Timely Filing HIPAA Regulations At Highmark
Timely filing is a Highmark requirement whereby a claim must be filed within a certain time period after the last date of service relating to such claim or the payment/denial of the primary payer, or it will be denied by Highmark. Any claims not submitted and received within the time frame as established within your contract will be denied for untimeliness. If timely filing is not established within your contract, claims must be received within 365 days of the last date of service in Pennsylvania and West Virginia, and within 120 days of the date of service in Delaware, unless the member’s policy provides for a different period. If Highmark is the secondary payer, claims must be submitted with an attached Explanation of Benefits (EOB) and received within the same timely filing time frames as when Highmark is primary; however, the time frame is based on the primary payer’s finalized or payment date.
When Highmark is a secondary payer, a provider must submit a claim within the timely filing time frames indicated above and attach an EOB to the claim that documents the date the primary payer adjudicated the claim. Secondary claims not submitted within the timely filing period will be denied and both Highmark and the member held harmless. Electronically-enabled providers should submit secondary claims electronically using the proper Claim Adjustment Segment (CAS) code segments.
When it is known or there is a reason to believe that other coverage exists, claims are not paid until the other carrier’s liability has been investigated. Highmark may send a letter/questionnaire to the covered person.
- If the covered person responds to the letter/questionnaire indicating that he/she is covered by additional policies, the records are marked to indicate that the other carrier information is required to complete claims processing when the other carrier’s policy is primary.
- If the covered person does not respond promptly to Highmark’s request for information, Highmark will deny claim payment using a remark code indicating the covered person is responsible. The provider may seek reimbursement from the covered person.
Federal Employee Program (FEP) claims are not denied but are pended until a response is received from the covered person. Highmark will not provide benefits for these FEP claims until a response is received.