CurrentAnthemPolicy G-06133

Proof of Timely Filing (Reimbursement)

Governs Anthem Medicare Advantage reconsideration of claims denied for late filing and what constitutes acceptable proof of timely receipt or good cause for providers submitting claims.

Policy Summary

PayerAnthem

PolicyProof of Timely Filing (Reimbursement)

Policy CodePolicy G-06133

Change TypeAdministrative clarification (no material coverage change)

Effective DateNov 19, 2021

Next Review Date

Key ActionProvider may request reconsideration of claims denied for late filing by submitting acceptable proof of claim receipt or demonstrating Good Cause.

SourceLink

POLICY UPDATE CHANGES

Policy history notes review approved: no changes on 09/27/2023.

11/19/2021 review updated policy title and language, clarified what will not be considered proof of timely receipt for fax or hand delivery and specified 'mailed' for claim log.

Anthem Medicare AdvantageTarget payer/program

2Accepted proof methods

6+Good Cause scenarios

2023-09-27Last review

Timely Filing Reconsideration Criteria

Anthem Medicare Advantage will reconsider denials for late filing when providers supply acceptable proof of timely receipt or demonstrate Good Cause. Specific documentation requirements and examples of Good Cause are listed below.

Claim was denied for failure to meet timely filing requirements and provider requests reconsideration

Reconsideration may be granted when ONE of the following is provided:

Provider supplies a date of claim receipt compliant with applicable timely filing requirements
Provider demonstrates Good Cause exists for the late filing

Acceptable proof of claim receipt (select the applicable method)

Policy Summary

PayerAnthem

PolicyProof of Timely Filing (Reimbursement)

Policy CodePolicy G-06133

Change TypeAdministrative clarification (no material coverage change)

Effective DateNov 19, 2021

Next Review Date

Key ActionProvider may request reconsideration of claims denied for late filing by submitting acceptable proof of claim receipt or demonstrating Good Cause.

SourceLink

On This Page

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Good Cause examples

Administrative error (incorrect or incomplete information furnished by official sources to the provider)
Retroactive enrollment (member subsequently received notification of enrollment effective retroactively to or before the date of service)
Incorrect information furnished by the member resulting in erroneous filing with another plan or the state
Unavoidable delay in securing required supporting claim documentation or evidence from third parties despite reasonable efforts
Unusual, unavoidable, or other circumstances beyond the provider's control that demonstrate the provider could not reasonably be expected to have been aware of the need to file timely
Destruction or other damage of the provider's records unless caused by the provider's willful act or negligence

Coding and Mailed Claim Log Requirements

General coding requirementmixed

Claims must be billed using industry standard CPT, HCPCS, and/or revenue codes and be supported in the medical record.

Required mailed claim log fields

Name of claimantName of claimant

Address of claimantAddress of claimant

Telephone number of claimantTelephone number of claimant

Claimant's federal tax identification number (TIN)Claimant's federal tax identification number

Name of addressee / carrier / designated addressName of addressee; Name of carrier; Designated address

Date of mailingDate of mailing

Subscriber and member identifiers / service datesSubscriber name; Subscriber ID number; Member's name; Date(s) of service/occurrence; Total charge; Delivery method

Provider Reconsideration and Acceptable Proofs

Prior Authorization

Request Reconsideration for Timely Filing Denials

Provider may request reconsideration of claims denied for failure to meet timely filing by providing a date of claim receipt that complies with applicable timely filing requirements or by demonstrating that Good Cause exists.

Documentation Required

Accepted Proofs of Claim Receipt

Provide one of the following depending on submission method: for mailed claims, an official mailing service return receipt or delivery confirmation plus a copy of the mailed claim log identifying each claim in the submission; for electronic claims, the clearinghouse-assigned receipt date from reconciliation reports.

Mail: official mailing service return receipt or delivery confirmation AND copy of mailed claim log identifying each claim in the submission
Electronic: clearinghouse-assigned receipt date from reconciliation (reconciliation reports)

Denial Risk

Unacceptable Proofs of Timely Receipt

Do not rely on fax transmissions or hand delivery as proof of timely receipt; facsimile transmissions and hand-delivered claim logs or signed receipts will not be accepted.

Fax: facsimile transmission is not acceptable proof
Hand delivery: claim log or signed receipt from hand delivery is not acceptable proof

Definitions: Proof and Good Cause

Proof of Claim Receipt — acceptable documentation

Official mailing service return receipt or delivery confirmationAn official mailing service return receipt or delivery confirmation documenting date of receipt within the timely filing period

Mailed claim log identifying each claim in the submissionA copy of the mailed claims log that identifies each claim included in the mailed submission (must include required fields)

Clearinghouse reconciliation receipt date (electronic submissions)Clearinghouse assigned receipt date from reconciliation reports for electronic submissions

Good Cause — circumstances that may establish good cause

Administrative errorIncorrect or incomplete information furnished by official sources to the provider

Retroactive enrollmentMember subsequently received notification of enrollment effective retroactively to or before the date of service

Incorrect member‑provided informationIncorrect information furnished by the member that resulted in filing with another insurer or state plan

Unavoidable delay securing documentationUnavoidable delay in securing required supporting claim documentation or evidence from third parties despite reasonable efforts by the provider

Unusual or unavoidable circumstancesCircumstances beyond the provider's control demonstrating the provider could not reasonably be expected to be aware of the need to file timely

Destruction or damage to provider recordsDestruction or other damage of the provider's records unless caused by the provider's willful act or negligence