Aetna Better Health will consider a claim for resubmission only if it is re. 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. You will receive directions from the Quality Improvement Organization (QIO) regarding additional appeal options. New Claim -MLTC claims must be submitted within 120 days from the date of service. What should providers do if the initial 365-day window for timely filing is expiring Providers are required to submit the initial claim within 365 days, even if the result is a denial. The Quality Improvement Organization will respond to you as soon as possible, but no later than 14 days after receiving your request for a second review.
You may ask for this review immediately, but must ask within 60 days after the day the Quality Improvement Organization said no to your Level 1 Appeal. Within 48 hours the reviewers will tell you their decision. Medicare non-participating provider claims Retroactive authorizations Some non-Medicare claims based on state legislation When you submit a dispute online through our provider website on Availity, the process for determining whether it goes to a reconsideration or an appeal is determined by Aetna using the criteria above.
When you'll hear back from the Quality Improvement Organization (QIO) (Please refer to above directions regarding filing an expedited appeal) Our timely filing limitations are as follows: New Claim Submissions Claims. If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to us instead. You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care. supplier and the provider or supplier cannot submit the claim to Medicare, because the the timely filing limit has expired (See 70.7.3). 36 months if the improper payment was due to a recovery by Medicaid, Medicare, the Children's Health Insurance program or any other state or federal health care program. 24 months if the improper payment was due to a coordination of benefits error. You can ask to change this decision so you're able to continue coverage. Time allowed to file an initial claim-payment dispute. When your coverage for that care ends, we'll stop paying our share of the cost for your care. You’ll receive a "Notice of Medicare Non-Coverage (NOMNC)" in writing at least 2 days before we decide it’s time to stop covering your care. (Usually, this means you’re getting treatment for an illness or accident, or you're recovering from a major operation.) Weve changed the standard nonparticipating-provider timely filing limit from 27 months to 12 months for traditional medical claims. Rehabilitation care as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF).Skilled nursing care as a patient in a skilled nursing facility.You have the right to keep getting your covered services for as long as the care is needed to diagnose and treat your illness or injury if you’re getting:
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