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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyBlue Cross Blue Shield NC Claims Timely Filing Pol…
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    CurrentBlue Cross Blue Shield - North CarolinaPolicy G-06050

    Claims Timely Filing

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    Sets Blue Cross NC's timely filing limits and rules for reimbursement of initial claims, and describes exceptions and interactions with federal/state mandates and other insurance; applies to providers submitting claims to Blue Cross Blue Shield of North Carolina (including Healthy Blue Medicaid).

    Policy Summary
    PayerBlue Cross Blue Shield - North Carolina
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material changes
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claim within the applicable timely filing limit (standard 365 days) or provide documentation proving a clean claim was filed within the applicable filing limit if submission is outside the limit.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    365 daystimely filing limit for participating providers and facilities
    365 daystimely filing limit for nonparticipating providers and facilities
    180 daystemporary prior limitation (outpatient)
    07/01/2021–06/30/2023

    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.

    period referenced for 180-day rule

    Timely Filing Coverage Criteria

    Timely filing criteria

    Reimbursement for initial claims depends on timely filing and supporting documentation; state or federal mandates supersede the plan standard.

    If the initial claim is received and accepted within the applicable timely filing limit, the plan will consider reimbursement.
    Standard timely filing limit is 365 calendar days for participating providers and facilities.
    Standard timely filing limit is 365 calendar days for nonparticipating providers and facilities.
    Timely filing is determined by subtracting the date of service from the date the plan receives the claim and comparing the resulting number of days to any applicable federal or state mandate; if no mandate applies, compare to the health plan standard.
    For services rendered on consecutive days, the timely filing limit is counted from the last day of service.
    If the member has other primary health insurance, timely filing is counted from the date of the other carrier's Explanation of Payment (EOP).
    Claims filed outside the timely filing limit will not be reimbursed unless the provider presents documentation proving a clean claim was filed within the applicable filing limit.

    Waiver/Exception

    • The health plan may waive timely filing requirements on a temporary basis following documented natural disasters.
    • The health plan may waive timely filing requirements under applicable state guidance.
    Claims must use appropriate CPT, HCPCS, and/or revenue codes and be fully supported by the medical record; failure to follow coding/billing guidelines may result in rejection, denial, or recovery of payment.

    Billing Codes and Thresholds

    Billing codes guidancemixed
    CPT/HCPCS/RevenueClaims should use appropriate CPT, HCPCS, and/or revenue codes and be fully supported in the medical record.
    Timely filing thresholds
    Standard timely filing limit365 calendar days for participating and nonparticipating providers and facilities
    Temporary historical outpatient limit180 days from date of service for outpatient services for DOS 07/01/2021–06/30/2023
    Inpatient historical note180 days from date of discharge for inpatient services for DOS 07/01/2021–06/30/2023

    Required Provider Actions and Exceptions

    Documentation Required

    Timely filing — submit claims within applicable limit or provide proof of timely filing

    Submit the initial claim within the applicable timely filing limit (standard 365 calendar days for participating and nonparticipating providers and facilities). If the claim is submitted after the timely filing limit, provide documentation proving a clean claim was filed within the applicable filing limit to be considered for reimbursement. Timely filing is measured from the date of service (or from the last day of service for consecutive services) to the date the plan receives the claim; if the member had other primary insurance, timely filing is measured from the other carrier's Explanation of Payment (EOP). The health plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.

    • Standard timely filing limit: 365 days for participating providers and facilities.
    • Standard timely filing limit: 365 days for nonparticipating providers and facilities.
    • Claims filed outside the timely filing limit must be supported by documentation proving a clean claim was filed within the applicable filing limit to be eligible for reimbursement.
    • Timely filing is calculated from date of service to date the plan receives the claim; for consecutive services, count from the last day of service.
    • If member has other primary insurance, timely filing is counted from the date of the other carrier's EOP.
    • Waiver of timely filing may be granted temporarily for documented natural disasters or per state guidance.

    Definitions — Timely Filing Rules

    Timely filing determination rules
    How to calculate timely filingSubtract the date of service from the date the plan receives the claim and compare the resulting number of days to the applicable mandate or health plan standard
    Consecutive servicesWhen services are rendered on consecutive days, the timely filing limit is counted from the last day of service
    Other primary insuranceIf the member has other primary health insurance, timely filing is counted from the date of the other carrier's Explanation of Payment (EOP)
    Late claims documentationClaims filed outside the timely filing limit will not be reimbursed unless provider presents documentation proving a clean claim was filed within the applicable filing limit
    Policy Summary
    PayerBlue Cross Blue Shield - North Carolina
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material changes
    Effective DateJun 3, 2025
    Last ReviewJun 3, 2025
    Next Review Date
    Key ActionSubmit initial claim within the applicable timely filing limit (standard 365 days) or provide documentation proving a clean claim was filed within the applicable filing limit if submission is outside the limit.
    SourceLink
    On This Page
    Timely Filing Coverage CriteriaBilling Codes and ThresholdsRequired Provider Actions and ExceptionsDefinitions — Timely Filing Rules