CurrentAnthemPolicy G-06050

Reimbursement Policy Claims Timely Filing

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Defines Anthem Wisconsin timely filing limits and rules for reimbursement of initial claims for BadgerCare Plus and Medicaid SSI providers and facilities. Applies to participating and nonparticipating providers submitting claims to the health plan.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Claims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material changes

Effective DateJun 3, 2025

Last ReviewJun 3, 2025

Next Review Date

Key ActionSubmit initial claims within the applicable timely filing limit (365 days standard) and provide documentation if claiming a timely-filed clean claim when filing outside limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365 daystimely filing limit (participating)

365 daystimely filing limit (nonparticipating)

0policy changes on 06/03/2025

Timely Filing Coverage Criteria

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CurrentAnthemPolicy G-06050

Reimbursement Policy Claims Timely Filing

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Policy Summary

PayerAnthem

PolicyReimbursement Policy Claims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material changes

Effective DateJun 3, 2025

Last ReviewJun 3, 2025

Next Review Date

Key ActionSubmit initial claims within the applicable timely filing limit (365 days standard) and provide documentation if claiming a timely-filed clean claim when filing outside limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365 daystimely filing limit (participating)

365 daystimely filing limit (nonparticipating)

0policy changes on 06/03/2025

Timely Filing Coverage Criteria

Claims will be considered for reimbursement when the initial claim is received and accepted within the applicable timely filing limit, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Standard timely filing limit is 365 days for participating providers and facilities.

Standard timely filing limit is 365 days for nonparticipating providers and facilities.

Timely filing is calculated by subtracting the date of service from the date the health plan receives the claim and comparing the resulting number of days to the applicable federal or state mandate; if no mandate exists, compare to the health plan standard.

If services are rendered on consecutive days, the timely filing limit is counted from the last day of service; limits are based on calendar days unless otherwise specified.

If the member has other primary health insurance, timely filing is counted from the date of the Explanation of Payment (EOP) from the primary carrier.

Claims filed outside the timely filing limit will not be reimbursed unless the provider documents that a clean claim was filed within the applicable filing limit.

The health plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.

Claims must use proper billing and submission guidelines (CPT, HCPCS, and/or revenue codes) and be fully supported in the medical record; failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection, denial, recovery/recoupment, or adjustment of payment.

Coding and Timely Filing Calculation

General coding expectationsmixed

Standard correct coding applies; use CPT, HCPCS, revenue codes as appropriate and fully support in medical record.

Timely filing calculation

Calculation methodTimely filing is calculated as: date health plan receives the claim minus the date of service.

Applicable standardIf no federal/state mandate applies, the health plan standard is 365 days for both participating and nonparticipating providers and facilities.

Consecutive-day servicesFor services rendered on consecutive days, the timely filing limit is counted from the last day of service.

Primary payer scenarioIf the member has other primary insurance, timely filing is counted from the date of the primary carrier’s Explanation of Payment (EOP).

Calendar days basisLimits are based on calendar days unless otherwise specified.

Submission and Exception Actions for Timely Filing

Documentation Required

Timely filing — submit within 365 days and document exceptions

Submit initial claims within the applicable timely filing limit (standard 365 days). If filing outside the limit, document and present proof that a clean claim was filed within the applicable filing limit to support reimbursement. The plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.

Initial claims must be received and accepted within 365 days for participating and nonparticipating providers and facilities.
Timely filing is calculated as the difference between date received and date of service (for consecutive days, use the last day of service); if member has other primary insurance, count from the primary carrier's EOP.
If claiming reimbursement for a claim filed outside the limit, provide documentation proving a clean claim was filed within the applicable filing limit.
The health plan may waive timely filing temporarily for documented natural disasters or per applicable state guidance.

Definitions — Timely Filing

Timely filing defined

DefinitionTimely filing is determined by subtracting the date of service from the date the health plan receives the claim and comparing the resulting number of days to applicable federal/state mandates or the health plan standard.

Multi‑day servicesWhen services occur on consecutive days, use the last day of service as the date of service for the calculation.

Comparison ruleIf a federal or state mandate applies, compare the calculated days to that mandate; otherwise compare to the health plan standard (365 days).

Requirement for reimbursement when lateClaims filed outside the timely filing limit are not reimbursed unless the provider documents that a clean claim was filed within the applicable filing limit.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Claims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material changes

Effective DateJun 3, 2025

Last ReviewJun 3, 2025

Next Review Date

Key ActionSubmit initial claims within the applicable timely filing limit (365 days standard) and provide documentation if claiming a timely-filed clean claim when filing outside limits.

SourceLink

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