Health plans usually impose claim filing deadlines, which require physicians to submit a claim within a certain time period after the date of service. If the physician fails to meet the deadline, the health plan will not pay for the service provided. California law prohibits health plans and insurers from imposing claim filing deadlines that are less than 90 days for contracted physicians or 180 days for non-contracted physicians after the date of service. If the payor is not the primary payor under coordination of benefits (COB), the payor cannot impose a deadline for submitting a COB claim that is less than 90 days from the date of payment or date of denial from the primary payor.
Moreover, even if the physician fails to submit the claim on time, California law provides a “good cause” exception that requires payors to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay.
Below are steps you can take to prevent timely filing denials:
- Submit claims as quickly as possible after services are rendered.
- Where possible, file claims electronically.
- Retain payor acknowledgement of receipt of claim. California law requires health plans to acknowledge receipt of an electronic claim within 2 days and a paper claim within 15 days of receipt.
- Appeal all claims that have been incorrectly denied for timely filing in writing. Include a copy of the payor's acknowledgment of receipt of the claim with your appeal.
- Review health plan contracts to ensure that deadlines for filing claims are no less than 90 days.
- Report health plan violations of the timely filing laws to the appropriate regulator and to the California Medical Association.
For a summary of California's unfair payment practices, see Know Your Rights: Identify and Report Unfair Payment Practices.
TIP: An acknowledgement of receipt of a claim from a clearinghouse is not an acknowledgement that the claim has been transmitted to and received by the payor. Check with your clearinghouse to determine its process for tracking health plan receipt of claims.
CMA RESOURCES: CMA On-Call documents #0146, “Payment Denials by Managed Care Plans and IPAs;” #1070, “Managed Care Contractual Protections;” and #1051, “Physician Complaints About Managed Care Plans;” Know Your Rights: Quick Guide for Appeals; Know Your Rights: Identify and Report Unfair Payment Practices.