Orchard - Unchanged

Timely Filing

A contracted provider has the responsibility to file the claim within 12 months from the date of service. Claims denied for untimely filing are not the member’s responsibility, unless one of the following exceptions is met:

  1. When PEHP becomes the secondary payer, the member is responsible to ensure timely filing from all providers. Claims must be submitted to PEHP within 15 months from the date of service to be eligible. PEHP requires the primary carrier’s Explanation of Benefits (EOB) information to be included on the claim.
  2. When the member provides inaccurate or incomplete information regarding medical plan coverage to the provider, therefore, preventing filing of the claim.

When a non-contracted provider is used, it is the responsibility of the member to ensure that the claim is filed promptly and properly. Claims that are not received within 12 months from the date of service will be denied. The member will be responsible for the entire claim.

If a provider disputes the date a claim was recieved, PEHP will only accept the following as proof of timely filing:

  • Electronic claims - the X12 277_CA report, also known as the Health Care Claim Acknowledgement Report, showing the date the claim was received.
  • Paper Claims – a fax acknowledgement report with a PEHP Customer Service/Claims fax number or a certified mail receipt showing the date the claim was received.