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Provider Manual

Claim Submission Reminder

Last Updated on January 24, 2019
 

ForwardHealth recommends that providers submit claims at least on a monthly basis. Billing on a monthly basis allows the maximum time available for filing and refiling before the mandatory submission deadline.

With few exceptions, state and federal laws require that providers submit correctly completed claims before the submission deadline.
Providers are responsible for resolving claims. Members are not responsible for resolving claims. To resolve claims before the submission deadline, ForwardHealth encourages providers to use all available resources.

Claims

To receive reimbursement, claims and adjustment requests must be received within 365 days of the DOS (date of service). This deadline applies to claims, corrected claims, and adjustments to claims.

Crossover Claims

To receive reimbursement for services that are allowed by Medicare, claims and adjustment requests for coinsurance, copayment, and deductible must be received within 365 days of the DOS. This deadline applies to all claims, corrected claims, and adjustments to claims. Providers should submit these claims through normal processing channels.

Exceptions to the Submission Deadline

State and federal laws provide eight exceptions to the submission deadline. Exceptions may be considered to the submission deadline only in the following circumstances:
• Change in a nursing home resident's level of care or liability amount.
• Decision made by a court order, fair hearing, or the DHS (Department of Health Services).
• Denial due to discrepancy between the member's enrollment information in ForwardHealth interChange and the member's actual
enrollment.
• Reconsideration or recoupment.
• Retroactive enrollment for persons on GR (General Relief).
• Medicare denial occurs after ForwardHealth's submission deadline.
• Refund request from an other health insurance source.
• Retroactive member enrollment.