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The following frequently asked questions focus on common issues providers ask when trying to better understand the rules and exemptions for timely filing. Additional information on timely filing is also available in the General Provider Information manual, available on the Billing Manual web page.
Effective June 1, 2018, the Department of Health Care Policy & Financing (the Department) extended the timely filing period to 365 days from the date of service (DOS). This is a permanent change, not a temporary extension. Providers always have at least 365 days from the DOS to submit a claim. A timely filing waiver or a previous Internal Control Number (ICN) is required if a claim is submitted beyond the 365-day timely filing period.
A claim is considered filed when the fiscal agent documents receipt of the claim.
Providers are required to submit the initial claim within 365 days, even if the result is a denial. Providers must also resubmit claims every 60 days after the initial timely filing period (365 days from the DOS) to keep the claim within the timely filing period. The previous ICN must be referenced on the claim, even if the claim is over 365 days.
If any of the scenarios listed below apply, but the claim in question is still within the 365-day window, a waiver is not needed and the provider only needs to resubmit the claim.
The following are examples of acceptable proof of timely filing:
Claims that are not able to be submitted within the 365-day guideline, but have one (1) of the above documents attached to the submission will be put into suspended status and will be reviewed by the fiscal agent. Attachments should be submitted with the claim via the Provider Web Portal. The fiscal agent does not accept attachments via batch submissions.
No. If there is an RA within the last 60 days, providers must reference the previous ICN.
Waiting for prior authorization or correspondence from the Department or the fiscal agent is not an acceptable reason for late filing. Phone calls and other correspondence are not proof of timely filing. The claim must be submitted, even if the result is a denial.
Issues resulting in failure to transmit accurate and acceptable claims or failure to identify transmission errors in a timely manner must be addressed. If the issue is between the provider and the software vendor, billing agent or clearinghouse, this does not constitute an acceptable reason to be outside the timely filing period.
Providers are expected to take appropriate and reasonable action to identify Health First Colorado eligibility in a timely manner. Some examples of appropriate action include:
It is not effective to rely solely on billing statements, collection notices, or collection agencies as the only means of obtaining eligibility and billing information. If the timely filing period expires because the provider is not aware that the member is Health First Colorado eligible, the fiscal agent is not authorized to override timely filing. The Delayed Notification of Eligibility form can no longer be used, as providers must submit within 365 days.
Providers who receive payment from Medicare or other insurance/Third Party Liability (TPL) no longer need to attach the EOB to the electronic claim. Providers must include the Medicare or TPL EOB date on the claim. Providers must keep the EOB and supporting documentation on file.
Claims with commercial insurance/TPL must be received within 365 days with no additional extension.
Providers have an additional 120 days from a Medicare payment or denial and must include the Medicare EOB date on the claim.
If a claim is an adjustment and the provider is returning money, or if the provider is requesting an adjustment that does not change the reimbursement amount, timely filing does not apply. However, if the claim is an adjustment to request additional reimbursement, timely filing does apply.
Providers must enroll and submit claims within 365 days from the DOS. In most cases, a provider's enrollment can be backdated 365 days from the date of enrollment approval if the provider was licensed continuously through those dates, and meets all enrollment criteria. Providers can use their backdate enrollment approval letter as an acceptable timely filing waiver by attaching it to claims submitted after the approval effective date. A backdate approval letter is acceptable is proof of timely filing (however, new enrollments, affiliations or updates are not acceptable reasons for late filing).
No. Submitting a reconsideration without a previous ICN or acceptable documentation will result in a denial.
No. All claims, even those with attachments, should be submitted via the Provider Web Portal.
Claims that were denied for timely filing outside of 240 days but are still within 365 days of the date of service as of June 1, 2018, can be resubmitted by the provider. The Department's fiscal agent will not be reprocessing any previous claims that denied for timely filing.
The timely filing extension to 356 days does not apply to pharmacy (point of sale) claims submitted through Magellan; however, Durable Medical Equipment (DME) claims are subject to the updated 365-day timely filing policy. DentaQuest claims are subject to the 365-day timely filing policy.