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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAnthem timely filing limits policy update | OpenPa…
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    CurrentAnthemPolicy G-06050

    Reimbursement Policy Claims Timely Filing

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    Defines the health plan's timely filing limits and related rules for claim submission and reimbursement for Anthem Blue Cross and Blue Shield Medicare Advantage members and providers.

    Policy Summary
    PayerAnthem
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit the initial claim within the applicable timely filing limit (90 days for participating providers; 12 months for nonparticipating).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 daystimely filing limit (participating)
    12 monthstimely filing limit (nonparticipating)
    calendar dayslimits based on

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    06/03/2025last approval/effective

    Timely Filing and Coverage Rules

    Timely filing criteria

    Claims reimbursement depends on timely submission and may be denied if filed outside limits unless documented exceptions apply.

    Health plan will consider reimbursement when the initial claim is received and accepted within the applicable timely filing limit.

    Timely filing limits

    • 90 days for participating providers and facilities.
    • 12 months for nonparticipating providers and facilities.
    • State or federal mandates supersede plan standards when applicable.
    Timely filing is calculated by subtracting the date of service from the date the claim is received and comparing the resulting number of days to an applicable federal or state mandate; if none applies, 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.
    If the member has other primary health insurance, timely filing is counted from the date of the Explanation of Payment (EOP) of the other 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 or the health plan grants a waiver (for example, temporary waivers following documented natural disasters or under applicable state guidance).
    Use proper billing and submission guidelines: submit industry-standard CPT, HCPCS, and/or revenue codes fully supported in the medical record and office notes. Failure to follow coding/billing guidelines may result in claim rejection, denial, recovery/recoupment, or payment adjustment.
    Provider, state, federal, or CMS contracts and requirements may override these timely filing standards.

    Billing, Coding, and Timing Calculations

    Billing and coding expectationsmixed
    CPT/HCPCS/RevenueUse industry-standard CPT, HCPCS, and revenue codes; codes must be supported in the medical record and office notes.
    Timely filing count (days calculation)
    Calculation methodSubtract the date of service from the date the claim is received and compare the resulting number of days to applicable federal or state mandates; if none, compare to the health plan standard.
    Calendar days basisLimits are based on calendar days unless otherwise specified.
    Primary insurance impactIf the member has other primary health insurance, count timely filing from the date of the Explanation of Payment (EOP) of the other carrier.

    Provider Submission Requirements and Exceptions

    Billing Rule

    Timely filing requirements and exceptions

    Submit the initial claim within the applicable timely filing limit. The health plan will consider reimbursement for an initial claim only when it is received and accepted within the applicable timely filing limit, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

    • 90 days for participating providers and facilities
    • 12 months for nonparticipating providers and facilities
    • Timely filing is determined by subtracting the date of service from the date we receive the claim and comparing the resulting number of days to any applicable federal or state mandate; if none, compare to the health plan standard
    • If services are rendered on consecutive days, the limit is counted from the last day of service
    • If the member has other health insurance that is primary, timely filing is counted from the date of the Explanation of Payment (EOP) of the other carrier
    • Claims filed outside the timely filing limit will not be reimbursed unless the provider presents documentation proving 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

    Definitions and Timing Rules

    Timely filing — definition and rules
    Definition of timely filingTimely filing is determined by subtracting the date of service from the date the claim is received and comparing the resulting number of days to the applicable federal or state mandate or to the health plan standard.
    Consecutive-day servicesIf services are rendered on consecutive days, the timely filing limit is counted from the last day of service.
    Waiver conditionsClaims filed outside the timely filing limit may be reimbursed only if provider documents a clean claim was filed within the applicable filing limit or if the plan waives requirements for documented natural disasters or per state guidance.
    Consecutive services — how counting begins
    Counting for consecutive servicesWhen services occur on consecutive days, count the filing limit from the last day of service.
    Calendar-day basis
    Policy Summary
    PayerAnthem
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit the initial claim within the applicable timely filing limit (90 days for participating providers; 12 months for nonparticipating).
    SourceLink
    On This Page
    Timely Filing and Coverage RulesBilling, Coding, and Timing CalculationsProvider Submission Requirements and ExceptionsDefinitions and Timing Rules
    Limits are based on calendar days unless otherwise specified.
    Relation to federal/state mandatesApply federal or state mandates first; if none apply, use the health plan standard for counting days.