What exactly is Timely? In the medical world this word is thrown around quite a bit. The definition of timely is done or occurring at a favorable or useful time; opportune.This can relate to a patient’s planned treatment, the creation of a chart note, the transfer of records to another physician, or it can refer to the submission of claims, medical records, and appeals to an insurance company.
Timely Filing means that there is a time limit to submit a claim for processing to an insurance company. This is the “timely” most people are familiar with. Timely filing can be as short as 90 days from the date of service up to 1 year. Having proof of timely filing is an important factor in overturning a timely denial, however, if the claim really was submitted out of timely, the claim may need to be written off as it is not appropriate to bill a patient for this. There is also the term timely processing. This is the timeframe insurance is allowed to complete the processing of a claim. This is mandated by the state and is typically 30 days from first receipt.
Timely Response is the amount of time allotted to respond to a request from an insurance company. This includes the submission of medical records, submitting a claim action request form or corrected claim, or other information needed to accurately process a claim. If this is not followed then a claim will be ‘closed’ and no further action will be taken by the insurance. The timeframe for these may be published in the provider manual, or you can get this information from calling provider relations. The average time allowed is 1 year from the initial determination on a claim.
Timely Review is the amount of time allowed to review the additional information after it has been submitted and received. Most payers allow 60 days to complete a review, and this may also be mandated by the state. Colorado State mandates that a “dirty” claim (claim needing additional information) must be paid, denied, or settled within 90 calendar days from the original receipt date or pay a 10% penalty. Read your laws carefully, most of these rules do not apply to self-funded policies.
Timely Appeal; as mentioned above there is also an allowed timeframe to submit an appeal. Average time is 180 days to 1 year from the date of denial. However, some are from date of service, so it is always best to ask when calling on denied claims. Medicare allows a redetermination to be submitted 120 days from the receipt of the Remittance Advice. They do allow 180 days for a Reconsideration (level 2 appeal) from the date of notice of the redetermination, so the rules may vary from payer to payer and appeal level to appeal level.
Timely Recoupments. Each state has a law governing the timeframe a payer can request an overpay back from a provider. Some states have a 12 month rule, in that an overpayment can only be requested within 12 months of the original payment. Some have no limits on the timeframe, and some, like Texas only allow 180 days from payment to initiate a recoupment. Like timely review however, these rules do not apply to self-funded insurance plans. Those are governed by ERISA law, a whole different ballgame. It is advisable to look up your states laws and keep them in mind when addressing these requests.
Timely Completion. This refers to the timeframe it takes to complete a medical record in a patient’s chart. Medicare suggests that records should be completed at the time of service or shortly thereafter and that a reasonable timeframe to complete a record is 24-48 hours if a situation has interfered with producing the record immediately. Medical records should never be altered, and if an addition or correction needs to be made, this should also be in a timely fashion and the change should clearly show the original entry and a time dated and signed alteration.
So you see, “timely” means so much more in the healthcare industry than just the timely filing we are all so familiar with.
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