Reimbursement Unit

% of claims that were originally submitted in a timely manner but were denied payment (timely filing) turned around in 15 business days or less

80.2%May 2022

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Notes on Methodology

Partners
  • Medicaid Providers
  • Gainwell Technologies
  • Department of Mental Health
  • Department of Aging & Independent Living
  • Department for Children & Families
Story Behind the Curve

This performance measure is important because it tracks how long it takes for timely filing requests from providers to be reviewed and processed. The goal is for requests to be completed in a timely and consistent manner. Providers appreciate having a decision sooner rather than later.

Medicaid has regulations on how long providers have to submit claims for reimbursement, this is called timely filling. For claims originally submitted in a timely manner but denied payment, the DVHA Reimbursement Unit will review for payment. This performance measure shows how long the Reimbursement Unit takes to review denied claims and to make a final decision on whether or not the supporting documentation supports payment or not. 

Starting in 2021 the Timely Filing metric was revamped due to a large increase in the volume of requests being received on a monthly basis. The increase can be mostly attributed to a persistent and significant increase in the number of Ad-hoc requests received and the volume of claims within each of the requests.

Ad-hoc timely filing requests are bundled requests submitted by a provider when they discover a large number of claims (~50+) were affected by the same issue resulting in late filing of the claims.. An example of this would be a provider experiencing a malware attack affecting their ability to submit claims in a timely manner. Submitting the request in this manner reduces administrative burden for the state, Gainwell and the provider. Prior to the surge, Ad-hoc requests were emailed to the state for priority review and completion as soon as they were received by Gainwell, whereas standard requests were uploaded via SharePoint and completed in the order received. As a result of this, Reimbursement decided to streamline the process and have all timely filing requests (standard and Ad-hoc) reviewed and completed in the order in which they are received. With the new standardized process Reimbursement will be able to include and track total timely filing requests received and completed in a month and have this reflected in the monthly scorecard.

Factors that can affect the trendline are large increases in the volume of requests received and Reimbursement’s ability to apply increased resources to this task while still meeting conflicting work demands, deadlines and temporary reductions in staff. From November 2020 to August 2021 the trendline reflects the above challenges faced by the unit in meeting our target.  The decrease in the trendline starting in January 2022 resulted from the unit onboarding a new employee in addition to actively recruiting for another open position.  At the same time, the unit switched from having one individual complete timely filing requests  to having all staff complete the requests on a rotating basis with training currently underway.   

Narrative last updated:  04/22/22

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