Timely Claim Filing
BCBSNM and HMONM Contracted Providers
The BCBSNM/HMONM contract requires providers to initially submit
claims within 90 days of date on which service was rendered;
see contract page 4, Article IIB.3. If an original claim is submitted
after the 90 day limit, it is denied for timely filing.
Appeal of Timely Filing
Claims submitted along with proof of initial timely filing,
which are within one year of the date of service, will be allowed.
Claims received for timely filing reconsideration that are more
than one year from date of service will be denied.
Proof of timely filing:
Claims submitted for consideration of timely filing must be reviewed
with information that indicates the claim was initially submitted
within the appropriate time frame. Acceptable proof of claim
filing within 90 days of the date on which service was rendered
include the following situations or documentation:
|
Proof
|
Examples
|
| Printout
indicating the original date the claim was submitted and to
whom |
• account
ledger posting that includes multiple patient submissions
• patient
ledger
• BCBSNM/HMONM
returned claim sheet
• UB-92
with date of original submission in box 86
|
| COB information
within 90 days from other insurance or Medicare processing date
|
• Medicare
EOB
• Other
insurance EOB or EOP
|
|
Proof of follow-up with member for lack of
insurance information
Member IS responsible for providing current
and appropriate insurance information to the provider.
|
• Copies
of dated letters requesting information from member
|
| Document indicating
claim sent to wrong carrier within 90 days from date of service
and received by BCBSNM/HMONM within six months of service date
|
• copy
of EOB from other Insurance Carrier showing denial
|
|
Enrollment issues are reviewed
on a case-by-case basis
|
• Member
not enrolled, claim returned to provider
|
|
Third-party liability issues
are reviewed on a case-by-case basis
|
|
|
Legal incapacity issues are
reviewed on a case-by-case basis
|
• physical
illness
• mental
condition
• death
of contract holder
• death
of provider
|
|
Copy of BCBSNM/HMONM acceptance report for
EDI claims
Report from provider’s clearing-house
vendor is NOT accepted as proof.
BCBSNM/HMONM rejection report is
NOT accepted as proof because the claim was never received
by our office. It is the Provider's responsibility to submit
a correct claim through EDI within the 90-day filing limit.
|
• EMC
Input Transaction Report
• Blue
Cross Data Collection – BCBSNM
•Accepted Claims Report
|
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page
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