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

10/23/2025latest history entry

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
Date of mailing
Subscriber name and subscriber ID number
Member's name
Date(s) of service/occurrence, total charge, and delivery method

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/HCPCS

Claims 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 determinationIf 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.

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

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Reimbursement Policy Proof of Timely Filing

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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
Date of mailing
Subscriber name and subscriber ID number
Member's name
Date(s) of service/occurrence, total charge, and delivery method

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.

Provider Reconsideration & Submission Actions

Prior Authorization

Request reconsideration by proving timely receipt and Good Cause

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

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.

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.