Claims Timeliness Standards

HMSA is committed to processing claims within the following timeliness standards:

• 95 percent of non-investigational claims will be processed within 15 calendar days.
• 99 percent of non-investigational claims will be processed within 60 calendar days.
• 100 percent of all claims will be processed within 90 calendar days.

Implementation Guidelines

A non-investigational claim contains all the information needed for processing. The information is accurate and includes but is not limited to the following:

• HMSA member ID number
• Member’s name and birth date
• Date of service
• Place of service
• CPT and ICD-9-CM/ICD-10-CM codes
• Information about a member’s other healthcare coverage, if applicable
• A referring physician name and HMSA provider number, if applicable
• The provider’s signature and correct HMSA provider number

An investigational claim requires extra review or contact with the member, the provider or a third party payer prior to processing. This might include a claim for services that are eligible for payment by a third party, a claim that requires an operative report or clinical notes for processing, a claim for services that may be considered “experimental” or “investigational”, or a claim for services when another insurance carrier is the primary insurer.

Notes:

Processing days are counted from the day the claim was received at HMSA until the day the processing of the claim was completed and it was released for payment. The period of time between the day the claim is released for payment and the day the provider’s regular weekly check is issued is not counted as part of the standard. For example, if a claim is received by HMSA on a Wednesday, and it is completely processed and released for payment on the following Monday, the claim will have taken five days to process. If the provider’s regular weekly check is issued Wednesday, the two days from Monday to Wednesday are not counted as part of the standard.

Claims submitted via electronic media (EMC) will be processed within the timeliness guidelines listed above, but in most cases the processing time for EMC will be shorter than that specified by the standard. Claims submitted via electronic media can be processed faster because they do not require sorting, microfilming and scanning prior to being entered into HMSA’s computer system. Because electronic claims are entered into HMSA’s claims processing system directly, they generally are processed two to three days sooner than hard-copy claims.

HMSA’s timeliness standards were developed using information about timeliness standards from several national sources including the national Blue Cross and Blue Shield Association and Medicare. The standards exceed Medicare standards for the timely processing of claims.

Revision History