Claims billed to wrong payer

[venkateshwfm]

Hi,

Few claims were billed to wrong payer and resubmitted to correct payer with proof of timely filing. Even though the claims were denied stating that proof is not sufficient to process the claims and TFL has passed away.

[PMRNC]

IF this is an ERISA group health plan, ask patient for a copy of their SPD. With ERISA being federal, it trumps everything. So if a carrier says 90 day timely filing but the patient's plan says 120 days, you can appeal using ERISA law.
IF ERISA, you will need patient to sign an ARF first so you can appeal it for them.

[venkateshwfm]

Hi...Thanks for the reply...But pat plan not included in ERISA group health plan....most of the claims are pending and unable to find solution...please help me...

[Michele]

Did you include clearinghouse reports showing submission of the claim as well as practice management reports showing the history of the claim?  We include multiple reports all showing the steps taken with the claim.  The more documentation you can provide to support the fact that the claim was submitted timely, but to the wrong carrier and what was done following that.  If there is a huge gap from the original time the claim was submitted and when it was corrected and resubmitted you don't have much to stand on.