Six Payer Categories. Six Different Rulebooks.

A practice that runs one billing workflow across every payer category writes off revenue it could have collected, and the deadlines are where it starts. Medicare requires the claim within one calendar year of the date of service (42 CFR 424.44). Texas Medicaid requires it at TMHP within 95 days for in-state providers, while Medi-Cal runs a six-month limit from the month of service. Commercial deadlines are set by the contract, and what a carrier owes you on a clean claim is set by state statute for fully-insured products and by ERISA for self-funded ones. Workers' compensation runs on its own state clock again. One operation, six calendars.

The same fragmentation runs through prior authorization, fee schedules, appeals processes, and patient-billing rules. Medicare Advantage applies PA gates to services traditional Medicare adjudicates without auth. ERISA self-funded plans use federal §503 appeal processes; state-fully-insured plans use state-DOI external review. Workers' comp claims pay under state fee schedules tied to a percentage of Medicare in some states and proprietary tables in others. Self-pay billing runs through the No Surprises Act Good Faith Estimate framework, where the patient-provider dispute process opens once billed charges are at least $400 above the estimate for that provider (45 CFR 149.620).

The problems that bring practices to these pages are narrow and concrete: Medicare claims denying for medical necessity under one MAC's local policy while the same code pays in the next jurisdiction; Medicaid claims pending for information and quietly falling outside the prompt-pay count; an ERISA appeal filed into a state external-review process that has no jurisdiction over the plan; out-of-network payments accepted because nobody opened the federal IDR window in time. A payer review takes your remittances for one payer, reads why the claims are actually failing — the payer's own policy, the coding, or the front end — and comes back with written findings and the fix, in 3 to 5 business days. Where a rule depends on your state, plan type or contract, we say so rather than generalizing.