CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Requirements for Documentation of Proof of Timely Filing

This policy governs Anthem Blue Cross and Blue Shield Medicare Advantage requirements for documentation that demonstrates timely filing of claims and describes what constitutes proof and good cause for late filing; it applies to providers submitting claims to Anthem Medicare Advantage.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyRequirements for Documentation of Proof of Timely Filing

Policy CodePolicy N/A

Change TypeNon-material administrative wording updates

Effective DateMay 24, 2019

Next Review DateN/A

Key ActionProvide a date of claim receipt and supporting proof (return receipt/delivery confirmation for mail, clearinghouse receipt for electronic, fax transmission proof, or signed hand-delivery receipt) when requesting reconsideration for late-filed claims.

SourceLink

POLICY UPDATE CHANGES

United States mail return receipt language updated.

Retroactive enrollment language added.

Medicare Advantageprogram affected

mail, electronic, fax, handaccepted submission methods

claims log fieldsminimum data elements

administrative, retroactive, delaysgood cause examples

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyRequirements for Documentation of Proof of Timely Filing

Policy CodePolicy N/A

Change TypeNon-material administrative wording updates

Effective DateMay 24, 2019

Next Review DateN/A

SourceLink

On This Page

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Timely filing proof and good cause criteria

Anthem Medicare Advantage will reconsider claims denied for late filing if the provider can demonstrate timely receipt or establish good cause.

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

Acceptable proof of receipt (one of)

Mail: official mailing service return receipt or delivery confirmation PLUS a copy of the claim identifying each claim in the submission.
Electronic: clearinghouse-assigned receipt date from reconciliation reports.
Fax: proof of facsimile transmission.
Hand delivery: copy of the claim identifying included claims AND signed receipt acknowledging hand delivery.

Provider claims log must include: claimant name, claimant address, claimant telephone number, claimant federal tax identification number (TIN), name of addressee, name of carrier, designated address, date of mailing or hand delivery, subscriber name, subscriber ID number, member name, date(s) of service/occurrence, total charge, and delivery method.

Good cause reasons (one or more)

Administrative error: incorrect or incomplete information furnished by official sources to the provider.
Retroactive enrollment: member notified of enrollment effective retroactively to or before the date of service.
Incorrect information furnished by the member to the provider resulting in erroneous filing.
Unavoidable delay in securing required supporting documentation or evidence from one or more third parties despite reasonable efforts by the provider.
Unusual or unavoidable 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 act.

Anthem Medicare Advantage will base cause determinations primarily on the provider's explanation or supporting evidence; if doubt exists, Anthem may request clarification or additional information from the provider.

Policy may be superseded by provider, state, federal, or CMS contracts or requirements; system logic or setup may affect claim processing.

Reconsideration Process and Required Proof

Prior Authorization

Reconsideration available with proof of timely claim receipt

Anthem will reconsider reimbursement of a claim denied for failure to meet timely filing when the provider can provide a date of claim receipt that complies with applicable timely filing requirements. Providers must supply proof of receipt appropriate to the submission method: mail — official mailing service return receipt or delivery confirmation plus a copy of the claim identifying each claim in the submission; electronic — clearinghouse-assigned receipt date from reconciliation reports; fax — proof of facsimile transmission; hand delivery — copy of the claim identifying included claims and a signed receipt acknowledging hand delivery.

Mail: official mailing service return receipt or delivery confirmation and a copy of the claim identifying each claim in the submission
Electronic: clearinghouse assigned receipt date from reconciliation reports
Fax: proof of facsimile transmission
Hand delivery: copy of the claim identifying included claims and signed receipt acknowledging hand delivery

Key Definitions

Good cause — definition and examples

Administrative errorIncorrect or incomplete information furnished by official sources to the provider (e.g., wrong info from payer or other official source)

Retroactive enrollmentMember subsequently received notification of enrollment effective retroactively to or before the date of service

Incorrect member informationIncorrect information furnished by the member to the provider resulting in erroneous filing with another health plan or state program

Unavoidable delaysUnavoidable delay in securing required supporting documentation or evidence from third parties despite reasonable efforts by the provider

Destruction of recordsDestruction or other damage of the provider's records unless caused by the provider's willful action

Other uncontrollable circumstancesUnusual, unavoidable or other circumstances beyond the provider's control that prevented timely filing

Documentation of claim receipt — acceptable proof by submission method

Mail submissionsOfficial mailing service return receipt or delivery confirmation plus a copy of the claim that identifies each claim included in the submission

Electronic submissionsClearinghouse-assigned receipt date from reconciliation reports as proof of receipt

Fax submissionsProof of facsimile transmission (fax confirmation)

Hand deliveryCopy of the claim identifying included claims and a signed receipt acknowledging hand delivery

OpenPayer

Requirements for Documentation of Proof of Timely Filing

Timely Filing and Good Cause Criteria

Billing Codes and Claims Log Requirements

Reconsideration Process and Required Proof

Key Definitions