If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last date of service.
See Also
What is Point of Service (POS) Insurance?Health Claims and Explanation of BenefitsCigna OAPIN | Information sourcesUnderstanding Your Plan & Benefits | Out-of-Area PPO Plan | Kaiser Permanente GeorgiaAs always, you can appeal denied claims if you feel an appeal is warranted. Remember: Your contract with Cigna HealthcareSM prohibits balance billing your patient if claims are denied because they were not submitted within the time frame outlined above.
Deadline Exceptions
There are some exceptions to these deadlines. These include:
- Applicable law requires a longer filing period
- Provider agreement specifically allows for additional time
- In Coordination of Benefits situations, timely filing is determined from the processing date indicated on the primary carrier's explanation of benefits (EOB) or explanation of payment (EOP)
- Medicare (Cigna Healthcare for Seniors): In accordance with Medicare processing rules, non-participating health care providers have 15 to 27 months to file a new claim. Medicare patients' claims must be filed no later than the end of the calendar year following the year in which the services were provided. However, the filing limit is extended another full year if the service was provided during the last three months of the calendar year.
- If Medicare is the primary payer, timely filing is determined from the processing date indicated on the primary carrier's explanation of benefit (EOB)
- If Medicare is the Secondary Payer (MSP), the initial claim must be submitted to the primary payer within our timely filing period. An initial determination on a previously adjudicated claim may be reopened for any reason for one year from the date of that determination. After one year and prior to four years from the date of determination, "good cause" is required for Medicare to reopen the claim. In general, Medicare does not consider a situation where (a) Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare's systems of records and; (b) a third party mistakenly paid primary when it alleges that Medicare should have been primary to constitute "good cause" to reopen.
- If a claim was timely filed originally, but Cigna Healthcare requested additional information. If a resubmission is not a Cigna Healthcare request, and is not being submitted as an appeal, the filing limit will apply.
- Extraordinary circ*mstances1
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