Timely Filing?

Question

If a participating provider neglects to submit a claim in a timely fashion and it is denied by the HMO for "timely filing", do they go back to the patient/member for payment? If yes...what recourse does the patient have? It is not the patient's fault that the provider dropped the ball, so to speak.

Thank you.

Answer 1

If the provider can prove that the patient did not provide the insurance information when requested repeatedly, THEN the patient can be back billed.  If the provider had the correct information but neglected to bill the claim on time, then the provider eats it - timely filing is NOT a secret, ALL providers' billing departments know what the basic guidelines are. (And when it doubt, the sooner you bill the company, the better.)

Answer 2

They can try and hope you don't know better but, the responsibility is not yours. The proof is the stamped date of the electronic submission from the providers office. The insurance company also has a stamped date that they received the claim.

Answer 3

I worked for an insurance company ... For timely filing , a lot of hospitals are experiencing this situation.. For this one , the patient is not responsible for the claim since its not your fault that the claim was denied for that reason.... its going to be the hospital problem. .The hospital will then submit an appeal and provide evidences to prove that they submitted the claim in timely manner... This appeal will be reviewed for a 30 bd... and if its going to be denied then its still not your responsible... Talk to the hospital and tell them its not your fault... The last option will be the meet and confer where the insurance and the hospital will meet and discuss this.... BUT YOU HAVE NO RESPONSIBILITY FOR THE CLAIM....tell the hospital that!!!

Ex Blue Cross CA Provider Care

Answer 4

The patient would not be responsible unless the patient did not provide the provider with the insurance info. By being part of the HMO the provider has agreed to the HMO's rules which include pricing and timely filing. The provider may try to come after insured in hopes they do not know better. If this happens contact the HMO and let them know what the provider is trying to do.

Answer 5

I was told by my insurance company, Cigna, that if an in-network provider did not file a claim in a timely manner, that they did NOT have recourse against the patient.

I haven't tested this yet, though, LOL.