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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 N/A

    Documentation of Proof of Timely Filing

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    This reimbursement policy governs documentation requirements and criteria for proving timely filing of claims for Anthem/Anthem Medicare Advantage providers and outlines circumstances for reconsideration when timely filing limits are missed.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyDocumentation of Proof of Timely Filing
    Policy CodePolicy N/A
    Change TypeWording/terminology updatesnon‑material revisions
    Effective DateMay 24, 2019
    Last ReviewMay 24, 2019
    Next Review DateN/A
    Key ActionProvider may request reconsideration of a denied claim for missed timely filing by providing the date of claim receipt and demonstrating good cause.
    SourceLink
    POLICY UPDATE CHANGES

    United States mail return receipt language updated; Word physician replaced with provider.

    Retroactive enrollment language added.

    'First class' language removed.

    Applies to Anthem Medicare Advantagepayers/policy audience
    4accepted proof methods

    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.

    10+required claim log fields
    Listedgood cause examples

    Timely Filing Documentation and Criteria

    Timely Filing Documentation and Reconsideration Criteria

    Covered when ALL of the following evidence and conditions are met:

    Provider can provide a date of claim receipt compliant with applicable timely filing requirements.

    Date of receipt must be documented using one of the acceptable evidence methods below.

    Acceptable proof of claim receipt (ONE of)

    • By mail: official mailing service return receipt/delivery confirmation PLUS a copy of the provider claim log identifying each claim in the submission.

      See claim log field requirements.

    • Electronically: clearinghouse-assigned receipt date from reconciliation reports.
    • By fax: proof of facsimile transmission.
    • By hand delivery: provider claim log identifying each claim AND a copy of the signed receipt acknowledging hand delivery.

    ALL of the following

    • Name of claimant
    • Address of claimant
    • Telephone number of claimant
    • Claimant's federal tax identification number
    • Name of addressee
    • Name of carrier
    • Designated address
    Provider demonstrates good cause for late filing (when applicable); Anthem Medicare Advantage will reconsider a denied claim for failure to meet timely filing when good cause is shown.

    Good cause determination is based primarily on the provider's explanation/evidence; Anthem may request clarification or additional information if validity is in doubt.

    Examples of circumstances that may constitute good cause (ONE or more)

    • Administrative error such as incorrect or incomplete information.
    • Retroactive enrollment: member received notification of enrollment effective retroactively to or before the date of service.
    • Incorrect information furnished by the member resulting in erroneous filing with another health plan or the state.
    • Unavoidable delay in securing required supporting claim documentation or evidence from third parties despite reasonable efforts by the provider.
    • Unusual, unavoidable or other circumstances beyond the provider's control that demonstrate the provider could not reasonably be expected to have been aware of the need to file timely.
    • Destruction or other damage of the provider's records unless caused by the provider's willful action.
    Limitations: Policy may be superseded by provider, state, federal, or CMS contract mandates; system setup may affect claim processing behavior.

    Billing and Coding Requirements

    Billing/Coding Requirementsmixed
    No codes listed
    Coding support requirement
    RequirementBilled code(s) are required to be fully supported in the medical record and/or office notes.
    Accepted coding systemsCurrent Procedure Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and/or revenue codes must be used on all claim submissions.
    ConsequencesIf coding/billing guidelines are not followed, Anthem Medicare Advantage may reject or deny the claim and may recover/recoup claim payment.
    ApplicabilityApplies to participating providers and facilities unless otherwise noted; non‑contracting providers accepting Medicare assignment reimbursed per original Medicare rates.

    Reconsideration and Provider Requests

    Prior Authorization

    Request reconsideration for missed timely filing — provide receipt date and demonstrate good cause

    Provider may request reconsideration of a claim denied for failure to meet timely filing by submitting a compliant date of claim receipt and demonstrating good cause. To initiate reconsideration, supply the date of claim receipt using one of the acceptable proof methods (mail return receipt/delivery confirmation with claim log, clearinghouse assigned receipt date from reconciliation reports for electronic submissions, proof of facsimile transmission for faxed claims, or claim log plus signed receipt for hand delivery) and documentation explaining the reason for the late filing to establish good cause.

    • Provide a date of claim receipt compliant with applicable timely filing requirements using the applicable proof: mail (official mailing service return receipt/delivery confirmation plus claim log), electronic (clearinghouse assigned receipt date from reconciliation reports), fax (proof of facsimile transmission), or hand delivery (claim log and signed receipt).
    • Demonstrate good cause by supplying an explanation or evidence for the delay; Anthem will evaluate the statement/evidence and may request clarification or additional information if validity is in doubt.
    • Good cause examples include administrative error, retroactive enrollment, incorrect or incomplete member information, unavoidable delay obtaining supporting documentation, destruction of provider records, or other circumstances beyond provider control.

    Definitions: Proof of Receipt and Good Cause

    Documentation of Claim Receipt — acceptable evidence
    MailOfficial mailing service return receipt/delivery confirmation plus a copy of the provider's claim log identifying each claim included in the submission.
    ElectronicClearinghouse-assigned receipt date from reconciliation reports.
    FaxProof of facsimile transmission.
    Hand deliveryProvider claim log identifying each claim and a signed receipt acknowledging the hand delivery.
    Good Cause — examples that may excuse late filing
    Administrative errorIncorrect or incomplete information leading to the filing delay (e.g., data entry mistakes).
    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyDocumentation of Proof of Timely Filing
    Policy CodePolicy N/A
    Change TypeWording/terminology updatesnon‑material revisions
    Effective DateMay 24, 2019
    Last ReviewMay 24, 2019
    Next Review DateN/A
    Key ActionProvider may request reconsideration of a denied claim for missed timely filing by providing the date of claim receipt and demonstrating good cause.
    SourceLink
    On This Page
    Timely Filing Documentation and CriteriaBilling and Coding RequirementsReconsideration and Provider RequestsDefinitions: Proof of Receipt and Good Cause
    Date of mailing or hand delivery
  1. Subscriber name and Subscriber ID number
  2. Member's name
  3. Date(s) of service/occurrence, total charge, and delivery method
    4. Retroactive enrollmentMember received notification of enrollment effective retroactively to or before the date of service.
    Incorrect member informationInformation furnished by the member that resulted in erroneous filing with another health plan or state program.
    Unavoidable delay obtaining documentationDelay in securing required supporting claim documentation or evidence from third parties despite reasonable efforts by the provider.
    Other unavoidable circumstancesUnusual, unavoidable or other circumstances beyond the provider's control (including destruction/damage of provider records) that prevented timely filing.