CurrentBlue Cross Blue Shield - MainePolicy G-06133

Proof of Timely Filing

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Defines evidence acceptable to demonstrate claims were received within timely filing limits and describes circumstances under which AMH Health will reconsider denials for late filing; applies to providers submitting claims to AMH Health, LLC.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProof of Timely Filing

Policy CodePolicy G-06133

Change TypeClarification (non-material)

Effective DateNov 19, 2021

Last ReviewSep 27, 2023

Next Review Date

Key ActionRequest reconsideration of a claim denied for timely filing by demonstrating Good Cause or providing a compliant date of claim receipt.

SourceLink

POLICY UPDATE CHANGES

Added information about what will not be considered proof the claim was received timely when submitted by fax or hand delivery.

listAcceptable proof types

listUnacceptable proof types

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CurrentBlue Cross Blue Shield - MainePolicy G-06133

Proof of Timely Filing

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Maine Policy G-06133 alerts

Get alerted when Policy G-06133 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProof of Timely Filing

Policy CodePolicy G-06133

Change TypeClarification (non-material)

Effective DateNov 19, 2021

Last ReviewSep 27, 2023

Next Review Date

Key ActionRequest reconsideration of a claim denied for timely filing by demonstrating Good Cause or providing a compliant date of claim receipt.

SourceLink

POLICY UPDATE CHANGES

Added information about what will not be considered proof the claim was received timely when submitted by fax or hand delivery.

listAcceptable proof types

listUnacceptable proof types

Timely Filing Reconsideration Criteria

Covered when the provider either demonstrates Good Cause for the delayed filing or provides acceptable proof a claim was received within the applicable timely-filing period.

ANY of the following

ALL of the following
- Provider submits a statement and/or supporting evidence establishing Good Cause
- AMH Health may request clarification or additional information if evidence raises doubt about the validity of the statement
- ANY of the following
  - Administrative error (including incorrect or incomplete information furnished by official sources to the provider)
  - Incorrect information furnished by the member resulting in filing with another plan or the state Medicaid plan
  - Retroactive enrollment where member received notification effective retroactively to or before the date of service
  - Unavoidable delay obtaining required supporting documentation or evidence from third parties despite reasonable efforts by the provider
  - Destruction or other damage to provider records unless caused by the provider's willful act or negligence
  - Other unusual, unavoidable, or circumstance(s) beyond the provider's control that reasonably prevented timely filing
ALL of the following
- ANY of the following
  - Electronic submission: clearinghouse-assigned receipt date from reconciliation reports
  - Mailed submission: official mailing service return receipt or delivery confirmation PLUS a copy of the claim identifying each claim in the submission
- ALL of the following
  - Fax: facsimile transmission is not acceptable
  - Hand delivery: provider-maintained hand-delivery claim log or a copy of a signed receipt is not acceptable
- If mailed, provider's mailed claims log should include: name and address of claimant; claimant federal tax ID; claimant telephone number; name of addressee; name of carrier; designated address; subscriber name and ID number; date of mailing or hand delivery; date(s) of service/occurrence; total charge; delivery method

Coding and Documentation Requirements

Required coding standardsmixed

CPT/HCPCS

Claims must use Current Procedure Terminology (CPT) and HCPCS codes as applicable; standard correct coding applies.

Documentation support

Documentation requirementServices billed must be fully supported in the medical record and/or office notes.

Accepted code setsUse industry-standard CPT, HCPCS, and revenue codes as applicable; billed codes must be supported by documentation.

PurposeSupports claims adjudication and potential recovery/recoupment if coding/billing guidelines are not followed.

Applies toBoth participating and non-participating professional providers and facilities unless otherwise noted.

Consequences of noncomplianceAMH Health may recover/recoup payment, reject or deny the claim, or adjust reimbursement to reflect appropriate services performed.

Actions When a Claim Is Denied for Timely Filing

Denial Risk

Reconsideration for Timely Filing Denials — Request Reconsideration

Request reconsideration of a claim denied for failure to meet timely filing by either demonstrating Good Cause with supporting explanation/evidence or by providing a date of claim receipt that complies with the applicable timely filing requirements.

Demonstrate Good Cause exists (see policy for examples).
Provide a date of claim receipt that is compliant with applicable timely filing requirements.

Good Cause — Definition and Examples

Good Cause — acceptable reasons

Examples of Good CauseAdministrative error; incorrect or incomplete information from official sources or the member; retroactive enrollment; unavoidable delay obtaining documentation from third parties; destruction of provider records not due to willful negligence; other circumstances beyond provider control.

Provider responsibilitySubmit an explanation and supporting evidence when requesting reconsideration of a timely-filing denial based on Good Cause.

Reconsideration optionsProvider may demonstrate Good Cause or provide a compliant date of claim receipt to request reconsideration of a timely-filing denial.

Not an exhaustive listOther unavoidable circumstances beyond provider control may also establish Good Cause on a case-by-case basis.