Attachment J.8 - TGD 007 (Timely Filing).pdf

Contractor Technical Guidance Document

TGD #007

Clarification Regarding Timely Filing Limits and Claim Review Time Limits for Medical Service Claims for the Clinical Centers of Excellence

Issue Date: February 28, 2020 Effective Date: April 1, 2020

Revised Effective Date: January 1, 2021

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:

The requirements in this Technical Guidance Document apply to the Clinical Centers of Excellence (CCE) and Health Program Support contractor.

Background:

The World Trade Center (WTC) Health Program recognizes that TFL requirements need to be revised in the contract Performance Work Statement (PWS). The time limit for CCE review of external provider claims has also been updated by The WTC Health Program and will be revised in the contract PWS.

Technical Guidance:

1. 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.

The PWS section C.3.5 Claims Submission and Payment will be changed as follows:

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

• For claims without Coordination of Benefits1 (COB):

(1) 15 months from the date of service

• For claims with COB:

(1) 18 months from the date of service (previously 15 months)

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

• For claims without COB:

(1) 95% submitted within 90 calendar days of the dates of service (previously 30 days)

(2) 100% submitted within 180 calendar days of the dates of service (previously 60 days)

• For claims with COB:

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

(1) 18 months (previously 15 months)

2. Time Limit Update for CCE Review of External Provider Claims:

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.

3. 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):

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

• 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

• 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

• Member’s primary insurance was billed in error

• Coordination of benefits caused the claim to be delayed

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

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

4. Quality Assurance Surveillance Plan:

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.

5. 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.

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.

Revision History:

Rev # Changes Made to Document Point of Contact Date

1 New Technical Guidance Document Beth Walker 2/28/2020

2 Revised – Added Section 3 Beth Walker 01/01/2021