Section 3901.381 of the
Revised Code establishes various time frames for the processing
and payment of claims. The time frames vary depending upon the
circumstances.
- A third-party payer has fifteen (15) days from receipt
to notify a provider when a materially deficient claim is
received. Examples of materially deficient claims include
claims with an incorrect patient name or benefit contracts
number, a patient that cannot be identified, a claim without
as or treatment code or a claim without a provider's identifying
number. The fifteen (15) day time period and the time spent
correcting the deficiencies do not count toward the calculation
of time in which a claim must be processed.
- A third-party payer has thirty (30) days to process a claim
if no supporting documentation is needed.
- A third-party payer has forty-five (45) days to process
a claim if the third-party payer requests additional supporting
documentation. However, third-party payers must request supporting
documentation within thirty (30) days of the initial receipt
of the claim. The time period of forty-five (45) days is
suspended until the third-party payer receives the last piece
of information requested in the initial thirty (30) day period.
- The time period is not suspended if a third-party payer
requests additional supporting documentation after receiving
initially requested information.
- A request for additional supporting documentation that
is made outside the thirty (30) day time period and that
is based on information received in the initial request
regarding a previously unknown pre-existing condition may
suspend the forty-five (45) day processing time.
- A third-party payer may refuse to process a claim submitted
by a provider if the provider submits the claim later than
forty-five (45) days after receiving notice from a different
third-party payer or a state or federal program that that
payer or program is not responsible for the cost of the health
care services, or if the provider does not submit the notice
of denial from the different third-party payer or program
with the claim.
- A third-party payer that has a timely filing requirement
must process an untimely claim if all the following apply:
- The claim was initially submitted to a different third-party
payer or state or federal program;
- The provider submits the claim to the second payer within
forty-five (45) days of receiving notice that the first
payer denied the claim; and
- The provider submits the notice of denial along with
the claim.
- When a claim is submitted later than one year after the
last date of service for which reimbursement is sought, a
third-party payer shall pay or deny the claim not later than
ninety (90) days after receipt of the claim or, alternatively,
pursuant to the requirements of sections
3901.381 to 3901.388 of the Revised Code.
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