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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyAnthem Timely Filing Policy Update | OpenPayer
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    CurrentAnthemPolicy G-06050

    Claims Timely Filing

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    Governs timely filing limits and reimbursement for initial claims submitted to Anthem Medicare Advantage; affects participating and nonparticipating providers and facilities in Anthem service states including NC not listed (policy lists specific states).

    Policy Summary
    PayerAnthem
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeReview — no material changes
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claim within applicable timely filing limits: 90 days for participating providers; 12 months for nonparticipating providers.
    SourceLink
    POLICY UPDATE CHANGES

    06/03/2025 - Review approved and effective: no changes

    90 daystimely filing limit for participating providers
    12 monthstimely filing limit for nonparticipating providers
    calendar daysmeasurement
    natural disasterwaiver option

    Timely Filing Coverage Criteria

    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 criteria

    Reimbursement for an initial claim is considered only when the claim is received and accepted within the applicable timely filing requirements; otherwise the claim is not eligible for reimbursement unless an exception or documentation demonstrates timely filing.

    Claim received and accepted within applicable timely filing limit (see participating vs nonparticipating rules).

    Timely filing limits

    • Participating providers and facilities: claim received within 90 days measured in calendar days from date of service (for consecutive services or hospital confinement, measure from the last day of service).90 days
    • Nonparticipating providers and facilities: claim received within 12 months measured in calendar days from date of service (for consecutive services or hospital confinement, measure from the last day of service).12 months
    If member has other primary health insurance, timely filing is measured from the date on the other carrier’s Explanation of Payment (EOP).

    Use EOP date as the starting point for measurement when other insurance is primary.

    If no applicable federal or state mandate exists, compare days to the company standard (limits shown above).
    Claims filed outside the timely filing limit are not eligible for reimbursement unless the provider presents documentation proving a clean claim was filed within the applicable filing limit.

    Exceptions/waivers

    • Health plan may temporarily waive timely filing requirements following documented natural disasters.
    • Health plan may temporarily waive timely filing requirements under applicable state guidance.

    Coding and Thresholds

    Coding requirementmixed
    Standard correct coding applies; use CPT, HCPCS, and revenue codes supported by medical records.
    Timely filing thresholds
    Participating providers and facilities90 days from date of service (calendar days unless otherwise specified).
    Nonparticipating providers and facilities12 months from date of service (calendar days unless otherwise specified).
    Measurement methodTimed from date of service to date the claim is received; for consecutive-day services (e.g., hospital confinement) count from the last day of service.
    Other insurance primaryIf another carrier is primary, timely filing is measured from that carrier's Explanation of Payment (EOP).
    Temporary waiversHealth plan may temporarily waive timely filing following documented natural disasters or per applicable state guidance.

    Provider Actions and Exceptions

    Prior Authorization

    Timely filing: submit initial claim within applicable limits; note exceptions

    Submit the initial claim within the applicable timely filing limits: 90 days for participating providers and facilities; 12 months for nonparticipating providers and facilities. Timely filing is measured from the date of service to the date the claim is received (for consecutive days, measure from the last day of service); when other insurance is primary, measure from that carrier’s Explanation of Payment (EOP). Claims received after the applicable limit will not be reimbursed unless the provider documents that a clean claim was filed within the timely filing limit. The health plan may temporarily waive timely filing requirements following documented natural disasters or per applicable state guidance.

    • 90 days for participating providers and facilities
    • 12 months for nonparticipating providers and facilities
    • Measure from date of service to date claim received; for consecutive services measure from last day of service
    • If other insurance is primary, measure from other carrier’s EOP
    • Claims outside limits require documentation proving a clean claim was filed within the limit
    • Temporary waivers may be granted for documented natural disasters or under applicable state guidance

    Definitions

    Clean claim
    DefinitionClean claim
    MeaningA claim that meets submission requirements and is filed within the applicable timely filing limit such that it is eligible for consideration for reimbursement.
    Related requirementsClaims filed outside the timely filing limit are not reimbursable unless provider presents documentation proving a clean claim was filed within the applicable filing limit.
    Coding supportClean claims must use proper, industry-standard codes (CPT, HCPCS, revenue codes) fully supported by the medical record.
    Policy Summary
    PayerAnthem
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeReview — no material changes
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claim within applicable timely filing limits: 90 days for participating providers; 12 months for nonparticipating providers.
    SourceLink
    On This Page
    Timely Filing Coverage CriteriaCoding and ThresholdsProvider Actions and ExceptionsDefinitions