OBH Facets Timely Filing

Source file in video: OBH Facets Timely Filing_050526.pdf. Same SOP as poc1; transcribed from this video pass.

Original Effective Date	03/01/2022
Revision Date	01/12/2027

Overview

Purpose

This document provides general instruction for determining timely filing on claims.

Note: Follow all group-specific memos and guidelines, as applicable.

Introduction

Background

When any claim is in question for timely filing, the Claims Processor must always check claims history and/or member notes for any indication of previous submission of the charges.
Optum will determine whether enough information has been submitted to enable proper consideration of the claim.
TFF is provider timely filing. This is standardly 90 days from DOS for In Network Providers.
TFO is plan/group timely filing rules, standardly is 12 months.
Exception: Indian Health Centers (IHC) 365 Days to submit a new day claim. (This would be listed on the Fee Schedule).
Note: For Medicaid Reclamation Claims: Refer to the OBH Facets Medicaid Reclamation for further instruction.

Configuration

Effective 08/18/2024.
Automations were implemented to assist with timely filing. When applicable criteria is met, timely filing is overridden, and an application note is added to claim note for tracking purposes.
If claim fails for manual TF review, continue to procedure below.

Procedure

Steps 1–2 full text was not legible at the top of page_02.png (capture starts at document search / Step 3). Re-extract from video if required.

Step/Action

Document search (pre–Step 3)

Press CTRL + F to open the navigation bar in the document.
In the Search Document box, enter the state the member resides in.
Example: For CA enter California.
Press Enter.
Proceed to next step.

3	Determine if results were returned for the member's state.
	If…	And… / Then…
3	Meets Criteria	Then: Skip to Emergency Response Bulletins Step/Action table.
3	Does not meet criteria	And: receiving MA CBHC SERVICES warning message and Group/Plan is Mass General Brigham Then: DOS 01/01/2023 – 06/30/2023 waive timely filing. All other DOS proceed to next step.
3	All others	Proceed to next step.

4	Is your claim for any of the Groups below?
4	Yes	Process claims according to Group step guidelines below and proceed to Step 10.
4	No	Proceed to the next step.

Group	Guidelines
GE	OON: Claims should be submitted by June 30 for expenses incurred in the previous calendar year. Claims filed after June 30 of the following year will not be reimbursed. INN: 90 days from DOS to submit a claim.
NALC	(Member submitted Claims Only) Members may submit claims through December 31 of the year following the year in which service was rendered (e.g., service date 4/1/2020 → submit through 12/31/2021). Note: Provider submitted claims follow normal timely filing guidelines based on TF1 or TF0.
MPI	OON providers — 15 months from DOS. INN providers — 90 days from DOS.
Medicaid Reclamation — 36 months (standard)	Providers billing directly for Medicaid recoupment — refer to OBH Facets Medicaid Reclamation P&P. Ohio Department of Job and Family Services (ODJFS) — 6 years per state legislative requirements.
VA Providers	New Day Claims: VA facilities may request reimbursement within 6 years from the last date on the claim. (Row truncated in screenshot.)

Step 5 — Submission types

Access the Timely Filing Calculator to determine days from DOS to received date. Exception: Facility claims — R&B from date of discharge.
Always check Group Notes for group exclusions.
Medica Group does not follow the Provider Timely Filing limit.

COB Submission Note (Applies to claims processed 01/01/2024 and after):

Open COB tab in Facets; locate Paid Date.
Other Carriers Paid Date auto-populates — use in timely filing calculation.
Exception: If COB Paid Date blank: update to current claim received date; use in place of other carrier paid date (F3); if TF denial drops, TF policy no longer applies.

If…	And…	Then…
COB Submission (includes new day COB claims). See COB note above.	Claims processed on or before 12/31/2023	INN or OON — 365 days from DOS or 90 days from other carriers Paid Date. Note: Electronic image does not reflect the date. If within guidelines → Skip to Step 9. If not → Skip to Step 6.
COB Submission	Claims processed on or after 01/01/2024	INN/OON: 90 days from Other Carriers Paid Date. Refer to COB Submission Note for paid date on electronic image.
Resubmission / Corrected Claim (7 or 8) Submission	INN Billing EWS/EAP: if original not in history, allow 365 days from DOS. (EWS rebrand of EAP.) INN — 365 days from date claim last processed/paid. OON — 365 days DOS or 90 days from payment.	If within guidelines: Bypass timely filing. Freq 7 → Frequency 7 indicator section in P&P. Freq 8 → Void Claim Indicator P&P. If not within guidelines → Skip to Step 6.
New day claim Submission	INN — 90 days from DOS. Exception: IHC OON — 365 days from DOS or discharge.	If within → Override Bypass Claim Accept Period with EXP OCA; Skip to Step 15. If not → Skip to Step 6.
Adjustments/Appeals Submission	INN — 365 days from processed/paid. OON — 90 days from payment or 365 days DOS if underpaid. Exception: Overpayment — 365 limit may be bypassed if original received within TF.	If within → EXP OCA; Skip to Step 15. If not → Skip to Step 6.

