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).
06/03/2025 - Review approved and effective: no changes
Timely Filing Coverage Criteria
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.
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
Use EOP date as the starting point for measurement when other insurance is primary.
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
| Standard correct coding applies; use CPT, HCPCS, and revenue codes supported by medical records. |
Provider Actions and Exceptions
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
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