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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAnthem Claims Timely Filing Policy Update | OpenPa…
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    CurrentAnthemPolicy G-06050

    Claims Timely Filing

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    Defines timely filing limits and reimbursement conditions for initial claim submission to Anthem Blue Cross Medicare Advantage in California, affecting participating and nonparticipating providers and facilities.

    Policy Summary
    PayerAnthem
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeRoutine review — no changes
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claims within 90 days for participating providers or within 12 months for nonparticipating providers to be considered for reimbursement.
    SourceLink
    POLICY UPDATE CHANGES

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

    90 daysparticipating provider limit
    12 monthsnonparticipating provider limit
    calendar dayscounting basis
    last dayconsecutive services start

    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 Coverage Criteria

    Reimbursement for initial claims is contingent on timely filing and meeting other policy and contractual requirements.

    Initial claim must be received and accepted within the applicable timely filing limit for the provider type.

    Provider type thresholds

    • Participating care providers and facilities: initial claim received and accepted within 90 days of the date of service.
    • Nonparticipating care providers and facilities: initial claim received and accepted within 12 months of the date of service.
    Timely filing is determined by subtracting the date of service from the date the claim is received and comparing the number of days to applicable federal or state mandates; if none apply, compare to the company standard (calendar days unless otherwise specified).
    When services are rendered on consecutive days (for example, hospital confinement), the timely 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.

    Exceptions and waivers

    • 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.
    • The health plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.
    Reimbursement remains subject to authorization, medical necessity, correct coding/billing, and applicable provider, state, federal, or CMS contracts and requirements.

    Coding, Billing, and Timely Filing Thresholds

    Coding and Billingmixed
    Use appropriate CPT, HCPCS, and/or revenue codes; standard correct coding applies
    Timely filing thresholds — participating and nonparticipating limits
    Participating providers and facilities90 days from date of service
    Nonparticipating providers and facilities12 months from date of service
    Basis for countingCalendar days unless otherwise specified

    Provider Requirements and Exceptions

    Billing Rule

    Timely Filing Requirements and Exceptions

    The health plan will consider reimbursement for the initial claim when received and accepted within the timely filing requirements, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Timely filing is determined by subtracting the date of service from the date we receive the claim and comparing the number of days to the applicable federal or state mandate. If there is no applicable federal or state mandate, the number of days is compared to the company standard. If services are rendered on consecutive days (for example, a hospital confinement), the limit is counted from the last day of service. Limits are based on calendar days unless otherwise specified. If the member has other health insurance that is primary, timely filing is counted from the date of the Explanation of Payment (EOP) of the other carrier. Claims filed outside the timely filing limit will not be subject to reimbursement unless the provider presents documentation proving a clean claim was filed within the applicable filing limit. The health plan reserves the right to temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance. Providers must use proper billing and submission guidelines, including industry-standard CPT, HCPCS, and/or revenue codes, and ensure claims are fully supported in the medical record; failure to follow coding/billing guidelines may result in claim rejection, denial, recoupment, or adjustment.

    • Company standard timely filing limits: 90 days for participating providers and facilities; 12 months for nonparticipating providers and facilities.
    • Timely filing calculation: date received minus date of service; for consecutive-day services, use the last day of service as the date of service.
    • When another payer is primary: timely filing begins from the Explanation of Payment (EOP) date from the other carrier.
    • Claims outside limits: reimbursement requires documentation that a clean claim was filed within the applicable filing limit.
    • Exceptions/waivers: plan may temporarily waive timely filing following documented natural disasters or when required by applicable state guidance.
    • Contract overrides: provider, state, federal, or CMS contracts and/or requirements may supersede these timely filing standards.

    Key Definitions and Determinations

    Timely filing determination method
    Determination methodSubtract the date of service from the date the claim is received and compare the number of days to applicable federal or state mandates or, if none, the company standard
    If other primary insurance existsCount from the date of the Explanation of Payment (EOP) of the other carrier
    AuthorityCompare to federal/state mandates first; if none, use company standard
    Consecutive day services — limit counted from last day of service
    Counting start for consecutive-day servicesTimely filing limit is counted from the last day of service (e.g., hospital confinement)
    Applies toServices rendered on consecutive days such as inpatient stays
    Calendar basisLimits remain based on calendar days unless otherwise specified
    Clean claim — definition and documentation requirement if claim filed late
    Definition of clean claimAn appropriately completed claim submission as required by the payer
    Late-filed claim documentation requirementProvider must present documentation proving a clean claim was filed within the applicable filing limit for consideration of reimbursement
    Exception handlingHealth plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance
    Policy Summary
    PayerAnthem
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeRoutine review — no changes
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claims within 90 days for participating providers or within 12 months for nonparticipating providers to be considered for reimbursement.
    SourceLink
    On This Page
    Timely Filing Coverage CriteriaCoding, Billing, and Timely Filing ThresholdsProvider Requirements and ExceptionsKey Definitions and Determinations