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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyBlue Cross Blue Shield - Maine timely filing Polic…
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    CurrentBlue Cross Blue Shield - MainePolicy 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, and outlines circumstances affecting filing deadlines for providers submitting claims to Blue Cross Blue Shield - Maine.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    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 initial claims within the applicable timely filing limit (90 days participating; 12 months nonparticipating).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsnonparticipating limit
    90 daysparticipating limit
    2025-06-03policy reviewed

    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 and Reimbursement Criteria

    Timely filing and reimbursement criteria

    Reimbursement for initial claims is subject to timely filing limits and supporting documentation.

    Claims must meet all of the following to be considered for reimbursement.

    ALL of the following

    • Timely filing limits

      • Claim received within 90 days of date of service for participating providers and facilities.
      • Claim received within 12 months of date of service for nonparticipating providers and facilities.
    • Timely filing is measured from the date of service (or from the last day of service for consecutive services, e.g., hospital confinement).
    • If the member has other primary health insurance, timely filing is measured from the date of the Explanation of Payment (EOP) of the primary carrier.
    • Claims filed outside the applicable timely filing limit will not be reimbursed unless the provider presents documentation proving a clean claim was filed within the applicable filing limit.
    • The plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.
    • Services must be billed with CPT, HCPCS, and/or revenue codes and fully supported in the medical record or office notes.

    Operational notes: Limits are based on calendar days unless otherwise specified. Timely filing is calculated by subtracting the date of service from the date the claim is received.

    Coding and Timely Filing Timeframes

    Required coding standardsmixed
    CPT/HCPCSClaims should be billed with CPT, HCPCS, and/or revenue codes and supported in the medical record.
    Participating provider timely filing
    Participating provider timely filing limit90 days from date we receive the claim (measured from date of service)
    ApplicabilityApplies to participating care providers and facilities submitting initial claims
    Exception for other primary insuranceIf member has other primary coverage, measurement may start from the EOP of the primary carrier
    Nonparticipating provider/facility timely filing
    Nonparticipating provider/facility timely filing limit12 months from date we receive the claim (measured from date of service)
    ApplicabilityApplies to nonparticipating care providers and facilities submitting initial claims

    Provider Requirements and Calculation Rules

    Billing Rule

    Timely filing requirement

    Submit initial claims within the applicable timely filing limit. The health plan follows the standard of 90 days for participating providers/facilities and 12 months for nonparticipating providers/facilities; claims filed outside these limits will not be reimbursed unless the provider presents documentation proving a clean claim was filed within the applicable filing limit or an exception applies.

    • 90 days for participating care providers and facilities
    • 12 months for nonparticipating care providers and facilities
    • Claims outside the timely filing limit require documentation proving a clean claim was filed within the applicable filing limit to be considered
    Billing Rule

    Calculation of timely filing

    Calculate timely filing from the date of service (or from the last day of service for consecutive services such as hospital confinement). If the member has other primary insurance, timely filing is measured from the Explanation of Payment (EOP) of the other carrier.

    Definitions and Special Rules

    Timely filing — definition
    DefinitionTimely filing: the time period within which an initial claim must be received by the health plan to be considered for reimbursement
    MeasurementCalculated by subtracting the date of service from the date the claim is received and comparing to the applicable limit
    Standards referencedIf no federal or state mandate applies, company standards (90 days participating; 12 months nonparticipating) are used
    Consecutive services rule
    Rule for consecutive servicesWhen services are rendered on consecutive days (e.g., hospital confinement), the timely filing limit is counted from the last day of service
    Measurement basisLimits are based on calendar days unless otherwise specified
    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    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 initial claims within the applicable timely filing limit (90 days participating; 12 months nonparticipating).
    SourceLink
    On This Page
    Timely Filing and Reimbursement CriteriaCoding and Timely Filing TimeframesProvider Requirements and Calculation RulesDefinitions and Special Rules
    Documentation requirementClaims filed outside this limit will not be reimbursed unless provider presents documentation proving a clean claim was filed within the applicable filing limit
    • Measured from date of service; for consecutive services, measured from the last day of service
    • If other primary insurance exists, measured from the primary carrier's EOP
    Denial Risk

    Waiver for disasters/state guidance

    The health plan reserves the right to temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.

    • Waivers are discretionary and applied by the plan based on documented natural disasters or state guidance
    Interaction with other primary insuranceIf 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