For all Medica and SelectCareSM/LaborCare® products except Medica Select SolutionSM and Medica Prime SolutionSM:
- Original claims submissions must be received at the designated claims address no more than 180 days after the date of service or date of discharge for inpatient claims.
For Medica Select Solution and Medica Prime Solution:
- When Medicare is the payer, the timely filing limit is 180 days after the payment date on the explanation of Medicare benefits (EOMB) statement.
- When Medica is the payer, the timely filing limit is 180 days after the date of service or date of discharge for inpatient claims.
Medica requires that claims, resubmissions and/or adjustments for these exceptions be received at the designated claims address within 18 months of the date of service or date of discharge for inpatient claims. In addition, SelectCare/LaborCare claims must be directed to the appropriate payer. Following is a list of exceptions to the 180-day timely filing limit standard for all Medica and SelectCare/LaborCare products (except when Medicare is the payer for Medica Select Solution or Medica Prime Solution claims):
- Coordination of Benefits (COB) claims when Medica is the secondary payer
- Patient’s date of birth less than one year before the date of service
- Duplicate payment for the same date of service
- Itemized billing for obstetric (OB) care and delivery
- Radiation treatment management services
- Member enrollment delays for COBRA continuation coverage (limited to 180 days after the member is enrolled and may take up to 60 days for complete enrollment)
There is a 180-day limit for adjustments:
- If a claim is denied or rejected (one line or all lines), the clean claim must be resubmitted and received within 180 days of the date of the denial or rejection.
- If the claim was paid, and an adjustment to the payment is being requested, the request must be received within 180 days of the check date on the provider remittance advice (PRA).
If a request for more information is received, the corrected claim or additional information must be resubmitted and received at the designated claims address within 60 days of the date on the response letter from Medica. If the corrected claim or additional information is not resubmitted within 60 days, the pended claim will be denied with reason code 054 (“Claim filed after time limit”).
Medica will not accept resubmissions or adjustments beyond 18 months after the date of service or date of discharge for inpatient claims (except when Medicare is the payer for a Medica Select Solution or a Medica Prime Solution claim and these resubmissions or adjustments meet the 180-day criteria listed above).
Terminated Self-Insured Groups: It is important to note that Medica is not liable for claims received after the run-out date for a self-insured employer group that has terminated coverage with Medica (even if submitted within the timely filing guidelines outlined in this document). These claims need to be submitted to the employer for consideration. The run-out date for terminated self-insured groups is available on Medica.com.
Medica understands that there are some circumstances that would warrant an appeal to this policy. If the provider would like to appeal a claim that is more than 180 days after the date of service but within 18 months of the date of service or date of discharge for inpatient claims, the provider can complete the Medica Late Claim Appeals Form in lieu of a Adjustment Request Form and submit it for review with documentation indicating appropriate timely filing guidelines have been followed. This documentation must include notes about accounts-receivable actions. For example notes documenting:
- Calls with Medica’s Provider Service Center,
- Member was sent to collections within 180 days after date of service, and/or
- A copy of the electronic acceptance report from your vendor
Please note: Appeals will only be processed if the claim was initially received within 180 days of the date of service. It should also be noted that documentation showing only claim submission will not be considered as valid documentation to waive timely filing.
If a provider disagrees with a denial after taking all appropriate steps to file the claim on time, contact the Medica Provider Service Center at 1-800-458-5512.
If the documentation supports the claim being filed after the time limit, the claim will be adjudicated and timely filing will be waived. If the documentation does not support the claim being filed after the time limit, the total claim or line will be denied with reason code 254 (“Resubmitted proof is not valid”).
Should the provider identify that something was missing in the supporting documentation; the provider can appeal by re-submitting the claim with the updated/ clarified supporting documentation using the Medica Late Claim Appeals Form. If documentation now supports the claim being filed after the time limit, the claim will be adjudicated, and the timely filing will be waived. If documentation still does not support the claim being filed after the time limit, the total claim or line will be denied with reason code 381 (“Reviewed timely filing denial upheld”).
Claims resubmitted more than 180 days after the denial or rejection (without documentation) will be denied with reason code 313 (“Resubmission filed after the filing limit”).
Download Medica Late Claim Appeals Form.
Download Adjustment Request Form.
If the patient or another insurance company is initially identified as the payer, providers must attach supporting documentation that the claim was either referred to collections prior to 180 days from the date of service or date of discharge for inpatient claims or be within 180 days from the other carrier’s denial. Use of a Late Claim Appeal form to submit these claims and the supporting documentation is required.
If providers have any questions about Medica’s timely filing policy, they are encouraged to call the Medica Provider Service Center at 1-800-458-5512.
Return to Administrative Policies and Procedures.