Timely Filing of Claims

To expedite billing and claims processing, we ask that your claims be sent to Group Health within 30 days of providing the service. The Washington State Office of the Insurance Commissioner (OIC) requires health carriers to meet specific claims-payment timeliness standards. Carriers failing to achieve those standards must pay interest to contracted providers. We exceed OIC standards with our policy of paying interest on any clean claim that is not paid within 60 days of receipt.

Clean Claims

The OIC defines a clean claim as "having no defect or impropriety, does not lack any required substantiating documentation, or does not have any particular circumstances requiring special treatment that prevents timely payment."

The Centers for Medicare and Medicaid Services (CMS) defines a clean claim as "a claim that has no defect or impropriety, including lack of required substantiating documentation for non-contracting providers and suppliers, or particular circumstances requiring special treatment or that prevents timely payment from being made on the claim. The claim must include information necessary for purposes of encounter data requirements."

Filing Guidelines by Health Plan

We follow both the CMS guidelines and the Revised Code of Washington (RCW) for timely filing of original and adjustment claims. These requirements are outlined here by type of health plan. To expedite claims processing, we encourage you to submit claims using electronic transactions.

Medicaid

Original claims: The claim must be received by Group Health within 12 months from the date of services.

Adjustment requests: The request must be received within 24 months from the date the claim was processed (RCW 48.43.605).

The Patient Protection and Affordable Care Act requires that Medicare and Medicaid overpayments be reported and returned within 60 days after they are identified by the provider.

Medicare Advantage HMO and PPO

Original claims: As a result of the Patient Protection and Affordable Care Act of 2010, the maximum period for submission of Medicare claims is reduced to not more than 12 months. Submission processes need to be adjusted to ensure that:

  • Claims with dates of service prior to Oct. 1, 2009, will be subject to pre-PPACA timely filing rules.
  • Claims with dates of service Oct. 1, 2009, through Dec. 31, 2009, received after Dec. 31, 2010, will be denied as being past the timely filing deadline.
  • Claims with dates of service Jan. 1, 2010, and later received more than one calendar year from the date of service will be denied as being past the timely filing deadline.

Adjustment requests: The request must be received within 24 months from the date the claim was processed (RCW 48.43.605). Group Health, as a Medicare carrier, may initiate an adjustment at any time.

The Patient Protection and Affordable Care Act requires that Medicare and Medicaid overpayments be reported and returned within 60 days after they are identified by the provider.

Commercial/PPO/POS

Original claims: The claim must be received by Group Health within 12 months from the date of service. Group Health may initiate an adjustment within 18 months from the date the claim was processed.

Adjustment requests: The request must be received within 24 months from the date the claim was processed (RCW 48.43.605).

Claims With COB Involvement

Original claims: The claim must be received by Group Health within 12 months from the date of service. If Group Health receives information of primary insurance for a member, we may initiate an adjustment within 12 months from the date of notification.

Adjustment requests: The request must be received within 30 months from the date the claim was processed (RCW 48.43.605).

Reviewed 11/16/2012

The Provider Manual is not intended for any use by any party other than as a resource for Group Health Cooperative's contracted providers in fulfilling their obligations under provider contracts. Group Health intends for the manual to be accurate for its intended purpose but doesn’t guarantee accuracy. Providers should comply with the terms of their provider contracts and any legal requirements in the event of an inconsistency between the manual and a requirement in their provider contracts or the law.