Sendero Health Plans, Timely Filing Limit

The most important thing to confirm with Sendero Health Plans, 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

• Sendero’s provider manual sets different timely-filing windows by claim type and by whether the claim is initial or corrected. For most initial claims, the window is 95 days from the relevant date; corrected claims generally have a 120-day window from the relevant date. The manual also sets a separate 95-day rule for COB claims from the other payer’s Explanation of Payment.

Initial claim filing limits

• Professional claims: 95 days from date of service.
• Ancillary services: 95 days from date of service.
• Monthly-billed ancillary services (e.g., home health or rehabilitation therapy): 95 days from the last day of the month billed.
• Outpatient hospital services: 95 days from date of service.
• Inpatient hospital services: 95 days from date of discharge.
• COB claims: 95 days from the date of the other payer’s Explanation of Payment.

Corrected claim filing limits

• Professional corrected claims: 120 days from date of service.
• Ancillary corrected claims: 120 days from date of service.
• Monthly-billed ancillary corrected claims: 120 days from the last day of the month billed.
• Outpatient hospital corrected claims: 120 days from date of service.
• Inpatient hospital corrected claims: 120 days from date of discharge.

Appeal and reconsideration deadlines

• Level I Appeal Reconsideration must be filed in writing within 120 calendar days of the initial decision (EOP or medical necessity determination).

Trigger basis and caveats

• For initial claims, the deadline is tied to date of service, date of discharge, or last day of the month billed depending on claim type.
• For COB claims, the deadline is tied to the other payer’s Explanation of Payment.
• For appeals, the deadline is tied to the initial decision date (EOP or medical necessity determination).
• The provider manual reviewed is rev. 11-26-24; older manuals show different timely-filing language, so use the current manual and any plan-specific notices for the applicable date of service.
• The manual says exceptions are limited and do not include neglect, indifference, or lack of diligence.
• Some claim-type rules may vary by billing format and line of business.

Provider resources

• Provider Portal Login (official)
• Provider Resources / Provider page (official)
• Provider Manual (rev. 11-26-24) (official)
• Provider Portal User Guide (official)
• Prior Authorization Process Description (official)
• Claim Reconsideration/Appeal Request Form (official)
• Preauthorization Code Interactive Lookup Tool (official)

Sources