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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAnthem timely filing policy update — Limits | Open…
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    CurrentAnthemPolicy G-06050

    Claims Timely Filing

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    Governs the time limits and conditions under which the health plan will consider reimbursement for submitted claims for Anthem (AMH Health, LLC) Medicare Advantage members; applies to participating and nonparticipating providers and facilities as described.

    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 ActionProviders must submit claims within stated timely filing limits; late claims require documentation proving a clean claim was filed within the applicable filing limit.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 daysparticipating provider limit
    12 monthsnonparticipating provider limit
    06/03/2025effective

    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.

    Medicare Advantage
    program

    Timely Filing Coverage Criteria

    Timely filing coverage criteria

    The plan will consider reimbursement only for claims received within the applicable timely filing requirements, except as noted below.

    Claims must be received and accepted within the applicable timely filing requirements unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

    Provider type

    • Participating care providers and facilities: timely filing limit = 90 days.
    • Nonparticipating care providers and facilities: timely filing limit = 12 months.
    Timely filing is determined by subtracting the date of service from the date the claim is received; limits are compared to any applicable federal or state mandate, otherwise to the company standard (calendar days unless specified).

    Special timing rules

    • For services rendered on consecutive days (e.g., 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 payer.
    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.

    Temporary exceptions

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

    Billing Codes, Documentation, and Thresholds

    Billing codes and documentationmixed
    Use proper CPT, HCPCS, and/or revenue codes supported by medical record documentation
    Timely filing thresholds
    Participating providers and facilities90 days from date of service (company standard)
    Nonparticipating providers and facilities12 months from date of service (company standard)
    Counting for consecutive-day servicesLimit counted from the last day of service (e.g., hospital confinement)
    When other health insurance is primaryTimely filing counted from the date of the Explanation of Payment (EOP) of the primary payer

    Submission Requirements and Exceptions

    Note

    Timely filing: submit claims within limits or provide proof of clean claim

    Submit all claims within the applicable timely filing limits: 90 days for participating providers/facilities and 12 months for nonparticipating providers/facilities. Claims received after these limits will not be reimbursed unless you provide documentation proving a clean claim was filed within the applicable filing limit. The plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.

    • Timely filing is measured from date of service to date claim is received; for consecutive-day services the limit is counted from the last day of service.
    • If member has other primary insurance, timely filing is counted from the date of the primary payer's Explanation of Payment (EOP).

    Key Definitions

    Timely filing — definition and counting rules
    DefinitionTimely filing is determined by subtracting the date of service from the date the plan receives the claim and comparing the number of days to the applicable mandate or company standard.
    Calendar daysLimits are based on calendar days unless otherwise specified.
    Consecutive-day servicesFor services rendered on consecutive days (e.g., hospital confinement), the filing limit is counted from the last day of service.
    Primary other insuranceIf 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.
    Exceptions and waiversThe 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 TypeNo material change
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionProviders must submit claims within stated timely filing limits; late claims require documentation proving a clean claim was filed within the applicable filing limit.
    SourceLink
    On This Page
    Timely Filing Coverage CriteriaBilling Codes, Documentation, and ThresholdsSubmission Requirements and ExceptionsKey Definitions
    Clean claim — definition and documentation requirements
    DefinitionClean claim: a claim submitted with appropriate billing and submission guidelines and supported documentation; required to demonstrate timely filing if submission is questioned.
    Required documentationClaims must include industry-standard CPT, HCPCS, and/or revenue codes fully supported in the medical record and/or office notes as applicable.
    PurposeDocumentation proving a clean claim within the applicable filing limit is required for reimbursement of claims filed outside the timely filing limit.
    Consequences if not metIf appropriate coding/billing guidelines or documentation are not followed, the plan may reject or deny the claim, recover/recoup payment, or adjust reimbursement.