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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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    Defines the health plan's timely filing limits and rules for claim submission and reimbursement for participating and nonparticipating providers for AMH Health Medicare Advantage.

    Policy Summary
    PayerAnthem
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material clinical or coverage changes
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claim within the applicable timely filing limit (90 days participating; 12 months nonparticipating) and provide documentation if filing outside limits.
    SourceLink
    POLICY UPDATE CHANGES

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

    12/27/2022 - Review approved and effective: policy template updated; minor administrative changes

    90 daysparticipating limit
    12 monthsnonparticipating limit

    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.

    calendar days
    measured in
    EOPother primary

    Timely Filing & Reimbursement Criteria

    Timely filing and reimbursement criteria

    Reimbursement consideration is contingent on timely submission and acceptance of an initial claim within applicable limits; exceptions and waivers are limited and documented.

    Initial claim must be received and accepted by the health plan within the applicable timely filing limit; otherwise reimbursement will not be considered unless an exception applies.

    ALL of the following

    • Timely filing limits

      • Participating providers and facilities: 90 days (measured in calendar days).
      • Nonparticipating providers and facilities: 12 months (measured in calendar days).
    • If services are rendered on consecutive days, the filing limit is measured from the last day of service.
    • If member has other primary health insurance, timely filing is measured from the date of the Explanation of Payment (EOP) from the other carrier.

    ALL of the following

    • Timely filing is determined by subtracting the date of service from the date the claim is received and comparing the resulting number of calendar days to the applicable federal or state mandate; if no mandate applies, compare to the health plan standard.

    ALL of the following

    • 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.

    Waiver and override conditions

    • Health plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.
    • Policy may be superseded by provider, state, federal, or CMS contracts and/or requirements; applicable mandates take precedence.
    Failure to follow proper billing, coding, or submission guidelines may result in claim rejection, denial, recovery/recoupment, or adjustment of reimbursement as described in policy.

    Coding Expectations & Timely Filing Thresholds

    Coding expectationsmixed
    No codes listed
    Timely filing thresholds and measurement rules
    Participating providers and facilities timely filing limit90 days from date of service (measured in calendar days)
    Nonparticipating providers and facilities timely filing limit12 months from date of service (measured in calendar days)
    Measurement rule for consecutive servicesLimit is counted from the last day of service when services are rendered on consecutive days
    When other insurance is primaryTimely filing is measured from the Explanation of Payment (EOP) date of the other carrier
    Late claims requirement for reimbursementClaims filed outside the timely filing limit require documentation proving a clean claim was filed within the applicable filing limit

    Submission Requirements and Exceptions

    Billing Rule

    Timely filing: submit initial claim within limits and exceptions

    Submit the initial claim within the applicable timely filing limit: 90 days for participating providers/facilities and 12 months for nonparticipating providers/facilities. If services occur on consecutive days, measure from the last day of service; limits are calendar days unless specified otherwise. If the member has other primary health insurance, measure timely filing from the other carrier’s Explanation of Payment (EOP). Claims filed outside these limits require documentation proving a clean claim was filed within the applicable filing limit. The plan may temporarily waive timely filing requirements for documented natural disasters or per applicable state guidance.

    • Measure days by subtracting date of service (or last day of service if consecutive) from the date the claim is received.
    • If other insurance is primary, count from the EOP of the other carrier.
    • Provide documentation proving a clean claim was filed within the applicable filing limit to request reimbursement for late claims.
    • Waivers may be granted for documented natural disasters or under applicable state guidance.

    Definitions

    Definitions — general reimbursement policy
    Scope of definitionsGeneral Reimbursement Policy Definitions (see policy for full definitions)
    Application of definitionsDefinitions inform standards for timely filing, reimbursement consideration, exceptions, and waiver conditions
    Waiver condition referencePolicy may allow temporary waivers (e.g., documented natural disasters) as described in timely filing rules
    Policy Summary
    PayerAnthem
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material clinical or coverage changes
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claim within the applicable timely filing limit (90 days participating; 12 months nonparticipating) and provide documentation if filing outside limits.
    SourceLink
    On This Page
    Timely Filing & Reimbursement CriteriaCoding Expectations & Timely Filing ThresholdsSubmission Requirements and ExceptionsDefinitions