Does the claim include proof of timely filing?

If…	Then…
Yes	Proceed to next step.
No	Skip to Step 10.

7	Verify on the POTF: Member name and/or ID number DOS matching the claim Submitted date Billed amount (if computer-generated activity screen print) Paid/Denied or Adjusted date (as applicable) Proceed to next step.

Is the valid POTF an EOB?

If…	Then…
Yes	Proceed to the next step.
No	Apply claim-level override Bypass Claim Accept Months and add Claim note with POTF type received. Skip to Step 15.

Was EOB received within 90 days from the other carriers Paid Date?

Electronic image: does not reflect primary payment date — use received date of claim with primary EOB.
Effective process date 01/01/2024+: use other carrier paid date (COB note in Step 5).
Paper: use date on EOB from Primary Payor if available.

If…	Then…
Yes	Click Clear COB; apply primary EOB payment date (should override TF; if not, apply Bypass Claim Accept Months + claim note). Skip to Step 15.
No	Proceed to the next step.

Search member/provider history for claim/line with same DOS, procedure code, and provider. Review all lines billed.

If…	Then…
Yes	Proceed to next step.
No	No claim/line in history, Freq 7/8: OBH Facets Kill-Delete Reroute Process; Kill/Delete Reason: IM; manual mail back for non-837I/837P. New Day denying for timely filing: Not within limit; allow deny. Skip to Step 15.

11	Note Original Claim/line Paid Date and current received date. Use Timely Filing Calculator: A4 (Service/Oldest Date), B4 (Received/Newest Date).

12	Compare calculator days to timely filing limit.

Has the new claim been resubmitted within the appropriate timely filing limit?

If…	And…	Then…
Yes	FREQ 7/8 Submissions	Apply override Bypass Claim Accept Months — EX CODE OCA. Continue to OBH Facets Claim Attachment Validation (FREQ 7/8 Manual Process).
Yes	All others	Proceed to next step.
No	—	Allow deny for timely filing; skip to Step 15.

Adjusters: For physician claims with only some DOS requiring a timely filing override, split the claim to process correctly.

Review original claim — processed/denied correctly (e.g., received timely but not paid correctly).

If…	Then…
Original claim in history paid (review allowed amount)	Add WFWM note with original claim number and adjustment need; pend to ADJ queue.
Denied incorrectly	Process per standard guidelines.
Processed/denied correctly	Apply EX CODE OCA; allow same denial reason as original.
Denied correctly but new information allows reprocessing	Apply EX CODE OCA; process per standard guidelines.

Adjuster — perform the following:

Adjust the history claim accordingly.
Once history is paid, process denying with TFD disallow: add Claim note, apply Bypass Claim Accept Months, deny as duplicate.

15	Press (F3) to process the claim.
16	Review any other warning and/or error messages.
17	Press (F4) to save the claim.

Source pages: 2–8 (procedure). page_02 … page_08

Timely Filing Review Process

Valid POTF Attachments

Optum correspondence (data entry send back letter).
Computer-generated activity page/print screen listing the date the claim was submitted.
Other insurance carrier denial/rejection/paid EOB/PRA.
Billing statement indicating the date they became aware the member had coverage.
Resubmission form or letter stating why the claim was billed incorrectly.
Idaho Medicaid Only Exception (specific note in document).
Electronic claims-acceptance report.

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Emergency Response Bulletins

Emergency bulletin If/Then table (DOS vs effective date; 12 months after expiration) visible on page_09 — full cell text partially small; split claim / Select to Move P&P / OCA / return to Step 16 or Step 4 per screenshot.

Not all DOS within Effective Date	Claim received within 12 months after Emergency Bulletin Expiration Date	Split per Select to Move P&P: DOS within → Claim Level Bypass Accept Period OCA, Refresh, return Step 16; DOS outside → Step 4.
Not all DOS within Effective Date	Claim not received within 12 months after expiration	Return to Step 4 of Timely Filing Step/Action Review.

Code Descriptions and Terminology

Code Descriptions	Refer to: EOB Codes List · Medicare Reason Codes · UM Service Group Code Glossary (links in source PDF)
Terminology	Optum Glossary of Terms, Abbreviations and Acronyms (link in source PDF)

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Revision History

Date Published	Section	Revision Details	Writer	App…
03/01/2022	Original	Initial Content Release	SS	Approver column cut off in screenshot

page_10

Business Details

Field	Value
Platforms	Facets
Audience(s)	Auditor · Processor · Adjuster
State/DIV(s)	All
LOB(s)	Commercial · Medicare · Medicaid
Product(s)	OBH
Documentation Contact	Knowledge Management Request Form (hyperlink in PDF)

Page 1: page_01 — All screenshots: ../screenshots/step1_pages/