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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAnthem Proof of Timely Filing Policy Update | Open…
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    CurrentAnthemPolicy G-06133

    Reimbursement Policy Proof of Timely Filing

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    Rules for what constitutes acceptable proof of claim receipt and criteria for reconsideration of claims denied for late filing, applicable to Anthem Blue Cross and Blue Shield Medicare Advantage providers in the states listed on the policy header.

    Policy Summary
    PayerAnthem
    PolicyProof of Timely Filing for Claims
    Policy CodePolicy G-06133
    Change TypeNo material changes
    Effective Date10/23/2025
    Last ReviewOct 23, 2025
    Next Review DateN/A
    Key ActionProvider may request reconsideration of a claim denied for untimely filing by providing a compliant date of claim receipt and demonstrating Good Cause.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    13 fieldsrequired data elements in mailed claims log
    7 examplesGood Cause scenarios

    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.

    10/23/2025
    latest history entry

    Timely Filing Reconsideration Criteria

    Timely Filing Reconsideration Criteria

    Reconsideration will be considered when ALL of the following are met:

    ALL of the following

    • ALL of the following

      • Acceptable proof of receipt (ONE of):

        • By mail: official mailing service return receipt or delivery confirmation PLUS a copy of the provider's mailed claim log that identifies each claim in the submission.
        • Electronically: clearinghouse-assigned receipt date from reconciliation reports.

    • ALL of the following

      • Good Cause may be established by provider explanation or evidence (ONE of):

        • If the claim includes an explanation for the delay (or other evidence that establishes the reason), the health plan will determine Good Cause based primarily on that statement or evidence.
        • If evidence raises doubt about the validity of the statement, the health plan may contact the provider for clarification or additional information necessary to make a Good Cause determination.

    ALL of the following

    • 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 to the provider, resulting in erroneous filing with another health plan, Original Medicare, or State Medicaid plan.
    • Unavoidable delay in securing required supporting claim documentation or evidence from third parties, despite reasonable efforts by the provider to secure such documentation or evidence.
    • Unusual or unavoidable 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 unintentional oversight.

    ALL of the following

    • Fax (facsimile) transmission is not acceptable proof.
    • Hand delivery: a claim log that identifies each claim and a signed receipt are not acceptable proof.

    ALL of the following

    • Name of claimant
    • Address of claimant
    • Telephone number of claimant
    • Claimant's federal tax identification number
    • Name of addressee
    • Name of carrier
    • Designated address

    ALL of the following

    • Reconsideration is subject to provider, state, federal, or CMS contracts and/or requirements that may indicate otherwise.
    • Standard correct coding, authorization, and medical necessity requirements apply; services must be billed with appropriate codes supported in the medical record.

    Operational: If validity of Good Cause is doubtful, plan may request clarification from provider.

    Billing and Coding Requirements

    Billing/coding requirementsmixed
    CPT/HCPCSClaims should be billed with appropriate CPT, HCPCS, and/or revenue codes supported by documentation.

    Provider Reconsideration & Submission Actions

    Prior Authorization

    Request reconsideration by proving timely receipt and Good Cause

    Providers may request reconsideration of a claim denied for untimely filing by supplying a compliant date of claim receipt and demonstrating Good Cause; reconsideration is subject to provider, state, federal, or CMS contracts and/or requirements that may indicate otherwise.

    • Provide a date of claim receipt compliant with applicable timely filing requirements.
    • Demonstrate that Good Cause exists for the late filing.

    Key Definitions

    Definitions (general)
    Policy titleGeneral Reimbursement Policy Definitions
    PurposeDefines terms used throughout the reimbursement policy, including proof of timely filing and Good Cause
    ScopeApplies to Anthem Blue Cross and Blue Shield Medicare Advantage providers in the states listed on the policy header
    Related documentsSee related policies: Claims Timely Filing; Corrected Claims; Eligible Billed Charges
    Effective date2025-10-23 (policy review affirmed no changes)
    Good Cause — examples and process
    Primary basis for Good Cause determination
    Policy Summary
    PayerAnthem
    PolicyProof of Timely Filing for Claims
    Policy CodePolicy G-06133
    Change TypeNo material changes
    Effective Date10/23/2025
    Last ReviewOct 23, 2025
    Next Review DateN/A
    Key ActionProvider may request reconsideration of a claim denied for untimely filing by providing a compliant date of claim receipt and demonstrating Good Cause.
    SourceLink
    On This Page
    Timely Filing Reconsideration CriteriaBilling and Coding RequirementsProvider Reconsideration & Submission ActionsKey Definitions
    Date of mailing
  1. Subscriber name and subscriber ID number
  2. Member's name
  3. Date(s) of service/occurrence, total charge, and delivery method
    4. If the claim includes an explanation for the delay (or other evidence), the health plan will determine Good Cause based primarily on that statement or evidence.
    Provider clarificationIf evidence raises doubt, the health plan will contact the provider for clarification or additional information to make a Good Cause determination.
    Administrative errorIncorrect or incomplete information furnished by official sources to the provider may constitute Good Cause.
    Retroactive enrollmentMember receives notification of enrollment effective retroactively to or before the date of service may constitute Good Cause.
    Incorrect member informationIncorrect information furnished by the member that led to erroneous filing with another plan (e.g., Original Medicare or State Medicaid) may constitute Good Cause.
    Unavoidable delay securing documentationUnavoidable delay in obtaining required supporting claim documentation or evidence from third parties despite reasonable efforts by the provider may constitute Good Cause.
    Destruction or damage to recordsDestruction or damage of the provider's records may constitute Good Cause unless caused by the provider's willful act or unintentional oversight.