CurrentAnthemPolicy G-06050

Reimbursement Policy Claims Timely Filing

Defines the health plan's timely filing limits and rules for reimbursement of initial claims for Anthem HealthKeepers Medicaid products in Virginia, and outlines when exceptions or waivers may apply.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Claims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material change

Effective Date06/03/2025

Next Review DateN/A

Key ActionSubmit initial claim within the applicable timely filing limit (standard 12 months) or provide documentation proving a clean claim was filed within the filing limit to be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstimely filing limit (participating)

12 monthstimely filing limit (nonparticipating)

06/03/2025effective / last approval

VAjurisdiction

Timely Filing Coverage Criteria

Timely filing reimbursement criteria

Reimbursement for initial claims is governed by timely filing limits and supporting documentation.

Health plan standard timely filing limit is 12 months for participating and nonparticipating providers and facilities unless a federal or state mandate specifies otherwise.

Timely filing is determined by subtracting the date of service from the date the claim is received; for services on consecutive days, count from the last day of service; when another carrier is primary, count from the date of that carrier's Explanation of Payment (EOP).

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

Waiver or exception

The health plan may temporarily waive timely filing requirements following documented natural disasters.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Claims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material change

Effective Date06/03/2025

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Timely Filing Thresholds

Coding requirementsmixed

Standard correct coding applies; claims should use CPT, HCPCS, and/or revenue codes supported by documentation.

Timely filing days threshold

Timely filing standard (health plan)12 months for participating providers and facilities; 12 months for nonparticipating providers and facilities

How threshold is appliedCompare days between date of service and date claim is received to an applicable federal or state mandate; if no mandate, compare to the health plan standard (12 months)

Consecutive days of serviceIf services are rendered on consecutive days, the timely filing limit is counted from the last day of service

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

Provider Submission and Waiver Actions

Documentation Required

Timely filing submission

Submit the initial claim so it is received and accepted within the applicable timely filing limit (health plan standard: 12 months for participating and nonparticipating providers and facilities). If a claim is filed outside the timely filing limit, provide documentation proving a clean claim was filed within the applicable filing limit for the claim to be considered for reimbursement.

Timely filing is determined by subtracting the date of service from the date the claim is received; for consecutive-day services, count from the last day of service.
If member has other health insurance that is primary, timely filing is counted from the date of the Explanation of Payment (EOP) from the other carrier.

Denial Risk

Waiver request during disasters/state guidance

Request a waiver of the timely filing requirement only when the plan has temporarily waived requirements following documented natural disasters or under applicable state guidance.

Waiver consideration is limited to temporary situations following documented natural disasters or per applicable state guidance.

Policy Definitions and Calculations

General Reimbursement Definitions

Scope of definitionsGeneral reimbursement policy definitions apply to terms used in this policy

Coding standardsUse industry-standard CPT, HCPCS, and/or revenue codes; billed services must be fully supported in the medical record or office notes

Application to provider typesUnless otherwise noted, reimbursement policies apply to both participating and non-participating professional providers and facilities

Timely filing calculation

Calculation methodTimely filing is calculated by subtracting the date of service from the date the claim is received and comparing the resulting number of days to the applicable mandate or plan standard

Consecutive-day servicesFor consecutive days of service, count the timely filing limit from the last day of service

When other insurance is primaryIf another carrier is primary, count timely filing from the date of that carrier's Explanation of Payment (EOP)

Calendar day basisLimits are based on calendar days unless otherwise specified