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

    Reimbursement Policy Claims Timely Filing

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    Governs timely filing limits and reimbursement eligibility for initial claims submitted to Anthem (California / Medicare Advantage), affecting participating and nonparticipating providers and facilities submitting claims for members.

    Policy Summary
    PayerAnthem
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit the initial claim within the applicable timely filing limit (90 days for participating; 12 months for nonparticipating).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 daystimely filing limit for participating providers and facilities
    12 monthstimely filing limit for nonparticipating providers and facilities
    last dayconsecutive days counted from last day
    EOPtimely filing when other insurance is primary
    waiver

    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.

    waiver possible for disasters or state guidance

    Timely Filing Coverage Criteria

    Timely filing criteria

    Reimbursement considered only for claims submitted within the applicable timely filing limits unless exceptions apply.

    Claim received and accepted within the applicable timely filing limit

    Health plan standard: 90 days for participating providers and facilities; 12 months for nonparticipating providers and facilities.

    Exceptions or alternative rules

    • A federal, state, provider contract, or CMS requirement specifies a different timely filing limit

      Applicable mandates take precedence over plan standard.

    • Member has other primary health insurance

      Timely filing is counted from the date of the Explanation of Payment (EOP) of the other carrier.

    • Documented natural disaster or applicable state guidance

      Health plan may temporarily waive timely filing requirements.

    If services rendered on consecutive days, filing limit is counted from the last day of service
    Claims filed outside the timely filing limit are not eligible for reimbursement unless provider submits documentation proving a clean claim was filed within the applicable filing limit

    Provider may present documentation to dispute untimely denial.

    If coding or billing guidelines are not followed, claim may be rejected/denied, payment recovered/recouped, or reimbursement adjusted

    Use correct CPT/HCPCS/revenue codes supported in the medical record.

    Billing Codes and Filing Limits

    Billing codesmixed
    CPT/HCPCSUse correct CPT, HCPCS, and revenue codes; must be supported in the medical record.
    Participating provider timely filing
    Participating providers and facilities timely filing limit90 days from date of service (health plan standard)
    Reimbursement conditionHealth plan will consider reimbursement for initial claims received and accepted within the timely filing limit unless overridden by provider, state, federal, or CMS requirements.
    Calendar day basisLimits are based on calendar days unless otherwise specified.
    Nonparticipating provider timely filing
    Nonparticipating providers and facilities timely filing limit12 months from date of service (health plan standard)
    Reimbursement conditionHealth plan will consider reimbursement for initial claims received and accepted within the timely filing limit unless overridden by provider, state, federal, or CMS requirements.

    Provider Submission and Documentation Requirements

    Billing Rule

    Timely claim submission

    Submit the initial claim within the applicable timely filing limit. The health plan standard is: 90 days for participating providers and facilities and 12 months for nonparticipating providers and facilities. Timely filing is measured from the date of service to the date the claim is received; for services rendered on consecutive days, count from the last day of service. If the member has other health insurance that is primary, timely filing is counted from the date of the other carrier's Explanation of Payment (EOP). The plan may waive timely filing temporarily following documented natural disasters or under applicable state guidance.

    • 90 days — participating providers/facilities
    • 12 months — nonparticipating providers/facilities
    • If member has primary other insurance — count from other carrier EOP
    • Consecutive days of service — count from last day of service
    • Waiver possible for documented natural disasters or state guidance

    Key Definitions and Timing Rules

    Timely filing determination
    How timely filing is determinedSubtract the date of service from the date the claim is received and compare the resulting number of days to the applicable federal or state mandate or, if none, to the health plan standard.
    PrecedenceIf a federal/state mandate applies, it takes precedence over the health plan standard.
    Right to waiveHealth plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.
    Consecutive services filing limit
    Consecutive-day services ruleWhen services are rendered on consecutive days, the filing limit is counted from the last day of service.
    Example implicationFor a multi-day inpatient stay, the days are measured from the final date of service when assessing timely filing.
    Policy Summary
    PayerAnthem
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit the initial claim within the applicable timely filing limit (90 days for participating; 12 months for nonparticipating).
    SourceLink
    On This Page
    Timely Filing Coverage CriteriaBilling Codes and Filing LimitsProvider Submission and Documentation RequirementsKey Definitions and Timing Rules
    Claims filed outside limitClaims filed outside the timely filing limit will not be subject to reimbursement unless provider presents documentation proving a clean claim was filed within the applicable filing limit.
    Documentation Required

    Documentation for late claims

    If a claim was filed but denied for late filing, providers may dispute the denial by providing documentation that a clean claim was originally submitted within the applicable filing limit. Acceptable documentation should demonstrate the original timely submission (for example, proof of electronic transmission with date/time stamp, dated proof of mailing, or other verifiable system-generated reports). The health plan will consider such documentation when adjudicating late-filing disputes. Note that this requirement is subject to any provider, state, federal, or CMS contract provisions that supersede the plan.

    • Provide proof that a clean claim was filed within the applicable filing limit
    • Acceptable evidence: electronic transmission logs with date/time stamp, dated USPS return receipt or certificate of mailing, system-generated reports showing submission date
    • Health plan will review submitted documentation to adjudicate late-filing disputes
    • Subject to overriding provider, state, federal, or CMS requirements
    Calendar day basisLimits are based on calendar days unless otherwise specified.
    Timely filing when other insurance is primary
    Other primary insurance ruleIf 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.
    Effect on measurementTimely filing clock begins on the EOP date rather than the original date of service when other insurance is primary.
    Documentation requirementClaims filed outside the timely filing limit may be considered if provider shows documentation proving a clean claim was filed within the applicable filing limit.