The following frequently asked questions focus on common issues providers ask when trying to better understand the rules and exemptions for timely filing. Additional information on timely filing is also available in the General Provider Information manual, available on the Billing Manual web page.
- What is the deadline for meeting timely filing requirements?
- Providers always have at least 365 days from the DOS to submit a claim. A timely filing waiver or a previous Internal Control Number (ICN) is required if a claim is submitted beyond the 365-day timely filing period.
- What date is used when considering timely filing deadlines?
- A claim is considered filed when the fiscal agent documents receipt of the claim.
- What should providers do if the initial 365-day window for timely filing is expiring?
- Providers are required to submit the initial claim within 365 days, even if the result is a denial. Providers must also resubmit claims every 60 days after the initial timely filing period (365 days from the DOS) to keep the claim within the timely filing period. The previous ICN must be referenced on the claim, even if the claim is over 365 days.
- How can a provider qualify for a timely waiver (override)?
If any of the scenarios listed below apply, but the claim in question is still within the 365-day window, a waiver is not needed and the provider only needs to resubmit the claim.
The following are examples of acceptable proof of timely filing:
- Claims that have been date-stamped by the fiscal agent or the Department and returned to the provider
- A backdate approval letter (new enrollments, affiliations or updates are not acceptable reasons for late filing). Providers must enroll and submit claims within 365 days from the DOS.
- A load letter for eligibility backdate
Claims that are not able to be submitted within the 365-day guideline, but have one (1) of the above documents attached to the submission will be put into suspended status and will be reviewed by the fiscal agent. Attachments should be submitted with the claim via the Provider Web Portal. The fiscal agent does not accept attachments via batch submissions.
- Can I attach a copy of my Remittance Advice (RA) as a timely extension?
- No. If there is an RA within the last 60 days, providers must reference the previous ICN.
- What if I contacted the Department or fiscal agent and I am still waiting for a response?
- Waiting for prior authorization or correspondence from the Department or the fiscal agent is not an acceptable reason for late filing. Phone calls and other correspondence are not proof of timely filing. The claim must be submitted, even if the result is a denial.
- What if the issue was with my vendor?
- Issues resulting in failure to transmit accurate and acceptable claims or failure to identify transmission errors in a timely manner must be addressed. If the issue is between the provider and the software vendor, billing agent or clearinghouse, this does not constitute an acceptable reason to be outside the timely filing period.
- What if the member did not notify the provider of eligibility?
Providers are expected to take appropriate and reasonable action to identify Health First Colorado eligibility in a timely manner. Some examples of appropriate action include:
- Reviewing past medical and accounting records for eligibility and billing information for services provided.
- Requesting billing information from the referring provider or facility where the member was seen.
- Contacting the member by phone or by mail.
- Verifying eligibility through the Provider Web Portal
It is not effective to rely solely on billing statements, collection notices, or collection agencies as the only means of obtaining eligibility and billing information. If the timely filing period expires because the provider is not aware that the member is Health First Colorado eligible, the fiscal agent is not authorized to override timely filing. The Delayed Notification of Eligibility form can no longer be used, as providers must submit within 365 days.
- Do I need to continue attaching the Explanation of Benefits (EOB) to electronic claims?
- Providers who receive payment from Medicare or other insurance/Third Party Liability (TPL) no longer need to attach the EOB to the electronic claim. Providers must include the Medicare or TPL EOB date on the claim. Providers must keep the EOB and supporting documentation on file.
- What is the 365-day rule?
- Claims with commercial insurance/TPL must be received within 365 days with no additional extension.
- What if Medicare is the primary payer and they processed the claim after the 365 days expired?
- Providers have an additional 120 days from a Medicare payment or denial and must include the Medicare EOB date on the claim.
- How does timely filing apply to adjustments and voids?
- If a claim is an adjustment and the provider is returning money, or if the provider is requesting an adjustment that does not change the reimbursement amount, timely filing does not apply. However, if the claim is an adjustment to request additional reimbursement, timely filing does apply.
- What if my enrollment was delayed and that delay took a year?
- Providers must enroll and submit claims within 365 days from the DOS. In most cases, a provider's enrollment can be backdated 365 days from the date of enrollment approval if the provider was licensed continuously through those dates, and meets all enrollment criteria. Providers can use their backdate enrollment approval letter as an acceptable timely filing waiver by attaching it to claims submitted after the approval effective date. A backdate approval letter is acceptable as proof of timely filing (however, new enrollments, affiliations or updates are not acceptable reasons for late filing).
- If I don't meet any of the above requirements, should I submit a reconsideration?
- No. Submitting a reconsideration without a previous ICN or acceptable documentation will result in a denial.
- If my claim is over 365 days, do I need to submit on paper with documentation?
- No. All claims, even those with attachments, should be submitted via the Provider Web Portal.
- Does the 365-day timely filing period apply to claims submitted through DentaQuest and Magellan?
- The timely filing extension to 365 days does not apply to pharmacy (point of sale) claims submitted through Magellan, however, Durable Medical Equipment (DME) claims are subject to the updated 365-day timely filing policy. DentaQuest claims are subject to the 365-day timely filing policy.