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    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAnthem Timely Filing Policy Update | OpenPayer
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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 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
    Last ReviewJun 3, 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

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    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.
    • Waivers may be granted under applicable state guidance or when provider, state, federal, or CMS contracts/requirements indicate alternative limits.
    Standard correct coding applies: claims must use CPT, HCPCS, and/or revenue codes supported by medical record documentation; failure to follow coding/billing guidelines may result in rejection, denial, or recovery of payment.

    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
    Policy Summary
    PayerAnthem
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective Date06/03/2025
    Last ReviewJun 3, 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
    On This Page
    Timely Filing Coverage CriteriaCoding and Timely Filing ThresholdsProvider Submission and Waiver ActionsPolicy Definitions and Calculations