CurrentBlue Cross Blue Shield - NevadaPolicy G-06133

Proof of Timely Filing (Reimbursement Policy)

Governs requirements and acceptable proof for timely filing of claims and the reconsideration of claims denied for late filing for Anthem Blue Cross and Blue Shield Medicare Advantage providers.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyProof of Timely Filing (Reimbursement Policy)

Policy CodePolicy G-06133

Change TypeClarified, Revised, Added

Effective Date11/19/2021

Next Review DateN/A

Key ActionProviders may request reconsideration of claims denied for untimely filing by demonstrating Good Cause and supplying acceptable proof of receipt.

SourceLink

POLICY UPDATE CHANGES

Added the following information will not be considered proof the claim was received timely if the claim is submitted by fax and hand delivery.

Policy title updated; policy language updated; added mailed claim log wording.

Retroactive enrollment language added.

G-06133Policy identifier

11/19/2021Effective date

09/27/2023Last approval

MultipleDocumentation types

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyProof of Timely Filing (Reimbursement Policy)

Policy CodePolicy G-06133

Change TypeClarified, Revised, Added

Effective Date11/19/2021

Next Review DateN/A

Key ActionProviders may request reconsideration of claims denied for untimely filing by demonstrating Good Cause and supplying acceptable proof of receipt.

SourceLink

On This Page

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Timely Filing Reconsideration Criteria

Anthem Medicare Advantage will reconsider denials for failure to meet timely filing requirements when the provider demonstrates Good Cause and supplies acceptable proof of receipt.

Provider must provide a date of claim receipt compliant with applicable timely filing requirements (or provider, state, federal, or CMS contracts/requirements indicate otherwise).

Acceptable proof of receipt (ONE of)

Mail: official mailing service return receipt/delivery confirmation PLUS a copy of the claim log identifying each claim submitted.
Electronic: clearinghouse-assigned receipt date from reconciliation reports.

Mailedd claim log contents: The mailed claims log must include name of claimant; claimant address; claimant telephone number; claimant federal tax identification number (TIN); name of addressee; name of carrier; date of mailing; designated address; subscriber name; subscriber ID number; member name; date(s) of service/occurrence; total charge; delivery method.

Unacceptable proof: Fax transmission and hand delivery (a claim log and signed receipt) will NOT be considered proof the claim was received timely.

Good Cause may be established by (ONE or more)

Provider explanation for the delay or other evidence establishing the reason — Anthem will base the Good Cause determination primarily on that statement or evidence.
If evidence creates doubt, Anthem may contact the provider for clarification or additional information necessary to make a Good Cause determination.
Circumstances that may constitute Good Cause: administrative error; incorrect/incomplete information furnished by official sources to the provider; incorrect information furnished by the member causing filing with another insurer or original Medicare; retroactive enrollment effective on or before the date of service; unavoidable delay securing required supporting documentation from third parties despite reasonable efforts; destruction or damage of provider records not caused by provider willful act or negligence; unusual or unavoidable circumstances beyond the provider's control preventing timely filing.

Anthem may request clarification or additional information if doubt exists regarding the validity of the provider's evidence.

Coding and Documentation Requirements

Standard correct coding appliesmixed

CPT/HCPCS/Revenue

Claims must use industry-standard CPT, HCPCS, and/or revenue codes supported by documentation.

Documentation elements for mailed claims log

Required fieldsName of claimant; Address of claimant; Telephone number of claimant; Claimant's federal tax identification number (TIN); Name of addressee; Name of carrier; Date of mailing; Designated address; Subscriber name and Subscriber ID number; Member's name; Date(s) of service/occurrence; Total charge; Delivery method

Claimant identifiersName of claimant; Claimant's federal tax identification number (TIN); Subscriber name and Subscriber ID number; Member's name

Contact & routingAddress of claimant; Telephone number of claimant; Name of addressee; Name of carrier; Designated address

Submission detailsDate of mailing; Date(s) of service/occurrence; Total charge; Delivery method

Actions for Providers

Denial Risk

Reconsideration for Timely Filing

Reconsideration for claims denied for failure to meet timely filing requirements may be requested when the provider can demonstrate Good Cause. Provide a date of claim receipt that complies with applicable timely filing requirements. Anthem Medicare Advantage (Blue Cross Blue Shield - Nevada) will reconsider reimbursement of such claims unless prohibited by provider, state, federal, or CMS contracts or requirements.

Provide a date of claim receipt compliant with applicable timely filing requirements
Anthem Medicare Advantage will reconsider reimbursement of a claim denied for failure to meet timely filing requirements when the provider can demonstrate Good Cause
Reconsideration exceptions do not apply where prohibited by provider, state, federal, or CMS contracts or requirements

Definitions

Proof of claim receipt

Acceptable proof - MailOfficial mailing service return receipt / delivery confirmation PLUS a copy of the claim log identifying each claim included in the submission

Acceptable proof - ElectronicClearinghouse-assigned receipt date from reconciliation reports

Unacceptable proof - FaxFacsimile transmission is not considered proof of timely receipt

Unacceptable proof - Hand deliveryA claim log and a copy of the signed receipt for hand delivery are not considered proof of timely receipt

Good Cause — definition and examples

DefinitionGood Cause is circumstances the payer accepts as justification for filing delay when supported by explanation or evidence; Anthem Medicare Advantage will base determination primarily on the provider's statement or evidence

Examples - administrative/errorAdministrative error or incorrect/incomplete information furnished by official sources to the provider

Examples - member or enrollment issuesIncorrect information from the member resulting in filing with another plan; retroactive enrollment effective on or before the date of service

Examples - documentation or recordsUnavoidable delay securing required supporting documentation despite reasonable efforts; destruction or damage of provider records not caused by provider negligence

Examples - other circumstancesUnusual, unavoidable, or other circumstances beyond the provider's control that made timely filing unreasonable or impossible