ATT020_SurvivorCCE_TGD007_TimelyFiling.pdf

Controlled Unclassified Information TGD 007 July 2022

General Contractor Technical Guidance Document

TGD #007

Clarification Regarding Timely Filing Limits and Claim Review Time Limits for Medical Service Claims

ORIGINAL PUBLICATION: April 1, 2022 DATE LAST REVIEWED: July 01, 2022

Purpose

The purpose of this Technical Guidance Document (TGD) is to provide clarification on timely filing limits (TFLs) and to update the time limit for review of external provider claims.

Stakeholders Affected Clinical Centers of Excellence (CCE) Nationwide Provider Network (NPN) William Street Clinic (WSC) Health Program Support Contractor or Third-Party Administrator (HPS/TPA)

Background The World Trade Center (WTC) Health Program requires internal and external claims to be filed in a timely manner, and also requires the CCE review of external provider claims.

Technical Guidance Update to Timely Filing Limits TFLs ensure claims are submitted within a specified time frame so that the WTC Health Program may track health care expenditures for budget planning. If a claim is submitted after the TFL, the claim will be denied. An appeal to override the TFL may be requested and approved in limited circumstances, though these appeals create inefficiency in claims processing.

External Claims

The TFLs for claims submitted from external providers will be:

1. For claims without Coordination of Benefits1 (COB):

a. 15 months from the date of service

2. For claims with COB:

a. 18 months from the date of service (previously 15 months)

Internal Claims The TFLs for claims submitted from external providers will be:

1. For claims without COB:

a. 95% submitted within 90 calendar days of the dates of service (previously 30 days)

1 Note that coordination of benefits applies only to members categorized as a Survivor.

Clarification Regarding Timely Filing Limits and Claim Review Time Limits for Medical Service Claims

b. 100% submitted within 180 calendar days of the dates of service (previously 60 days)

2. For claims with COB:

a. 18 months (previously 15 months)

Time Limit Update for CCE Review of External Provider Claims Not applicable to the NPN The CCE must approve, deny, or pend 90% of claims from external providers within five business days of the claims being posted on the Claims Portal and 100% of the claims within 10 business days. All pended claims must be resolved within 30 business days from the pend date (or sooner if the TFL will be exceeded), unless a written explanation is sent to the WTC Health Program Claims Official. The resolution should be reported as soon as it is completed. This new timeline reflects a change from the previous guideline which required that all claims from external providers be reviewed and either approved or denied within one week2 of being posted on the Claims Portal.

Requests to override the Timely Filing Limit There are situations when consideration may be given to allow a claim, which is beyond the Timely Filing Limit, to be considered for reimbursement. Consideration will be given for the following reasons (not a complete list):

1. The claim was submitted timely by the provider but was delayed by the Program or it’s representative through no fault of the provider

2. The provider was not enrolled on the date of service but was later enrolled with a retroactive enrollment date that covers the date of service on the claim

3. The code was not in the Codebook or under appropriate benefit plan on the date of service but was added through the WTC-5 process with a retroactive date that covers the date of service on the claim

4. Member’s primary insurance was billed in error

5. Coordination of benefits caused the claim to be delayed

6. CCE attempted to work with provider to change CPT or IDC-10 code to Program allowed code, causing the delay in submission

7. Claim was not received Timely, but provider has proof of Timely submission

Deliverable Claims related QA metrics within the Semi-Annual Internal Audit Report should reflect the updated timely filing limits starting with the May 2020 Semi-Annual Report.

Quality Controls On an annual basis, the WTC Health Program will conduct an internal evaluation of claims and appeal requests to ensure compliance with this technical guidance. CCEs will be notified of non-compliance and corrective actions needed.

Supplemental Material(s) PWS section C.3.5 Claims Submission and Payment and C.3.10 Summary of Services and Requirements Selected for Inspection (QASP) Technical Guidance for Quality Assurance and Internal Audits (QA Metrics)

2 Note that this requirement has been interpreted as five business days or seven calendar days in the past.

Clarification Regarding Timely Filing Limits and Claim Review Time Limits for Medical Service Claims

Revision History

Rev # Changes Made to Document Date

1 New Technical Guidance Document 02/28/2020

2 Revised – Added Section 3 01/01/2021

3 Updated to 2022 TGD Template 07/01/2022

WTC Health Program Approval The undersigned acknowledges they have reviewed this WTC Health Program technical guidance document (TGD) and agree with the approach it presents. Changes to this TGD will be coordinated with and approved by the undersigned or their designated representative(s).

Signature: ______________________________________________ Date: ____________

Date_2: 7/15/2022