Capital Health Plan, Timely Filing Limit

The most important thing to confirm with Capital Health Plan, is not just the number of days, but also what event starts the clock. Some payer documents measure from date of service, some from discharge, and some publish different rules for corrected claims or appeals.

At a glance

• For the Florida State member handbook reviewed, Capital Health Plan requires post-service claims to be received within six months of the date the service was rendered, but in any event no later than one year from the date the service was rendered unless the member is legally incapacitated. No separate official timely-filing rule for corrected claims or appeals was located in the sources reviewed.

Initial claim filing limits

• Post-service claims must be received within 6 months of the date the service was rendered.
• No post-service claim will be considered for payment if not received within 1 year of the date the service was rendered, unless the member is legally incapacitated.

Corrected claim filing limits

• Not clearly published in the researched sources.

Appeal and reconsideration deadlines

• Member grievance/appeal deadlines in the reviewed handbook are generally within 1 year of the event/action that initiated the grievance or appeal.

Trigger basis and caveats

• The filing clock in the handbook is triggered by the date the service was rendered for claims.
• The one-year outer limit is stated as from the date the service was rendered.
• The cited timely-filing language comes from the State of Florida member handbook, so it may not apply to every Capital Health Plan product or group arrangement.
• No official corrected-claim deadline was found in the reviewed sources.
• Appeal deadlines are not the same as claim filing deadlines.

Provider resources

• Provider Care Resources (official)
• Network Support Services (official)
• Provider FAQ (official)
• Provider Directory (official)
• Referrals and Prior Authorization (official)

Sources