CLAIM FILING REQUIREMENTS
Timeliness
All claims must be submitted within ninety (90) days of the discharge date or date of service. We encourage providers to submit claims on a monthly basis. Claims where a payment is due that are not submitted within the 90-day timeframe will not be considered for reimbursement.
The 90-day timeframe applies to every claim, including claims that are expected to result in a zero-dollar payment, no reimbursement, or a denial. Providers must submit these claims so that all services are accurately recorded and adjudicated. Providers who fail to submit zero-dollar claims that support an Alternative Payment Arrangement within the 90-day filing timeframe may be subject to temporary or permanent suspension of their monthly APA arrangement and payment. Carelon’s standards for claim turnaround time are to pay “clean claims” within 30 days of initial receipt. A clean claim is a claim received by Carelon with all required data present and valid that was adjudicated without having to obtain information from an external source.
Providers will receive notification of claims payment or denial via check and remittance advice. If the member’s eligibility cannot be identified, the provider will receive notification via voucher designated “PAUNK.” The member’s name will be included on this voucher so that the provider can research and resubmit if necessary.