DENIAL PATHWAY

Claim denied for untimely filing

DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
document may not be reproduced or reviewed by any person who is not an employee of Pacific.
 Claim denied for untimely filing

Meaning:

Every insurance has a filing limit to submit the claim. Filing limit is counted from the date of service. It varies
from insurance to insurance

Steps in CareCloud:

1. To be entered by Vishal

Pre-Call Analysis:

1. If the Mode of transmission is through electronic, check in Clearing house for any rejection of the
claim
2. Claim successfully sent – Clearing house states claim accepted by Payer, call payer.
3. Claim Rejected: Work on the rejection accordingly (No calling is required in this case)

Question to be asked On Call:

1. Get the denial date/received date, claim#, request for EOB?

2. May I have the filing limit for this claim? Check in CareCloud when was the claim billed. (Claim billed
Within TFL?)
3. What documentation do you require to appeal for timely filing?
4. Could you give me the fax # so that I can go ahead and fax it to your attention.
5. What is the appealing limit & appeals Mailing Address?

Claim scenario 1:

Claim Billed Within Timely Filing – Check the received date, if received is within TFL & denial is incorrect.

Action:

1. Place a call to insurance company

2. Share the claim acceptance date (as per the clearing house) with the insurance rep
3. Ask the representative to reprocess the claim
4. Select the follow up date according to the payer guidelines

Action Description Action Taken Code Care Cloud Follow-up

Action Days
Marked for follow-
Denial is invalid and Mark for follow Payer specific
up: Payer sent claim
sent for reprocessing up follow up days
for review

DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
document may not be reproduced or reviewed by any person who is not an employee of Pacific.
Claim scenario 2:

Claim Was Not Received within timely filing, & proof is available

Action:

1. Place a call to insurance company

2. Check, which proof of timely filing do they accept?
3. Create a task to send an appeal to insurance with the proof of timely filing
4. Follow the payer specific appeal format

Action Description Action Taken Code Care Cloud Follow-up

Action Days
Appeal faxed/Mailed to Pended: Appeal Create a NA
insurance Task

Claim scenario 3:

Claim was never billed within the timely filing

Action:

1. Place a call to insurance company

2. Confirm the timely filing limit
3. Create a task to adjust the account

Action Description Action Taken Code Care Cloud Follow-up

Action Days
Denial is valid and need to Create a
Pended: Timely filing NA
write off Task

DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
document may not be reproduced or reviewed by any person who is not an employee of Pacific.