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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAmerigroup timely filing policy update | OpenPayer
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    CurrentAmerigroupPolicy G-06050

    Reimbursement Policy Claims Timely Filing

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    Rules governing how long providers have to submit initial claims to Amerigroup for reimbursement and when the plan may waive or deny late claims; applies to participating and nonparticipating providers under the described Amerigroup Georgia products.

    Policy Summary
    PayerAmerigroup
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claim within the applicable timely filing limit (standard: six months from month of service).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6 monthsstandard timely filing limit for participating providers
    6 monthsstandard timely filing limit for nonparticipating providers
    Count from EOPtimely filing when other primary insurance
    Possiblewaiver after disasters/state guidance

    Timely Filing Coverage Criteria

    Policy Summary
    PayerAmerigroup
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claim within the applicable timely filing limit (standard: six months from month of service).
    SourceLink
    On This Page
    Timely Filing Coverage CriteriaCoding and Timely Filing LimitsProvider Actions & ExceptionsDefinitions and References

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Timely filing rules and exceptions

    Reimbursement is considered only when initial claims are received and accepted within the applicable timely filing limits. Exceptions and waiver criteria are described below.

    Initial claims must be received and accepted within the applicable timely filing limit to be considered for reimbursement.
    Standard timely filing limit: six months following the month in which services were rendered for both participating and nonparticipating providers and facilities.
    Timely filing is determined by subtracting the date of service from the date the plan receives the claim; limits are based on calendar days unless otherwise specified.
    If services are rendered on consecutive days, the filing limit is counted from the last day of service.
    If the member has other primary health insurance, timely filing is counted from the date of the Explanation of Payment (EOP) from the other carrier.
    Claims filed outside the timely filing limit will not be reimbursed unless the provider presents documentation proving a clean claim was filed within the applicable filing limit.

    Waiver/Exceptions

    • The health plan may temporarily waive timely filing requirements following documented natural disasters.
    • The health plan may waive or apply exceptions in accordance with applicable state guidance or when provider, state, federal, or CMS contracts/requirements indicate otherwise.
    Proper coding and billing guidelines must be used; failure to follow coding/billing or reimbursement policies may result in claim rejection, denial, recovery/recoupment, or adjustment of reimbursement.

    Coding and Timely Filing Limits

    Coding guidancemixed
    No codes listed
    Timely filing limit
    Standard timely filing limit (participating providers)Six months following the month in which services were rendered
    Standard timely filing limit (nonparticipating providers)Six months following the month in which services were rendered
    Consecutive service datesIf services are rendered on consecutive days, the filing limit is counted from the last day of service
    Claims with other primary insuranceIf member has other primary health insurance, timely filing is counted from the date of the Explanation of Payment (EOP) from the other carrier
    Late claims exceptionClaims filed outside the timely filing limit will not be reimbursed unless provider presents documentation proving a clean claim was filed within the applicable filing limit
    Waiver authorityThe health plan may waive timely filing requirements temporarily following documented natural disasters or per applicable state guidance

    Provider Actions & Exceptions

    Denial Risk

    Timely filing — submit initial claim within six months; exceptions and denial risk

    Submit the initial claim so it is received and accepted within the applicable timely filing limit. The health plan’s standard limit is six months following the month in which services were rendered for both participating and nonparticipating providers; if services are on consecutive days, count from the last day of service. If the member has other primary insurance, count timely filing from the date of the Explanation of Payment (EOP) from the other carrier. Claims submitted after the timely filing limit will not be reimbursed unless the provider presents documentation proving a clean claim was filed within the applicable filing limit. The health plan may waive timely filing requirements temporarily following documented natural disasters or per applicable state guidance.

    • Submit initial claim within six months following the month of service (participating and nonparticipating providers).
    • For consecutive-day services, file from the last day of service.
    • If member has other primary insurance, file from the date of the other carrier’s EOP.
    • If claim is late, provide documentation proving a clean claim was filed within the filing limit to avoid denial.
    • Be aware the plan may temporarily waive timely filing after documented natural disasters or per state guidance.

    Definitions and References

    General definitions
    Referenced definitionsGeneral Reimbursement Policy Definitions are referenced by this policy
    ScopeDefinitions apply to reimbursement and timely filing terms used throughout the policy
    Location of termsSee the General Reimbursement Policy Definitions for standardized term meanings used in this policy