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What is the timely filing for Part D claims filed by Provider?
3 Years from Fill Date
If a claim is denied with reason D8, how long does the member have to submit a Post Service Appeal?
60 days from the denial date
If a provider called to have a check reissued for a claim they didn't receive, what must be documented?
The providers financial address
If a check was not sent to a correct affiliation, what are the steps to S2W?
Submit to Workflow > MAPD/PDP > Claim > Claim Ops
Where would you find the Procedure code that was denied on a D8 Denial?
Authorization
What is the timely filing for Medicare Advantage Par Providers?
180 Days (6 months) from Date of Service
How long do members have for timely filing?
12 months from the Date of Service
What would be in documentation for member calling in to check claim status?
DOS, ALLOWED AMOUNT, PAY AMOUNT, PAID DATE, MBR LIABILITY, AND CLAIM #
When is Denial Code D8 used?
When prior approval not granted because the criteria was not met and the service is being billed without approval.
What would the Resolution Action be for a member calling in about a denial letter?
Appeal Rights Provided
What two pieces of information should always be in documentation regarding a claim?
Claim # & DOS
If a member wants to request a claim form to file claim, what are the steps for s2w?
Submit to Workflow > MAPD/PDP > Claims > Member- Filed Claim
What type of appeal rights do members have with D8 Denial?
Post Service Provider Appeal
What is the Denial Reason for code D8?
DENY:PAR PROV DO NOT BILL MBR-SVC NOT PRIOR APPROVED & NOT URG/EMERGENT
What is the timeframe to process or reprocess a claim?
45 Days
How long does a provider have to file a corrected claim?
12 Months from Date of Service


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