Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis.
Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The member's benefit plan determines coverage. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. If you’re practice is having trouble in this regard, it may be time to look into a practice management system that facilitates claims filing.By clicking on “I Accept”, I acknowledge and accept that: The best way to avoid them is by processing claims as quickly as possible. If your claim qualifies for one of the above exceptions, it can be opened for review by sending a request letter along with supporting documentation to the following address:Īs you can see, Medicare timely filing denials are not always final, but disputing a claim denial can prove difficult with so few possible exceptions. Medicare timely filing denials are not subject to a formal appeal. The Medicare timely filing deadline is then extended to the last day of the sixth month from the day payment is recalled. For instance, a patient receives treatment while eligible for one of the said programs, but later receives the notification of disenrollment retroactive to the date of the provided service, resulting in a payment recoup. It’s similar to the State Medicaid Agencies exception but involves Medicare Advantage plans and Program of All-Inclusive Care of the Elderly organizations. Retroactive Disenrollment from a MA Plan or PACE Provider Organization
The timely filing deadline would then be extended to the last day of the sixth month after payment was recouped from the provider. This could happen if a patient was only entitled to Medicaid at the time of treatment, but receives notification of Medicare coverage effective retroactive to the date of treatment resulting in the recovery of the Medicaid payment. In this situation, a State Medicare Agency recovers payment for a dually eligible beneficiary (Medicare and Medicaid) six months or more after the start date the claim. Retroactive Medicare Entitlement Involving State Medicaid Agencies In this case, the Medicare timely filing deadline will be extended to the last day of the sixth month after the notice of entitlement was received. For example, a patient wasn’t covered at the time of treatment and the end date passes, but then the patient receives notice of Medicare entitlement with an effective date prior to the date treatment was rendered. This applies if a patient receives notice of Medicare entitlement retroactive to the date service was provided. If successfully disputed, the end date will be extended to the last day of the sixth month after notice of an error correction was received. Medicare timely filing claim denials can only be contested based on the following four exceptions:Ī claim can be appealed if the deadline was missed due to an error committed by an employee, Medicare contractor or another agent performing Medicare functions. Therefore, it’s best not to procrastinate. If a claim is sent prior to the end date but is received after, it will still be denied.
#Medicare timely filing full#
The end date for Medicare timely filing is exactly one full calendar year after the start date.Ĭlaims must be received and time-stamped by the appropriate Medicare claims processing contractor before the end date. The start date for a particular Medicare claim is considered to be the date the service is provided to the patient or the “From” date recorded on the claim form. Learn about the pros and cons of in-house billing vs.
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