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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAmerigroup timely filing policy update | OpenPayer
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    CurrentAmerigroupPolicy G-06133

    Reimbursement Policy Proof of Timely Filing

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    Defines documentation and criteria Amerigroup will accept to reconsider claims denied for late submission and explains when 'good cause' for late filing may be established. Applies to providers submitting claims to Amerigroup (Georgia programs listed).

    Policy Summary
    PayerAmerigroup
    PolicyReimbursement Policy Proof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material changes
    Effective Date10/23/2025
    Last ReviewOct 23, 2025
    Next Review Date
    Key ActionProviders may request reconsideration of claims denied for untimely filing by providing acceptable proof of receipt (e.g., mail return receipt/delivery confirmation and mailed claim log or clearinghouse assigned receipt date for electronic submissions) or demonstrating Good Cause per policy criteria.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Reviewed 10/23/2025most recent history entry
    Detailed logrequired mailed claim log
    Enumeratedgood cause examples
    Mail/electronicsubmission methods

    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.

    Reconsideration and Good Cause Criteria

    Reconsideration criteria for timely filing

    Amerigroup will reconsider reimbursement for claims denied as untimely when the provider can either demonstrate proof of timely receipt or establish Good Cause.

    ANY of the following

    • Proof of receipt

      • If mailed: provide official mailing service return receipt or delivery confirmation
      • If mailed: provide a mailed claim log that identifies each claim included in the submission and includes: name of claimant; address of claimant; telephone number of claimant; claimant's federal tax identification number; name of addressee; name of carrier; designated address; date of mailing; subscriber name; subscriber ID number; member's name; date(s) of service/occurrence, total charge, and delivery method
      • If electronic: provide the clearinghouse-assigned receipt date from reconciliation reports

    • Documentation not acceptable as proof

      • Fax (facsimile transmission) is not acceptable
      • Hand delivery: a claim log that identifies each claim included in the delivery and a copy of the signed receipt are not acceptable
    Reconsideration will follow applicable timely filing requirements and any applicable state, federal, or CMS contract provisions; provider may alternatively demonstrate Good Cause per policy criteria

    Good Cause criteria

    Good Cause may be established based on the provider's explanation or supporting evidence; the plan may request clarification if the evidence raises doubt.

    ALL of the following

    • Provider provides an explanation for the delay or other evidence that establishes the reason for late filing
    • If evidence raises doubt about validity, the health plan may contact the provider for clarification or additional information

    Examples of circumstances that may meet Good Cause

    • Administrative error: incorrect or incomplete information furnished by official sources to the provider
    • Retroactive enrollment: member received notification of enrollment effective retroactively to or before the date of service

    Coding Guidance

    General coding guidancemixed
    Standard correct coding applies; use CPT, HCPCS, revenue codes as appropriate

    Provider Reconsideration and Documentation Requirements

    Prior Authorization

    Request reconsideration — provide proof of receipt or Good Cause

    Provider may request reconsideration of a claim denied for failure to meet timely filing by providing acceptable proof of receipt or by demonstrating Good Cause under policy. For mailed submissions, supply an official mailing service return receipt or delivery confirmation plus the mailed claim log with the required fields. For electronic submissions, supply the clearinghouse-assigned receipt date from reconciliation reports. Fax transmissions and hand-delivery logs/signed receipts are not acceptable proof.

    • If mailed: official mailing service return receipt or delivery confirmation AND a mailed claim log containing the required fields (e.g., claimant name/address/telephone, claimant federal tax ID, addressee, carrier, designated address, date of mailing, subscriber name/ID, member name, date(s) of service, total charge, delivery method).
    • If electronic: clearinghouse-assigned receipt date from reconciliation reports.
    • Not acceptable: fax facsimile transmission; hand delivery claim log or signed receipt.
    • Alternatively, demonstrate Good Cause per policy (provider explanation/evidence; plan may request clarification).

    Good Cause Definitions and Examples

    Good Cause examples and evidentiary standards
    Administrative errorProvider clerical or administrative mistake (e.g., misfiled or misrouted claim) that prevented timely submission; provider may document and explain circumstances.
    Retroactive enrollmentMember retroactive enrollment that results in the claim appearing untimely; provider may submit enrollment documentation to support reconsideration.
    Incorrect member informationClaims delayed due to inaccurate or incomplete member information provided to the provider; provider may supply evidence of attempts to obtain correct information.
    Delays in third-party documentationUnavoidable delays obtaining documentation from third parties (e.g., other payers, facilities) that prevented timely filing; provider may present correspondence or records showing the delay.
    Unavoidable circumstances beyond provider controlUnusual or unavoidable events (natural disasters, system outages, etc.) that prevented timely filing; provider should provide evidence of the circumstance.
    Policy Summary
    PayerAmerigroup
    PolicyReimbursement Policy Proof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material changes
    Effective Date10/23/2025
    Last ReviewOct 23, 2025
    Next Review Date
    Key ActionProviders may request reconsideration of claims denied for untimely filing by providing acceptable proof of receipt (e.g., mail return receipt/delivery confirmation and mailed claim log or clearinghouse assigned receipt date for electronic submissions) or demonstrating Good Cause per policy criteria.
    SourceLink
    On This Page
    Reconsideration and Good Cause CriteriaCoding GuidanceProvider Reconsideration and Documentation RequirementsGood Cause Definitions and Examples
    Incorrect information from the member that resulted in erroneous filing with another insurer (including Original Medicare or State Medicaid)
  1. Unavoidable delay in securing required supporting claim documentation or evidence from third parties despite reasonable efforts by the provider
  2. Unusual, unavoidable, or other circumstances beyond the provider's control demonstrating the provider could not reasonably be expected to have been aware of the need to file timely
  3. Destruction or other damage of the provider's records, unless caused by the provider's willful act or intentional oversight
    4. Destruction or damage of provider recordsLoss or destruction of provider records not caused by a willful act by the provider; provider may submit attestation and supporting details.
    Provider clarification processIf submitted explanation or evidence is insufficient or doubtful, Amerigroup may request additional information or clarification from the provider to determine Good Cause.