The filing limit may be extended for newborn claims, and where the eligibility has been retroactively received by Sunshine Health, up to a maximum of 365 days. Providers must submit, all claims and encounters within 180 days of the date of service, unless Sunshine Health or its vendors created the error. Payment for service is contingent upon compliance with referral and prior authorization policies and procedures, as well as the billing guidelines outlined in this manual. Referral and prior authorization processes were followed.The service provided is a covered benefit under the Enrollee’s contract on the date of service.The Enrollee is effective on the date of service.Changes to a Provider’s Tax Identification Number and/or address are NOT acceptable when conveyed via a claim form.Ĭlaims eligible for payment must meet the following requirements: Please submit this information on a W-9 form. We recommend that providers notify Sunshine Health in advance of changes pertaining to billing information. Such claims are not considered “clean” and therefore cannot be entered into the system. Claims missing the requirements in bold will be returned, and a notice sent to the provider, creating payment delays. Sunshine Health will return claims when billing information does not match the information that is currently in our files. Providers must bill with their NPI number in box 24J of the HCFA 1500 if applicable. Billing name and address (if different).Physical location address (as noted on current W-9 form).Provider National Provider Identifier (NPI).Provider nine (9) digit Medicaid Number.Provider Name (as noted on his/her current W-9 form).Please confirm with your Provider Relations Department that the following information is current in our files: It is important that providers ensure Sunshine Health has accurate billing information on file. Simply put, it has a low chance of appeal after you’ve received the denial, thus you lose money.Physicians, other licensed health professionals, facilities, and ancillary provider’s contract directly with Sunshine Health for payment of covered services. Submitting a claim past an insurance's timely filing limit will come back to you as Claim Adjustment Reason Code (CARC) 29 and state, “The time limit for filing has expired.”ĬARC 29 has a high chance of prevention but a low overturn rate. On the flipside, if your team isn't familiar with the limits for the insurances the majority of your patients use, you're losing revenue. Knowing the deadlines of payers that attribute to most of your revenue before your patients visit your office will help your team anticipate and submit your claims faster. ![]() Why not use it as a guide to help identify the most important timely filing limits your team should be aware of? ![]() It's helpful in breaking down what percentage of revenue comes from common insurances. When speaking to our clients, most of them know their payer mix.Ī payer mix is a listing of the different healthcare insurances your patients use. But which are they actually using? Of course, I'm referring to what's known within the industry as a "payer mix." There are hundreds of thousands of insurance options your patients can choose from. Some of those responsibilities include patient care, coding, and keeping track of healthcare requirements.Įnsuring your team is submitting patient claims on time is another important responsibility you need to know. With a small amount of extra effort, you can lower your timely filing denial rate even more.Ĭhances are, you and your staff already have a ton of work to complete on a daily basis. As a simple example for reference, 0.01% of $3,000,000 is $30,000.įurthermore, that percentage is only true if you have all of those payers and submit an equal amount of claims to each. If the deadline isn’t 180 or 365 days then there’s a 56% chance that the limit is 90 daysīy submitting your claims within 90 days the chances that you receive a claim denial related to timely filing is 0.01%.Ī 0.01% chance stacks the odds in your favor, although that percentage can still have a significant negative effect on your bottom line if you aren't vigilant. If the deadline isn’t 180 days then there is a 46% chance that their limit is 365 days There is a 34% chance that an insurance company has a deadline of 180 days The two most popular timeframes are 180 days and 360 days From the bar graph and statistical data above we can conclude that…
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