Moda Health Plan, Timely Filing Limit

The most important thing to confirm with Moda 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

• Moda’s commercial provider manual sets a 365-day timely filing limit for initial claims. For secondary claims where Moda is secondary to another carrier, the 365-day clock runs from the primary carrier’s Explanation of Payment date. Corrected/reconsideration claims, disputes, and appeals are tied to the date of the Moda EOP. Final appeals have a separate 60-day limit from the first appeal response letter. A Medicare Advantage manual also states most eligible claims must be received within 90 days after the date of service, with an exception allowing claims submitted as soon as reasonably possible when it was not reasonably possible to submit within the period; claims received later than 12 months after date of service are invalid and not payable.

Initial claim filing limits

• Commercial: 365 calendar days from date of service to date received by Moda Health.
• Commercial COB: 365 days from the primary carrier’s EOP date.
• Medicare Advantage: 90 days after date of service; claims later than 12 months after date of service are invalid and not payable.

Corrected claim filing limits

• Commercial: 180 days from receipt of the denial/EOP for corrected or reconsideration claims, claim disputes, or appeals.

Appeal and reconsideration deadlines

• Commercial: 180 days for claim disputes/appeals from denial/EOP receipt; final appeal within 60 days from the first appeal response letter.
• Medicare Advantage: timely filing denial is not subject to appeal.

Trigger basis and caveats

• Commercial initial claims are measured from date of service to date received, except observation and inpatient stays, which are counted from date of discharge.
• Commercial COB clock starts when the provider receives notice from the primary payer of payment or denial.
• Commercial corrected/reconsideration/dispute/appeal deadlines are calculated from the Moda EOP date.
• Commercial final appeal deadline is calculated from the first appeal response letter date.
• Timely filing requirements vary by product line.
• For Medicare Advantage, the manual distinguishes timely filing denials as not appealable.
• Moda notes it may work with providers to extend filing when a member does not disclose other coverage until after the normal COB period.
• Providers should retain mailing evidence when filing by mail.

Provider resources

• Medical provider contact us (official)
• Referral and Authorization Guidelines (official)
• Commercial Provider Manual (PDF) (official)
• Medicare Advantage Provider Manual (PDF) (official)
• Provider billing and claims | Moda Health Idaho (official)

Sources