CurrentBlue Cross Blue Shield - NevadaPolicy G-06050

Reimbursement Policy Claims Timely Filing

Governs timely filing requirements for claims submitted to Blue Cross Blue Shield - Nevada (Anthem affiliate), specifying filing timeframes for participating and nonparticipating providers and conditions for exceptions.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyClaims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material changes

Effective DateJun 3, 2025

Next Review Date

Key ActionProviders must submit initial claims within timely filing limits: participating providers 90 days, nonparticipating providers 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystimely filing limit for participating providers

12 monthstimely filing limit for nonparticipating providers

approved 06/03/2025last approval status

participating & non-participatingapplicability

Timely Filing Coverage Criteria

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Claims must be received and accepted within the timely filing limits to be considered for reimbursement.

ALL of the following

ONE of
- Participating providers and facilities: claim received within 90 days of date of service.
- Nonparticipating providers and facilities: claim received within 12 months of date of service.

ALL of the following

Count calendar days from the date of service to the date the claim is received.
For consecutive services (e.g., hospital confinement), count from the last day of service.
If another carrier is primary, count from the date of the primary carrier's Explanation of Payment (EOP).

ALL of the following

ONE of
- Claims filed outside the timely filing limit will not be reimbursed unless the provider documents that a clean claim was filed within the applicable filing limit.
- The health plan may temporarily waive timely filing requirements following documented natural disasters or per applicable state guidance.

ALL of the following

Provider, state, federal, or CMS mandates and contracts may supersede these timely filing requirements.

Operational note:

The plan may recover or recoup payments, reject/deny claims, or adjust reimbursement if billing/coding guidelines or reimbursement policies are not followed.

Coding and Thresholds

Coding requirementsmixed

Standard correct coding applies; use CPT, HCPCS, revenue codes as appropriate and ensure documentation supports billed services.

Timely filing thresholds

Participating providers and facilities90 days from date of service (company standard)

Nonparticipating providers and facilities12 months from date of service (company standard)

Temporary waiversPlan may temporarily waive timely filing requirements following documented natural disasters or per applicable state guidance

Submission Requirements and Exceptions

Prior Authorization

Timely filing: submit initial claims within limits and document exceptions

Submit the initial claim so it is received and accepted within the applicable timely filing limit: participating providers and facilities — 90 days; nonparticipating providers and facilities — 12 months. Timely filing is calculated from the date of service (for consecutive services, from the last day of service), or from the Explanation of Payment (EOP) date from the primary carrier when other insurance is primary. Claims received after these limits will not be reimbursed unless the provider documents that a clean claim was filed within the applicable filing limit. The plan may temporarily waive timely filing requirements following documented natural disasters or per applicable state guidance.

Participating providers/facilities: submit within 90 days of date of service.
Nonparticipating providers/facilities: submit within 12 months of date of service.
For consecutive services (e.g., hospital confinement), use the last day of service to calculate the filing limit.
If other insurance is primary, calculate timely filing from the primary carrier's EOP date.
If claim is outside limits, provide documentation proving a clean claim was filed within the applicable limit to be considered for reimbursement.
The plan may temporarily waive requirements after documented natural disasters or per state guidance.

Key Definitions — Timely Filing

Definition of timely filing

How timely filing is determinedSubtract the date of service from the date the claim is received and compare the number of days to the applicable federal/state mandate or company standard

Consecutive services ruleIf services are rendered on consecutive days (e.g., hospital confinement), the timely filing limit is counted from the last day of service

When other insurance is primaryTimely filing is counted from the date of the Explanation of Payment (EOP) from the primary carrier

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyClaims Timely Filing

Policy CodePolicy G-06050

Change TypeNo material changes

Effective DateJun 3, 2025

Next Review Date

Key ActionProviders must submit initial claims within timely filing limits: participating providers 90 days, nonparticipating providers 12 months.

SourceLink

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