We may process these claims as secondary without a claim form or remittance advice from your office. This means Medicare will automatically pass the remittance advice to us electronically after the claim has been processed. We participate in Medicare Crossover for all our members who have Medicare as their primary benefit plan.
When you receive the primary carrier’s explanation of benefits (EOB)/remittance advice, submit it to us along with the claim information. If Oxford is secondary to a commercial payer, bill the primary insurance company first. The secondary benefit plan pays the difference between the allowable expense and the amount paid by the primary plan, if the difference does not exceed the normal plan benefits which would have been payable had no other coverage existed. Under COB, the primary benefit plan pays its normal plan benefits without regard to the existence of any other coverage. Requirements for claim submission with COB If a claim is submitted past the filing deadline due to an unusual occurrence (e.g., health care provider illness, health care provider’s computer breakdown, fire, flood) and the health care provider has a historic pattern of timely submissions of claims, the health care provider may request reconsideration of the claim. If the member has a health benefit plan with a specific time frame regarding the submission of claims, the time frame in the member’s certificate of coverage will govern.If COB caused a delay, you have 90 days from the date of the primary carrier explanation of benefits to submit the claim to us.If an agreement currently exists between you and Oxford or UnitedHealthcare containing specific filing deadlines, the agreement will govern.Claims submitted after the applicable filing deadline will not be reimbursed the stated reason will be “filing deadline has passed” or “services submitted past the filing date” unless one of the following exceptions applies. It is not based on the date the claim was sent or received. The claims filing deadline is based on the date of service on the claim. New Jersey - 90 or 180 days if submitted by a New Jersey participating health care provider for a New Jersey line of business member.To be considered timely, health care providers, other health care professionals and facilities are required to submit claims within the specified period from the date of service: Medical/clinical and administrative policy updates - 2022 Administrative Guide.Member rights and responsibilities - 2022 Administrative Guide.Clinical process definitions - 2022 Administrative Guide.Case management and disease management programs - 2022 Administrative Guide.Quality assurance - 2022 Administrative Guide.Claims recovery, appeals, disputes and grievances - 2022 Administrative Guide.Member billing - 2022 Administrative Guide.Claims process - 2022 Administrative Guide.Utilization reviews - 2022 Administrative Guide.Emergencies and urgent care - 2022 Administrative Guide.Radiology and cardiology procedures - 2022 Administrative Guide.Using non-participating health care providers or facilities - 2022 Administrative Guide.Utilization management - 2022 Administrative Guide.Quality of care and patient experience program - 2022 Administrative Guide.Health care provider responsibilities and standards - 2022 Administrative Guide.
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