Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage 6

Anthem is Changing Their Timely Filing Requirements for All Plans, Including Medicare Advantage

Cyndee Weston, CMRS, CMCS, CPC
Cyndee is the Executive Director of American Medical Billing Association

This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We’ve seen this letter, or something very similar, was sent to doctors and other healthcare providers from California to Kentucky.
In their notice, Anthem states:
Effective for all commercial and Medicare Advantage Professional Claims submitted to the plan on or after Oct. 1, 2019, your Anthem Blue Cross and Blue Shield (Anthem) Provider Agreement(s) will be amended to require the submission of all commercial and Medicare Advantage professional claims within ninety (90) days of the date of service. This means all claims submitted on or after October 1, 2019 will be subject to a ninety (90) day timely filing requirement.”
 
They further state:
If you object to the enclosed amendment, you must provide us with written notice of your appeal within 30 days of receipt of this letter. If, after 30 days, we are unable to reach an agreement, your contract will terminate on or before October 1, 2019.”
If you do not accept these terms, you can “object,” according to Anthem’s wording, but it’s pretty clear that your contract with Anthem will terminate on October 1, 2019.
Below is the letter we received from an AMBA member’s Kentucky doctor (Click Here to Download a Larger Image of this Letter):
 
Medicare allows 12 months on timely, right?
If you ask Medicare Advantage payers whether they follow Medicare rules and regulations, they will tell you that they do. But in fact, this is a classic example of Medicare Advantage payers NOT following Medicare regulations. We all already know this, but here is Medicare’s rule regarding timely filing:
 
“Claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished.”
Medicare Advantage Plans do not have to follow the same rules that Medicare Fee-for-Service plans must. Here are the regulations for Medicare Advantage Plans.
 
How Anthem and others (UHC, Aetna) get around the 12-month timely filing limitation
It’s very simple – these payers have tied their timely filing policy to the provider’s contract. If you are NOT contracted with Anthem, then you may have other remedies to rely on, such as your state law (Florida requires at least 6 months, Virginia requires at least 12 months). You should ensure you are benefitting from these longer deadlines if you are not contracted. It’s only fair when most Medicare Advantage Plans are already using contracts to limit those providers to 90-day timely filing deadlines.
Here’s a tip if you have passed the timely filing deadline: a Medicare Advantage patient can absolutely file a grievance with Anthem or any other Medicare Advantage payer and may be able to get the full 12 months allowed under Medicare regulations.
And here’s another tip: an ERISA appeal may provide 12 months on plans that are subject to ERISA law (employer group plans that are not a church plan and not a Government plan).
Watch for more notifications from Anthem – there is a new prior authorization letter circulating and we will be talking about this as well as their new modifier -25 edits in the next few days.
This Week’s Audit Tip Written By:
Cyndee Weston, CMRS, CMCS, CPC
Cyndee is the Executive Director of American Medical Billing Association
Follow American Medical Billing Association on Facebook

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email [email protected].
  2. Read more: What can you expect from a coding and compliance review?
Here’s why thousands of providers trust DoctorsManagement to help improve their coding and documentation.

Quality of coders and auditors. Our US-based auditors receive ongoing training and support from our education division, NAMAS (National Alliance of Medical Auditing Specialists). All team members possess over 15 years of experience and hold both the Certified Professional Coder (CPC®) as well as the Certified Professional Medical Auditor (CPMA®) credential.

Proprietary risk-assessment technology – our auditing team uses ComplianceRiskAnalyzer(CRA)®, a sophisticated analytics solution that assesses critical risk areas. It enables our auditors to precisely select encounters that pose the greatest risk of triggering an audit so that they can be reviewed and the risk can be mitigated.

Synergy – DoctorsManagement is a full-service healthcare consultancy firm. The many departments within our firm work together to help clients rise above the complexities faced by today’s healthcare professionals. As a result, you receive quality solutions from a team of individuals who are current on every aspect of the business of medicine.