CurrentBlue Cross Blue Shield - MainePolicy G-06050

Claims Timely Filing

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Governs the timeframes and conditions under which Anthem Blue Cross and Blue Shield (including Maine) will consider reimbursement for initial claims; affects participating and nonparticipating providers and facilities submitting claims to the health plan.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyClaims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material change

Effective DateJun 3, 2025

Last ReviewJun 3, 2025

Next Review Date

Key ActionProviders may request a temporary waiver of timely filing requirements following documented natural disasters or per applicable state guidance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysparticipating provider limit

12 monthsnonparticipating provider limit

06/03/2025

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CurrentBlue Cross Blue Shield - MainePolicy G-06050

Claims Timely Filing

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Maine Policy G-06050 alerts

Get alerted when Policy G-06050 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyClaims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material change

Effective DateJun 3, 2025

Last ReviewJun 3, 2025

Next Review Date

Key ActionProviders may request a temporary waiver of timely filing requirements following documented natural disasters or per applicable state guidance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysparticipating provider limit

12 monthsnonparticipating provider limit

06/03/2025

Timely Filing and Reimbursement Conditions

Timely filing and reimbursement conditions

Reimbursement for initial claims is conditional on timely filing and compliance with billing and coding requirements, and federal/state/CMS mandates.

Claim is received and accepted within the applicable timely filing limit.

Timely filing limits

Participating providers and facilities: 90 days from date of service (count calendar days).90 days
Health plan standard
Nonparticipating providers and facilities: 12 months from date of service (count calendar days).12 months
Health plan standard

When a federal or state mandate specifies a filing limit, that mandate supersedes the plan standard.

For consecutive-day services, count from the last day of service.

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

Claims filed outside the applicable timely filing limit will not be reimbursed unless the provider documents that a clean claim was filed within the applicable filing limit; the plan may waive timely filing requirements on a temporary basis for documented natural disasters or under applicable state guidance.

Claims must use appropriate CPT/HCPCS/revenue codes supported by the medical record; failure to follow billing/submission guidelines may result in rejection, denial, recovery, or adjustment of payment.

Billing Codes and Timely Filing Calculations

Billing code requirementsmixed

CPT, HCPCS, revenue codes

Standard industry procedure and revenue codes must be used and supported by the medical record.

Timely filing calculation (how to count days)

Counting daysCount calendar days from the date of service (or the last day of service for consecutive-day services) to the date the claim is received by the health plan.

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

Federal or state mandatesIf an applicable federal or state mandate exists, compare the calculated number of days to that mandate; if none exists, compare to the health plan standard.

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

Provider Responsibilities and Consequences

Documentation Required

Timely filing waiver

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 the applicable federal or state mandate. If there is no applicable federal or state mandate, the number of days is compared to the health plan standard. If services are rendered on consecutive days, the limit is counted from the last day of service. Limits are based on calendar days unless otherwise specified. 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. The health plan reserves the right to waive timely filing requirements on a temporary basis following documented natural disasters or under applicable state guidance.

If a provider believes an untimely claim should be considered for payment due to a documented natural disaster or state guidance, the provider may request a temporary timely filing waiver.
Providers must submit documentation supporting the request for waiver (e.g., proof of disaster impact, dates affected, and any relevant state-issued guidance).
Timely filing is measured from date of service to date the claim is received by the plan; for multiple consecutive service days, measurement begins from the last day of service.

Key Terms

Timely filing — definition

DefinitionThe time period (calendar days) between the date of service (or the last day of service for consecutive services) and the date the claim is received by the health plan, used to determine eligibility for reimbursement.

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

Comparison to mandatesThe counted days are compared to any applicable federal or state mandate; if none, they are compared to the health plan standard.

Participating vs Nonparticipating providers — timely filing limits

Participating providers/facilities90 days from date of service for initial claim submission.

Nonparticipating providers/facilities12 months from date of service for initial claim submission.

Denial Risk

Late claim documentation and consequences

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. Acceptable evidence that a clean claim was timely filed may include submission confirmation from the provider’s clearinghouse or electronic transmission logs showing the original timely submission, contemporaneous correspondence with the health plan acknowledging receipt, or other verifiable system-generated receipts. If the provider cannot produce such documentation, the claim may be denied for untimely filing. Providers retain the right to appeal claim denials and may request a timely filing waiver when appropriate (for example, in the case of documented natural disasters or applicable state guidance).

A "clean claim" means a claim containing all required information and codes necessary for adjudication.
Evidence to overturn an untimely denial should demonstrate the date a clean claim was first submitted to the plan or primary payer.
Appeals of denials for untimely filing should follow the plan’s standard appeal processes and include any supporting submission logs or correspondence.
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.