Timely filing edits
Timely Filing requires that a provider submit a claim as soon as possible after the healthcare service has been provided. Typically, this can be for a year, but there can be different policies for different contracts or states. The Timely Filing edit lets you configure the values associated with setting the timely filing pend code and the sequence in which to apply it.
The Timely Filing value is configured in days and is used from a defined order of precedence. The delivered order is:
- System (Default)
You can modify this order of precedence as necessary and you can configure each level in this order individually.
Each level in the order contains an optional value that represents the number of days to be used for that level to determine whether or not the claim was processed in a timely manner. Smart Claims Engine starts at the top and continues through the order until it locates an available value. If no values have been found at the end of the order, the edit ultimately uses the value defined in Claims Engine Configuration (System).
The number of days retrieved by this method is subtracted from the service start date on the claim to determine the timely filing date. If the claim received date is after the calculated timely filing date, a pend code is reported.
Configuring the Timely Filing edit
To configure the Timely Filing edit, do the following:
- Modify the CE_TimelyFilingStateOrder decision table to establish the order of
precedence for retrieving and applying the Timely Filing days’ value.
- Set the source and value of the edit to the appropriate value:
- For the Contract level, set the Timely Filing days value in the Patient’s Contract record.
- For the State level, set the days value in the TF_StateList decision
- Both the System default, and the Federal contract timely filing settings may be configured in the Timely Filing section of the System Configuration page. Note: System default is a required property.
Timely filing pend code
If the total number of days between the submission date on the claim and the from date of service on the claim is greater than the timely filing days returned through the tables configured in the timely filing decision tree or the default value set in the system configuration, then the system sets the timely filing pend code of 3000 as the InternalPendCode.
To add a new business edit to the system, create the appropriate rule for that business edit, and then add it to the ProcessBusinessEdits collection rule in the sequence where it will be run.
You can also copy an existing edit to create a new one and modify it to fit your circumstances. A new pend is updated in Smart Claims Engine through the CE_AddPend activity. In this activity, the InternalPendCode property sets the actual pend number that drives the pend processes defined in the Business Analyst portal.
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