed Request for Claim Review Form is included.
        • The 12-digit control number from the original EOP is included.
        • The submission contains a specific explanation of the dispute.
        • The original supporting EOP is included.
        • Applicable supporting documentation is included, such as surgical or operative notes, office notes, pathology reports, medical invoices, or medical record entries.

    Exceptions and special filing situations

    Exceptions or special handling may apply to alternate-payer retractions, EDI claims not on file, and coordination-of-benefits claims.

    ONE of

    • ANY of the following

      • An alternate payer retracted payment after determining that HNE was the primary payer.
      • The provider submits the claim within six months of the alternate payer's retraction date.Within six months of the alternate payer's retraction date
      • The alternate payer EOP is dated within six months of the retraction date and shows the payment amount and retraction date.
      • Documentation shows that the provider checked member eligibility with the alternate payer on the date of service.

    Filing Deadlines and Determination Timeframe

    Standard appeal filing limit
    Filing limitComplete and accurate paperwork must be submitted within 12 months of the date of service or date of discharge.
    Applies toRequests to review claim payment denials with an initial claim adjudication.
    Late submissionsDocumentation received after the 12-month filing limit is considered untimely, unless an identified exception applies.
    Alternate-payer exception filing limit
    Exception deadlineThe claim may be submitted within six months from the alternate payer's retraction date.
    Required conditionThe alternate payer must have retracted payment because it determined Health New England is the primary payer.

    How to Submit and Manage an Appeal

    Denial Risk

    Appeal an Untimely Filing Denial

    Submit an appeal for an untimely filing denial when requesting reconsideration of an original claim denial. Eligible scenarios include a first-time claim or replacement/corrected claim submitted outside the filing limit, coordination-of-benefits filing-limit denials, or a misidentified member/alternate-payer submission. Providers may appeal payment disputes based on disagreement with a claim decision or reimbursement.

    • The standard filing limit for an initial claim adjudication is 12 months from the date of service or date of discharge, unless an exception or alternate timeline applies.
    • This policy applies to both in-network and out-of-network providers.
    Documentation Required

    Submit Complete Appeal Documentation

    Submit complete and accurate documentation with the appeal. Incomplete disputes may be returned, and the new receipt date begins when the completed documentation is received.

    Key Terms

    Timely filing denial
    DefinitionA claim payment denial resulting from submission outside the applicable filing limit.
    First-time claimsThe denial may result from a first-time claim submitted outside the filing limit.
    Replacement or corrected claimsThe denial may result from a replacement or corrected claim submitted outside the filing limit.
    Alternate payer
    DefinitionA payer other than HNE.
    Primary-payer determinationThe alternate payer may determine that HNE should have been the primary payer.
    Payment retraction
    Policy Summary
    PayerHealth-New-England
    PolicyProvider Appeal Claim Past Filing Time Limit Denial
    Policy CodePolicy PA03POL
    Change TypeNo material change
    Effective DateOctober 1, 2022
    Next Review DateN/A
    Key ActionSubmit complete appeal documentation, including the Request for Claim Review Form and 12-digit control number, within the applicable filing limit.
    SourceLink
    On This Page
    Appeal Eligibility and ExceptionsFiling Deadlines and Determination TimeframeHow to Submit and Manage an AppealKey Terms

  1. ALL of the following

    • An EDI vendor report shows that HNE accepted the claim for processing within the filing-limit period.
    • A response report or 277 acknowledgement is provided.
    • A patient account ledger is not accepted as documentation for an EDI claim.

      Do not submit a patient account ledger as EDI documentation.

  2. A coordination-of-benefits claim involves HNE Commercial as secondary to Original Medicare, an auto accident, third-party liability, workers' compensation, or subrogation; different timelines and requirements apply, and the claim should be handled under the Provider Manual.
    3. Follow-up appealAfter submitting the claim and receiving a timely-filing denial, the provider may submit a request for HNE to review the denied claim.
    Final determination timeframe
    Determination timeframeHNE makes a final determination within 90 business days.
    Time beginsThe timeframe begins after receipt of an on-time, completed Request for Claim Review Form.
    Required submissionThe request must include all necessary and appropriate supporting documentation.
    • Completed Request for Claim Review Form with the 12-digit control number from the original EOP and a specific explanation of the dispute.
    • Copy of the original supporting EOP.
    • All applicable supporting documentation, such as surgical, operative, or office notes; pathology reports; medical invoices; and medical record entries.
    • For alternate-payer and EDI claims, include the additional documentation described in the applicable exception below.
    Documentation Required

    Document Alternate-Payer Retraction

    Document an alternate-payer retraction when the alternate payer retracts payment because it determined Health New England is the primary payer. After the retraction, submit the claim, receive the untimely filing denial, and request HNE review within the applicable deadline.

    • Submit the claim and appeal within six months of the alternate payer’s retraction date.
    • Include the alternate payer’s EOP dated within six months of the retraction date.
    • The EOP must show the payment amount and retraction date.
    • Include documentation that the provider checked the member’s eligibility with the alternate payer on the date of service.
    • Include the Request for Claim Review Form and the 12-digit control number from the original EOP.
    Documentation Required

    Document Electronic Claim Acceptance

    For a claim not on file because of electronic delivery, request review when evidence shows that Health New England accepted the claim for processing within the filing-limit period.

    • Include a copy of the EDI vendor report showing HNE accepted the claim for processing within the filing-limit period.
    • Include the response report or information from the 277 acknowledgement (277 ACK).
    • A Patient Account Ledger is not acceptable documentation for EDI claims.
    Billing Rule

    Route Coordination-of-Benefits Appeals Correctly

    Route coordination-of-benefits appeals under the applicable rules rather than using this policy when different timelines or requirements apply. COB includes situations in which HNE Commercial is secondary to another payer.

    • Examples include Original Medicare, auto accident, third-party liability, workers’ compensation, and subrogation.
    • The standard Claim Review Form may be used to provide information needed to reprocess the claim, but the applicable COB or subrogation rules govern the timeline and required documentation.
    • Refer to the HNE Provider Manual, under “Coordination of Benefits and Subrogation,” for the applicable requirements.
    • The Federal No Surprise Act guidelines and regulations apply outside this policy when applicable to claims payment.
    Denial Risk

    Do Not Balance Bill Members

    Do not balance bill members for services denied because the claim was submitted untimely under this policy.

    • This prohibition applies when HNE does not receive the claim within the specified filing period, subject to the exceptions and alternate timelines described in this policy.
    An alternate payer may retract payment after determining that HNE is the primary payer.
    Coordination of benefits
    DefinitionCoordination of benefits occurs when HNE Commercial is secondary to another coverage or liability source.
    Applicable situationsSituations include Original Medicare, an auto accident, third-party liability, workers' compensation, and subrogation.
    Separate requirementsCOB claims may have different timelines and requirements and do not fall under this policy; consult the Provider Manual.
    Electronic delivery / EDI
    DefinitionElectronic data interchange claim transmission.
    Evidence of acceptanceAn EDI vendor report may show that HNE accepted the claim for processing within the filing-limit period.
    Required acknowledgementA response report or information from the 277 acknowledgement may support the claim's electronic acceptance.