Frequently Asked Questions: Claims
Q. I am a member of the Magellan
provider network, what is my timely filing limit?
A. Under Magellan's policies and procedures, the standard
Magellan timely filing limit is 60 days. This means that, subject
to applicable state or federal laws, claims must be submitted
to Magellan within 60 days of the date of service or inpatient
discharge. If claims are submitted after the timely filing limit,
they will be denied for payment, subject to applicable state and
federal laws.
Q. Are there any
exceptions to the timely filing limits noted in the contract?
A. Yes. If your state law allows a longer period of
time in which to file claims, that period of time will take precedence
over the Magellan standard of 60 days. Extended filing time is
also allowed for member submitted claims and coordination of benefit
(COB) claims where Magellan is the secondary payor.
Q. Do any states have specific
timely filing limits that would override contracted limits?
A. Yes. The following states have timely filing limits
that supersede Magellan's timely filing standard of 60 days:
- New Hampshire and Tennessee -- a claim must be filed within 90 days of the date of service or inpatient discharge to be considered timely.
- Florida, Missouri, Maryland, New Jersey, North Carolina and the District of Columbia -- a claim must be filed within 180 days of the date of service or inpatient discharge.
- Texas -- a claim must be filed within 95-days of the date of service or inpatient discharge.
- Michigan or rural hospitals in Louisiana -- a claim must be filed within one (1) year of the date of service or inpatient discharge.
- Wisconsin -- a claim must be filed within 365 days of the date of service or inpatient discharge.
- California -- a claim by a contracted provider must be filed within 90 days of the date of service to be considered timely. A claim by an out-of-network provider must be filed within 180 days of the date of service to be considered timely. If a state or federal law requires filing before these times, the deadline in the state or federal law must be followed. Where the Magellan company is the secondary payer, supplemental or COB claims must be filed within 90 days of payment or denial from the primary payer.
Q. I have never had a claim
denied for timely filing reasons before, why is it being
denied now?
A. Magellan continuously looks at our processes and
procedures to improve service and increase efficiencies. By enforcing
the timely filing requirement in the provider contract, we are
able to focus our resources on what our providers have asked us
to do - promptly pay claims. Enforcing this clause also brings
us in line with industry practices.
Q. This claim is a
resubmit, why was it denied?
A. Magellan did not receive your resubmitted claim within
our timely filing limits (or within the timely filing limits of
your state) after the initial date of denial. For this reason,
your resubmitted claim has been denied.
Q. Does this timely filing limit
apply to all claims for all members (e.g., COB, Medicare,
etc.)?
A. No, COB and Medicare timely filing limits are in
excess of one year. Also, if you have a member who has benefit
coverage by Magellan through a plan in another state, that state's
filing limits would apply for that claim.
Q. I recently joined
the Magellan provider network. Will the timely filing standards
be applied to claims I submitted prior to being a Magellan
provider?
A. No, claims are paid based on your status on the date
of service. The Magellan timely filing standards (or in accordance
with your state law) will be applied to claims for services rendered
after you joined the Magellan network.
Q. I did not submit a claim
due to a change in coverage for the member in question. Do
the timely filing limits apply to this claim?
A. Yes. You need to verify the insurance coverage of
the member at the time of service.
Q. I have proof that
I submitted the claim within the timely filing limits, what
is the appeals process? Where do I send the claim information?
A. If you believe your claim was denied in error, please
send your request for appeal along with support information to
the address in your authorization of care letter or call the number
on your EOB to obtain the appropriate appeal submission address.
Submitting any of the following information with your appeal is
considered evidence that your claim was submitted in a timely
manner: 1) copy of an EOP with a date within the timely filing
period; 2) certified or overnight mail receipts dated within the
timely filing period; 3) copies of the microfilmed claim with
Magellan's date stamp within the timely filing period.
Q. Why was my claim denied?
A. There are several reasons claims may not be paid upon their
first submission. These reasons range from complex systems
interface and electronic adjudication challenges to simple
administrative issues. Magellan is working on the more complex
issues, but there are a number of things you can do to make
sure your claim doesn't get held up because of administrative
reasons.
Here's a quick list of ten simple things to check each time you submit a claim:
- Complete the appropriate claim form- CMS-1500 forms are required for outpatient services and UB-04 forms are required for inpatient services.
- Be sure to send your claim form to the appropriate claims payer and specific address. Magellan has separate post office boxes for the accounts for which we provide claims payment services. If you are not sure which address to submit a claim to, refer to your quick reference guides, or call the Care Management Center number on your authorization letter.
- Make sure the member's name appears on the claim form just as it appears on the insurance card. Watch out for name variations or changes.
- Be sure to include the specific member, or member's dependent identification number.
- Make sure that service dates are within the authorized time period.
- Make sure the number and type of sessions submitted for payment are within the parameters of the authorization.
- Make sure diagnosis and CPT codes are correct and match the services authorized and rendered.
- Include and verify the correct Taxpayer Identification Number (TIN)- especially if it is a different number than the identification number of the service provider. Remember that services authorized under a group TIN must be submitted for payment under that group's TIN.
- Identify the service provider including degree level.
- Review the Explanation of Payment (EOP), if applicable, and correct the issue noted that kept the claim from being paid before resubmitting a denied claim.
Q. I believe I am being
paid the incorrect rate.
A. The easiest way to determine your current rates is to review
the current rate sheet for your Magellan or affiliate company
agreement. If after reviewing your rates you still believe there
is an error, please contact the Care Management Center number
on your authorization letter. Individual and group practitioners
can also check their rates by signing in to the Magellan provider
website and clicking "Check Rates."
Q. I have a specific question
about claims.
A. Questions related to a specific claim should be directed
to the toll-free number on the member's card, or in the authorization
of care letter.