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If the claim was not received at the carrier's office and no mail log or other agreed-upon method was used to document receipt of first class mail, then the provider would have no way to create a presumption of claims receipt.For this reason, TDI strongly encourages parties to make use of the mail log or agree to use a similarly reliable system for evidencing receipt of claims and other communications.Q: What is the filing deadline to appeal an MCC's request for refund of overpayment, or following an audit under 28 TAC §21.2818?A: A preferred provider, or a non-contracting physician or provider, may appeal a MCC's request for refund by providing written notice of disagreement with the MCC's refund request not later than 45 days after receipt of the MCC's notice described in 28 TAC §21.2818.Q: What if an insured or enrollee does not inform a MCC of other coverage until after 95 days after the date of service, but within the contracted filing deadline?
A: In order to minimize disruption and miscommunication, payers should notify physicians and providers when events occur that will change claims processing timeframes and expectations, but are not expressly required to do so.Q: What is the filing deadline for a preferred provider to appeal an underpayment by a MCC?A: A preferred provider that receives less than 100 percent of the contracted rate with a notice of intent to audit must notify the MCC within 270 days in compliance with 28 TAC §21.2815(f)(2) to qualify to receive a penalty for the underpaid amount.Q: If an electronic claim is submitted to a clearinghouse, which is the payer's designated claim address, and the clearinghouse changes the electronic claim to paper before forwarding it to the payer, what is the appropriate statutory deadline for payment to a preferred provider - 30 days for an electronic claim, or 45 days for a paper claim?
A: If an electronic claim that is subject to the prompt pay laws is submitted and received at the payer's designated claim address in a HIPAA-compliant electronic format, then the claim is subject to the 30-day prompt pay timeframe for electronic claims.
A provider and a MCC may agree by contract to extend the period for submitting a claim.