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    v1.0.31
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyHealthy Blue LA Timely Filing Policy Update | Open…
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    CurrentHealthy Blue LouisianaPolicy G-06050

    Reimbursement Policy Claims Timely Filing

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    This policy governs when Healthy Blue Louisiana will consider reimbursement for initial claims and how timely filing limits are calculated for participating and nonparticipating providers and facilities under Louisiana Medicaid Managed Care.

    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 3, 2025
    Next Review DateNot specified
    Key ActionSubmit the initial claim so that it is received and accepted within the applicable timely filing limit.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    365 daysParticipating provider filing limit
    365 daysNonparticipating provider filing limit
    Calendar daysFiling calculation basis
    Initial claimClaim type
    Disasters or state guidance

    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.

    Temporary waiver circumstances

    Timely Filing Reimbursement Criteria

    Timely Filing Reimbursement Criteria

    Reimbursement for an initial claim is considered when the claim is received and accepted within the applicable timely filing limit and all applicable provider, state, federal, CMS, authorization, medical necessity, coding, and billing requirements are met.

    ALL of the following

    • Timely receipt and filing limit

      • The initial claim is received and accepted within the applicable timely filing limit.

        The standard is 365 calendar days for participating and nonparticipating providers and facilities, unless a provider, state, federal, or CMS contract or requirement specifies otherwise.

      • The filing period is calculated by subtracting the date of service from the date the health plan receives the claim.

        For services rendered on consecutive days, calculate the limit from the last day of service. Limits are based on calendar days unless otherwise specified.

      • When another health insurance plan is primary, the timely filing period is calculated from the date of the other carrier's Explanation of Payment (EOP).

    • Claim and service requirements

      • The service is covered under the member's benefit plan.
      • The service meets applicable authorization and medical necessity guidelines for the procedure, diagnosis, and the member's state of residence.
      • The claim follows proper billing and submission guidelines and uses industry-standard, compliant CPT, HCPCS, and/or revenue codes as applicable.

        The codes billed must be fully supported by the medical record and/or office notes.

    • Exception or relief from the filing limit

      • If the claim was filed outside the applicable timely filing limit, the provider presents documentation proving that a clean claim was filed within the applicable filing limit.

        Without this documentation, the claim is not subject to reimbursement.

      • The health plan temporarily waives the timely filing requirement following a documented natural disaster or under applicable state guidance.

    Timely Filing Standards and Claim Submission

    Standard correct codingmixed
    No codes listed
    Industry-standard claim submission codesmixed
    No codes listed
    Participating provider and facility timely filing limit
    Standard limit365 calendar days for participating providers and facilities.
    Controlling requirementsAn applicable federal, state, provider, or CMS contract or requirement may specify a different limit.
    Calculation basisLimits are based on calendar days unless otherwise specified.
    Nonparticipating provider and facility timely filing limit
    Standard limit365 calendar days for nonparticipating providers and facilities.
    Controlling requirementsAn applicable federal, state, provider, or CMS contract or requirement may specify a different limit.

    Claim Submission Responsibilities

    Billing Rule

    Submit the initial claim on time

    Submit the initial claim so that it is received and accepted within the applicable timely filing limit. The standard limit is 365 calendar days for participating and nonparticipating providers and facilities unless an applicable federal, state, provider, or CMS contract or requirement specifies otherwise.

    Documentation Required

    Document proof of timely filing

    If a claim is filed outside the applicable timely filing limit, provide documentation proving that a clean claim was filed within the applicable filing limit.

    Timely Filing Terms

    Timely filing
    DefinitionTimely filing is determined by subtracting the date of service from the date the health plan receives the claim.
    ComparisonThe resulting number of days is compared with the applicable federal or state mandate; if none applies, it is compared with the health plan standard.
    Time basisThe filing limits are based on calendar days unless otherwise specified.
    Clean claim
    DefinitionA clean claim is submitted within the applicable filing limit.
    Claim requirementsThe claim satisfies clean-claim requirements.
    Supporting documentation
    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 3, 2025
    Next Review DateNot specified
    Key ActionSubmit the initial claim so that it is received and accepted within the applicable timely filing limit.
    SourceLink
    On This Page
    Timely Filing Reimbursement CriteriaTimely Filing Standards and Claim SubmissionClaim Submission ResponsibilitiesTimely Filing Terms
    Calculation basisLimits are based on calendar days unless otherwise specified.
    Consecutive-day services calculation
    Calculation ruleFor services rendered on consecutive days, count the filing limit from the last day of service.
    Time basisThe filing limit is based on calendar days unless otherwise specified.
    ApplicationThe calculation applies when determining whether the claim was received within the applicable timely filing limit.
    Other insurance calculation
    Primary other insuranceWhen another health insurance carrier is primary, calculate timely filing from the date of that carrier's Explanation of Payment (EOP).
    Starting dateThe other carrier's EOP date starts the timely filing calculation.
    Applicable situationThis rule applies when the member has other health insurance that is primary.
    Denial Risk

    Late filing may result in nonreimbursement

    Claims filed outside the applicable timely filing limit will not be subject to reimbursement unless the provider presents documentation proving that a clean claim was filed within the applicable filing limit.

    The claim is supported by documentation when proof is requested.
    Explanation of Payment (EOP)
    DefinitionAn Explanation of Payment (EOP) is the payment or explanation document issued by the primary other carrier.
    Timely filing roleWhen other insurance is primary, the EOP date starts the timely filing calculation.
    Applicable situationThe EOP rule applies when the member has other health insurance that is primary.
    General Reimbursement Policy Definitions
    Referenced sourceGeneral Reimbursement Policy Definitions.
    PurposeThis source provides the applicable general reimbursement terms.
    Policy referenceThe Claims Timely Filing policy directs readers to this source for general definitions.