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Magellan Health

Frequently Asked Questions: Claims

Q. As a Magellan network provider, what is my timely filing limit?
A. Under Magellan's policies and procedures, the standard 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. 

For exceptions to the standard timely filing requirements for specific states and/or plans/programs, refer to your contract with Magellan and/or its affiliates; see the Magellan state-, plan- and EAP-specific handbook supplements; refer to our timely filing exception grid; or consult state and federal laws. Please note: as these requirements can be subject to change, the grid may not contain a complete list of exceptions. It is important for you to stay current with your specific state and/or plan/program requirements.    

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 for timely filing?
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. See first question and answer above.

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 are responsible for verifying the member's coverage 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 to the appeal submission address found on the Explanation of Payment (EOP). The following items when submitted with your appeal may be 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. Copy of the claim with Magellan's date stamp within the timely filing period
  4. Copy of 2nd level EDI 277 acceptance reports
  5. Copy of EOP from the medical/health plan vendor substantiating their denial date.  

Q. Why was my claim denied? 
A. There are several reasons claims may not be paid upon their first submission. As a first step, always review the Explanation of Payment (EOP) or Explanation of Benefits (EOB) and determine the reason why the claim was denied before resubmitting a new claim.

10 things to check each time you submit a claim:

  1. Complete the appropriate claim form- CMS-1500 forms are required for outpatient services and UB-04 forms are required for inpatient services.
  2. Make 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.
  3. 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.
  4. Be sure to include the specific member, or member's dependent identification number.
  5. Make sure that service dates are within the authorized time period, if applicable.
  6. Make sure the billed service submitted for payment is covered by the authorization, if applicable.
  7. Make sure diagnosis and procedure codes are correct and match the services rendered.
  8. Bill only for services included in your provider contract.
  9. Include and verify the correct Taxpayer Identification Number (TIN) and National Provider Identifier (NPI) - Remember that services authorized under a group TIN must be submitted for payment under that group's TIN.
  10. Identify the service provider including degree level, using appropriate modifiers, if necessary.

Q. I believe I am being paid the incorrect rate. What should I do?
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 toll-free number on the member's ID card or the Member’s Explanation of Benefits, or call your Magellan network representative.

Q. I have a specific question about a claim. What should I do?
A. Questions related to a specific claim should be directed to the toll-free number on the member's ID card or the Explanation of Benefits.