CurrentAnthemPolicy G-06133

Proof of Timely Filing for Claims Reimbursement

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Defines what documentation and criteria Anthem (Wisconsin) requires to reconsider claims denied for late filing under BadgerCare Plus and Medicaid SSI programs and who may submit such requests (care providers).

Policy Summary

PayerAnthem (Wisconsin)

PolicyProof of Timely Filing for Claims Reimbursement

Policy CodePolicy G-06133

Change TypeNo material change

Effective Date10/23/2025

Last ReviewOct 23, 2025

Next Review Date

Key ActionProvider may request reconsideration of a claim denied for late filing by providing proof of claim receipt within applicable timely filing limits and demonstrating Good Cause per policy criteria.

SourceLink

10/23/2025last approval/effective date

BadgerCare Plus & Medicaid SSI (WI)jurisdiction

mail & electronicacceptable proof types

6 listedgood cause examples

Timely Filing Reconsideration Criteria

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CurrentAnthemPolicy G-06133

Proof of Timely Filing for Claims Reimbursement

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Policy Summary

PayerAnthem (Wisconsin)

PolicyProof of Timely Filing for Claims Reimbursement

Policy CodePolicy G-06133

Change TypeNo material change

Effective Date10/23/2025

Last ReviewOct 23, 2025

Next Review Date

SourceLink

10/23/2025last approval/effective date

BadgerCare Plus & Medicaid SSI (WI)jurisdiction

mail & electronicacceptable proof types

6 listedgood cause examples

Timely Filing Reconsideration Criteria

The health plan will reconsider reimbursement for claims denied for timely filing when the provider supplies proof of claim receipt within applicable timely filing limits and demonstrates Good Cause per the policy.

ALL of the following

ALL of the following
- ONE of: Mail submissions: official mailing service return receipt or delivery confirmation AND a mailed claims log that identifies each claim in the submission
  Mailed claims log must include name/address/phone of claimant; claimant's federal tax ID; name of addressee; name of carrier; designated address; date of mailing; subscriber name and ID; member name; date(s) of service, total charge; and delivery method.
- ONE of: Electronic submissions: clearinghouse-assigned receipt date from reconciliation reports
  Clearinghouse reconciliation reports must show the assigned receipt date.
ALL of the following
- ONE of: Provider explanation or other evidence establishing the reason for delay (plan will base determination primarily on provider statement/evidence).
- ONE of: If doubt exists about the evidence, the plan may contact the provider for clarification or additional information to make a Good Cause determination.
- ONE of
  - Administrative error: incorrect or incomplete information furnished by official sources to the provider.
  - Retroactive enrollment: member received notification of enrollment effective retroactively to or before the date of service.
  - Incorrect member information furnished to the provider, resulting in filing with another plan, Original Medicare, or State Medicaid plan.
  - Unavoidable delay in securing required supporting documentation from third parties despite reasonable efforts by the provider.
  - Unusual, unavoidable, or other circumstances beyond the provider's control such that the provider could not reasonably be expected to be aware of the need to file timely.
  - Destruction or damage of provider records, unless caused by the provider's willful act or unintentional oversight.

ALL of the following

Fax transmission (facsimile).
Hand delivery: a claim log and a copy of a signed receipt are not acceptable proof.

ALL of the following

Reconsideration is permitted unless superseded by care provider, state, federal, or CMS contracts and/or requirements.

Coding and Billing Requirements

Coding and Billing Requirementsmixed

CPT/HCPCS/Revenue

Claims must use proper CPT, HCPCS, and/or revenue codes as appropriate and be supported in the medical record.

Required mailed claims log fields

Name of claimantName of claimant

Address and telephone of claimantAddress of claimant; Telephone number of claimant

Claimant federal tax IDClaimant's federal tax identification number

Addressee and carrierName of addressee; Name of carrier

Designated address and date of mailingDesignated address; Date of mailing

Subscriber and member identifiersSubscriber name; Subscriber ID number; Member's name

Service/date and charge detailsDate(s) of service/occurrence, total charge, and delivery method

Requesting Reconsideration for Timely Filing

Prior Authorization

Request Reconsideration for Timely Filing Denials

Provider may request reconsideration of a claim denied for late filing by supplying proof that the claim was received within the applicable timely filing period and, where applicable, evidence that ‘Good Cause’ exists. Acceptable proof for mailed claims is an official mailing service return receipt or delivery confirmation together with a mailed claims log; acceptable proof for electronic claims is the clearinghouse‑assigned receipt date from reconciliation reports. Fax transmissions and hand‑delivery items (claim log and signed receipt) are not acceptable proof.

Mail: official mailing service return receipt or delivery confirmation AND a mailed claims log that identifies each claim (see required mailed claims log fields).
Electronic: clearinghouse assigned receipt date from reconciliation reports.
Not acceptable: fax transmission; hand delivery (claim log and signed receipt).
Good Cause: provider statement/evidence will be the primary basis; plan may request clarification and considers administrative error, retroactive enrollment, incorrect member information, unavoidable delay obtaining documentation, unusual circumstances beyond provider control, or destruction/damage to provider records (unless caused by provider).

Definitions (General Reimbursement)

Definitions (general reimbursement)

Definitions sourceGeneral Reimbursement Policy Definitions (see policy Definitions section)

Proof of receipt (mail)Official mailing service return receipt or delivery confirmation required for mailed claims

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

Not acceptable as proofFax transmission and hand-delivery claim log/signed receipt are not considered proof of timely receipt

PurposeGuides reconsideration of claims denied for failure to meet timely filing requirements

Policy Summary

PayerAnthem (Wisconsin)

PolicyProof of Timely Filing for Claims Reimbursement

Policy CodePolicy G-06133

Change TypeNo material change

Effective Date10/23/2025

Last ReviewOct 23, 2025

Next Review Date

SourceLink

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