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

    Timely Filing Limit

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    This policy governs deadlines and submission requirements for claims submitted to Health New England by participating and non-participating physicians and other qualified health care professionals across specified commercial, Medicare Advantage, and BeHealthy Partnership plans.

    Policy Summary
    PayerHealth-New-England
    PolicyTimely Filing Limit
    Policy CodePolicy PP045POL
    Change TypeAdministrative clarification
    Effective DateNovember 1, 2023
    Last ReviewFeb 27, 2026
    Next Review DateApril 1, 2027
    Key ActionSubmit accurate claims within the applicable filing limit and include the primary insurer's Explanation of Benefits for coordination-of-benefits claims.
    SourceLink
    POLICY UPDATE CHANGES

    Medicare coordination-of-benefits language was aligned.

    The document template and resource links were updated.

    90 daysCommercial claim filing limit
    365 daysMedicare claim filing limit
    90 daysCOB filing limit
    0Member billing after late-filing denial

    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.

    Claim Filing Requirements by Plan

    Commercial claims

    Commercial participating and non-participating providers must meet all of the following filing requirements:

    ALL of the following

    • ALL of the following

      • Submit commercial claims within the applicable filing period.90 days from the date of service or date of discharge
      • For non-participating providers, submit claims within the applicable commercial filing period.90 days
    • When coordinating benefits with a primary insurance carrier, submit the claim within 90 days from the date the primary insurer processed the claim; indicate the process date on the primary insurer's Explanation of Benefits (EOB) and include the EOB with the claim submission.
    • Do not bill members for services denied because the filing limit was exceeded.

    Medicare claims

    Medicare participating and non-participating providers must meet all of the following filing requirements:

    ALL of the following

    • Submit claims for Medicare members within 365 days from the date of service.365 days from the date of service
    • For inpatient admissions, submit claims within 365 days from the date of discharge.365 days from the date of discharge
    • When coordinating benefits with a primary insurance carrier, submit the claim within 90 days from the date the primary insurer processed the claim; indicate the process date on the primary insurer's Explanation of Benefits (EOB) and include the EOB with the claim submission.90 days from the primary insurer's processing date

    Be Healthy Partnership claims

    Providers submitting Be Healthy Partnership claims must meet all of the following filing requirements:

    ALL of the following

    • Submit claims for Medicare members within 90 days from the date of service.90 days from the date of service
    • For inpatient admissions, submit claims within 90 days from the date of discharge.90 days from the date of discharge
    • When coordinating benefits with a primary insurance carrier, submit the claim within 90 days from the date the primary insurer processed the claim; indicate the process date on the primary insurer's Explanation of Benefits (EOB) and include the EOB with the claim submission.90 days from the primary insurer's processing date

    Self-funded claims

    Providers submitting claims under the self-funded section must meet all of the following filing requirements:

    ALL of the following

    • Submit claims for Medicare members within 90 days from the date of service.90 days from the date of service
    • For inpatient admissions, submit claims within 90 days from the date of discharge.90 days from the date of discharge
    • When coordinating benefits with a primary insurance carrier, submit the claim within 90 days from the date the primary insurer processed the claim; indicate the process date on the primary insurer's Explanation of Benefits (EOB) and include the EOB with the claim submission.90 days from the primary insurer's processing date

    Claim Filing Limits

    In-Network Commercial Fully Insured
    Claim filing limit90 days
    MeasurementFrom the date of service or date of discharge
    Provider scopeIn-network commercial fully insured providers
    In-Network Commercial Self-Funded
    Claim filing limit90 days
    MeasurementFrom the date of service or date of discharge
    Provider scopeIn-network commercial self-funded providers

    Submission and Billing Responsibilities

    Note

    Authorization Requirements

    Authorization requirements are not applicable under this policy.

    Documentation Required

    Accurate Claim Submission and Audit

    Providers are responsible for submitting accurate claims. HNE reserves the right to audit any provider or facility for compliance with the payment-policy guidelines in accordance with its provider review policy.

    Documentation Required

    Coordination-of-Benefits Documentation

    When coordinating benefits with a primary insurer, submit the claim to HNE within 90 days from the date the primary insurer processed the claim. The primary insurer’s processing date must be shown on the primary insurer’s Explanation of Benefits (EOB), and the EOB must be included with the HNE claim.

    Claim Filing Period Definition

    Claim Filing Limit
    Date of serviceThe filing period may be measured from the date of service
    Inpatient dischargeFor applicable inpatient claims, the filing period may be measured from the date of discharge
    Coordination of benefitsWhen coordinating benefits, the filing period is measured from the date the primary insurer processed the claim
    Policy Summary
    PayerHealth-New-England
    PolicyTimely Filing Limit
    Policy CodePolicy PP045POL
    Change TypeAdministrative clarification
    Effective DateNovember 1, 2023
    Last ReviewFeb 27, 2026
    Next Review DateApril 1, 2027
    Key ActionSubmit accurate claims within the applicable filing limit and include the primary insurer's Explanation of Benefits for coordination-of-benefits claims.
    SourceLink
    On This Page
    Claim Filing Requirements by PlanClaim Filing LimitsSubmission and Billing ResponsibilitiesClaim Filing Period Definition
    Do not bill members for services denied because the filing limit was exceeded.
    Do not bill members for services denied because the filing limit was exceeded.
    Do not bill members for services denied because the filing limit was exceeded.
    Commercial Out-of-Network
    Claim filing limit90 days
    MeasurementFrom the date of service or date of discharge
    Provider scopeCommercial non-participating providers
    Medicare
    Claim filing limit365 days
    Standard measurementFrom the date of service
    Inpatient admissionsFrom the date of discharge
    Be Healthy Partnership
    Claim filing limit90 days
    Standard measurementFrom the date of service
    Inpatient admissionsFrom the date of discharge
    Self-Funded Section
    Claim filing limit90 days
    Standard measurementFrom the date of service
    Inpatient admissionsFrom the date of discharge
    Coordination of Benefits
    Claim filing limit90 days
    Starting pointThe date the primary insurer processed the claim
    Required documentationIndicate the primary insurer's processing date and include the primary insurer's Explanation of Benefits with the claim submission
  1. This coordination-of-benefits filing limit applies when the primary insurer is Medicare or another primary carrier.
  2. Contracts may differ and supersede this information.
    3. Denial Risk

    Timely Filing Denial and Member Billing

    Claims submitted after the applicable filing limit may be denied. Members cannot be billed for services denied because the filing limit was exceeded.

    • For commercial members, the filing limit is generally 90 days from the date of service or discharge, including for non-participating providers.
    • For Medicare members, the applicable limit varies by the governing provision and contract: 365 days from the date of service (or discharge for inpatient admissions) under one Medicare provision, or 90 days from the date of service (or discharge for inpatient admissions) under other contract-dependent provisions.
    • Contracts may differ and supersede this information.