If Medicare is the primary payer, timely filing is determined from the processing date indicated on the primary carrier's explanation of benefit (EOB).However, the filing limit is extended another full year if the service was provided during the last three months of the calendar year. Medicare patients' claims must be filed no later than the end of the calendar year following the year in which the services were provided. 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.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).Provider agreement specifically allows for additional time.Applicable law requires a longer filing period.There are some exceptions to these deadlines. Remember: Your contract with Cigna Healthcare SM prohibits balance billing your patient if claims are denied because they were not submitted within the time frame outlined above. The law does not prohibit providers/practitioners from billing with the SSN.If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last date of service.Īs always, you can appeal denied claims if you feel an appeal is warranted. Social Security numbers may be used for internal verification or administrative purposes, as long as the use does not result in the public display or disclosure of the number in violation of requirements. Utilization Management Medical TeamĪssociate Medical Directors: Allyson Kreshak, MD, Elizabeth Rosenblum, MD Confidentiality Utilization management criteria are available to the member, practitioner and public. All decisions are communicated to the requesting provider via EPIC, and member notification of decisions is sent via MyUCSDChart or mailed to the patient.We sometimes use the expertise of our medical specialists to assist in making determinations. The utilization management department consists of administrative data entry coordinators with extensive coding and clinic experience, registered nurses, and a board-certified medical director who oversees all medical decision-making.UC San Diego Health does not sub-delegate any decision-making to any other entity.Financial incentives do not encourage decisions that result in under-utilization.We do not reward practitioners or others for issuing denials of coverage or service care. This process is based only on the appropriateness of care and service and the existence of coverage.
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