03/30/2022

Appealing a Timely Filing Denial for a Paid Claim that is being Recouped for Patient Having Other Insurance at Time of Service

We received an approval and billed for a custom AFO to Fidelis. The claim was paid. 18 months later Fidelis sent us a letter that the patient actually had Medicare as a primary and they are requesting a refund. We attempted to then bill Medicare but it is past the timely filing deadline and was rejected. Do we have any recourse on this type of situation?

To appeal this timely filing denial, a redetermination should be sent to Medicare for the claim for the AFO. When submitting the appeal request form to Noridian to reconsider the claim for payment, you will need to be as detailed and explicit on why a claim is being submitted past the one-year filing limit. It is highly recommended to outline the situation where the patient did not present their Medicare information and the practice was under the impression that they were only covered by Medicaid Managed Care with Fidelis. With all the pre-certification documentation, along with the recoupment request letter that prompted the claim to be submitted to Medicare after timely filing, that should be used as the basis to have the claim reconsidered under extenuating circumstances. There is no guarantee that the claim will be paid, but this would be the strongest chance to recoup the payment being retracted by Fidelis Care.