29: The time limit for filing has expired

Denial Occurrence:

• This denial occurs when insurance receives the claim after TFL expired.

TFL:

• TFL stands for timely filing limit.
• A timely filing limit is a time frame set by an insurance company for providers to submit a claim.
• TFL must be calculated from the date of service (DOS).

POTF:

• POTF stands for Proof of timely filing.
• You can consider the below proofs as POTF,
• An initial filed claim to the same insurance which is not received by the payer.
• Initially rejected claims. 
• Initial billing to any other payer.

AFL:

• AFL stands for appeal filing limit.
• ATL must be calculated from the date of denial (DOD).

On Call Scenario:

                                                          Claim denied as Past timely 
                                                               filing or TFL expired
                                                                             ↓
                                                            May I get the denial date?
                                                                             ↓
                                                       When did you receive the claim?
                                                                             ↓
                                                    How much is the Timely filing limit?
                                                                             ↓
                                             Check if the claim was received within TFL
                                              ↙                                                                  ↘
                                       Yes                                                                        No
                                         ↓                                                                           ↓
                   Could you please send the                                       Check if POTF available
                  claim back for reprocessing                                        ↙                                 ↘
                  since the claim was received                                  Yes                                     No
                            within TFL?                                                    ↓                                        ↓
                                    ↓                                         Can we appeal with POTF?            May I have

             What is the TAT for reprocessing?                                ↓                                 the claim# &
                                    ↓                                          What is the fax# or Mailing             call ref#?
                   May I have the claim# &                    address to send an appeal? &                  

                              call ref#?                                     What is the appeal limit?

                                                                                                    ↓

                                                                                  May I have the claim# &

                                                                                               call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can be different from your process update.
• If the claim was denied incorrectly and the rep send the claim back for reprocessing then you can set the follow-up for the TAT provided by the rep. 
• If the claim was billed after TFL expired and POTF is available that proves that we billed the claim within TFL then send an appeal to insurance.
• If the claim was billed after TFL expired and there is no POTF available then you can adjust the claim.
• You may come across a scenario where a claim was initially billed within TFL to different insurance and billed to current insurance after TFL expired then you can use initial billing information as POTF and send an appeal to insurance.
• Calculate the appeal filing limit, if it is not crossed then send the POTF, or else write off the claim if the appeal filing limit is crossed.
• Sometimes the client wants us to send POTF even if the AFL is crossed, so work accordingly.
• You may also come across a scenario where the claim was billed to insurance on the last date of the TFL period but the claim was received by insurance after the TFL expired (for example, TFL is 90 days and the claim was billed on 90th day to insurance but the claim was received by the insurance on 91st day or afterward). Then you can send an appeal on such claims with POTF to receive the payment.
• Click here to go to Quiz

Prepare Notes:

Source of Status:

* Call Website EOB System

Clearing House Comment (Please make the changes if required):

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Denial Date:

*

Received Date:

*

TFL:

*

Is claim received within the TFL?:

* Yes No

TAT for Reprocessing:

*

Is POTF Available?:

* Yes No

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Website Link:

*

Appeal Limit:

*

Mailing Address:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Adjusted the claim Need to allow time Need client assistance Need to submit an appeal Appeal sent



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