What is the time limit for filing a medical insurance claim?

The time limit to file a claim differs from insurance company to insurance company as well as among different policies sold by the same insurer. Medical providers generally have up to a year from the date of service to forward the claim to the insurance company, but insurers can shorten this time limit to as little as six months or even three months in some instances. Let’s look at timelines for insurance companies in California as an example.

Insurers in California Have to Give at least 90 days for Contracted Providers and 180 Days for Noncontracted Providers

According to the California Insurance Code, deadlines imposed for a medical provider to submit a claim on behalf of an insured can’t be less than 90 days from the date of service for contracted providers and 180 days for noncontracted providers.

The law further states that if the health insurer is not the primary payor under a coordination of benefits, the insurer can’t impose a deadline for submitting supplemental or coordination of benefits claims to any secondary payor that is less than 90 days from the date of payment or date of contest, denial or notice from the primary payor.
When a health insurer denies a claim because it was filed past the deadline, if the provider demonstrates good cause for the delay, then the insurer is required by law to settle and pay the claim “as soon as practical” and not later than 30 days, unless the insurer continues to contest the claim.

You Might Have to File the Claim Yourself

In some cases, such as when your provider is out of network, you may have to file the claim yourself. The healthcare provider should tell you this at the time of service, so you know they are not filing for you, and you can submit the claim within the required deadline. These days, you can likely enter a claim form online or download a printed version to complete and mail to the insurer. Make sure you are using the correct form and that the form is filled out accurately and completely. You’ll need an itemized bill from the doctor to complete the claim form. If the doctor’s statement doesn’t include billing procedure codes, you might need to run these down from the doctor’s or hospital’s billing department, as these codes will likely be required on the claim form.

Once the insurance company receives your claim, a claims processer will check to see that the request is accurate, complete and for a covered service. If they do their job right, they’ll pay the covered portion of your claim, and the provider will send you a bill for the remainder. You should get an Explanation of Benefits (EOB) from the insurer telling you what they paid, and you can match up the EOB with the doctor’s bill to make sure the doctor or hospital is charging you the correct amount.

What do I do if the insurance company says my claim is untimely?

Insurers looking for any reason to deny a claim for benefits might view their self-imposed deadlines very strictly and turn away claims that are untimely filed. Initially, it is up to the healthcare provider to bill the insurance carrier on your behalf. When you check in to a hospital or doctor’s office, the first thing they do is ask for your insurance. They make a copy of your card and get your authorization to bill the insurer, leaving you responsible for any applicable deductible or co-insurance payment (co-pay).

If your claim was submitted past the insurance company’s deadline for receiving claims, you might first check-in with your healthcare provider to see if they are to blame. Did they fail to file in time? Did they put in the wrong name, policy number date of service or billing code? If the provider messed up, they should be the ones to fix it. You are likely to be the one who suffers, though, so get legal help if you need it to enforce your right to coverage as well as recover compensation if a provider’s negligent mistake caused you further harm.

Insurance Companies Have Timelines Too

The insurance company might have deadlines they set for receiving a claim from you or the healthcare provider, but California law imposes deadlines on the insurance companies too. Insurers are required by law to act promptly when they receive a claim. Once you file a claim, the following timelines apply:

• Insurers have 15 days to acknowledge they received your claim and provide you with all forms they need from you, along with instructions for completing the forms.
• Insurers have 15 days to respond to any inquiry from you and 21 days to respond to an inquiry from the California Department of Insurance.
• Insurers have 40 days from when they received your claim to either accept it or deny it in whole or in part. If the insurance company says it needs more time to evaluate your claim, they have to let you know that, tell you why, and update you on the status of your claim at least every 30 days.
• Insurers have 30 days to pay claims once they have accepted or settled the claim.

California Insurance Attorneys can Help You Get Your Claims Paid

If the insurance company is unreasonably delaying your claim, or if they denied your claim as being untimely filed when it wasn’t your fault, call a California insurance lawyer for help getting your claim paid. You could be entitled to additional compensation for damages on top of the benefits you are owed and have your attorney’s fees paid by the insurance company.