CurrentHighmark Blue Cross Blue Shield WnyPolicy 06050

Reimbursement Policy Claims Timely Filing

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Defines the health plan's timely filing limits and rules for reimbursement of initial claims for Highmark BCBS WNY Essential Plan (EP) members; applies to participating and nonparticipating providers submitting claims for EP program members.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClaims Timely Filing

Policy CodePolicy 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 (120 days participating, 15 months nonparticipating).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 daystimely filing limit (participating)

15 monthstimely filing limit (nonparticipating)

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CurrentHighmark Blue Cross Blue Shield WnyPolicy 06050

Reimbursement Policy Claims Timely Filing

Customize your policy alerts

Sign up for Highmark Blue Cross Blue Shield Wny Policy 06050 alerts

Get alerted when Policy 06050 changes without checking for updates manually.

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Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyClaims Timely Filing

Policy CodePolicy 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 (120 days participating, 15 months nonparticipating).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 daystimely filing limit (participating)

15 monthstimely filing limit (nonparticipating)

Timely Filing Coverage Criteria

Timely Filing Criteria

Reimbursement is considered for initial claims received within the applicable timely filing limit; exceptions and measurement rules below.

If no state or federal mandate applies, use health plan standard timely filing limits: 120 days for participating providers and facilities; 15 months for nonparticipating providers and facilities.

Timely filing is calculated as: (date claim received by the health plan) minus (date of service). For services on consecutive days, use the last day of service. Measurement is by calendar days unless otherwise specified.

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 received after the applicable timely filing limit will not be reimbursed unless the provider submits documentation proving a clean claim was filed within the applicable filing limit.

Waiver exceptions

Health plan may temporarily waive timely filing requirements following documented natural disasters.
Health plan may waive timely filing per applicable state guidance.

Standard correct coding and billing requirements apply: services must be billed with appropriate CPT/HCPCS/revenue codes and supported by medical record documentation.

Billing Codes, Documentation, and Thresholds

Billing Codes and Documentationmixed

CPT/HCPCS/Revenue codes

Services should be billed with appropriate CPT, HCPCS, and/or revenue codes and supported by medical record documentation.

Timely filing thresholds

Timely filing limit — participating providers/facilities120 days

Timely filing limit — nonparticipating providers/facilities15 months

How timely filing is measuredTimely filing = date claim received by health plan minus date of service; for consecutive-day services, measurement is from the last day of service; calendar days unless specified otherwise.

Other primary insurance ruleIf member has other primary insurance, timely filing is measured from the date of the other carrier’s Explanation of Payment (EOP).

Late filing rebuttalClaims filed outside the timely filing limit are not reimbursed unless provider presents documentation proving a clean claim was filed within the applicable filing limit.

Waiver conditionsHealth plan may temporarily waive timely filing requirements for documented natural disasters or under applicable state guidance.

Timely Filing Requirements and Provider Responsibilities

Denial Risk

Timely Filing Requirements and Exceptions

Submit initial claims within the applicable timely filing limit or risk denial. Timely filing is measured from the date of service to the date the health plan receives the claim, and the plan will consider reimbursement only when a claim is received and accepted within the applicable limit unless overridden by provider, state, federal, or CMS contract requirements.

120 days for participating providers and facilities
15 months for nonparticipating providers and facilities
If services are rendered on consecutive days, the timely filing limit is counted from the last day of service.
Limits are based on calendar days unless otherwise specified.
If the member has other health insurance that is primary, timely filing is counted from the date of the Explanation of Payment (EOP) from the primary carrier.
Claims filed outside the timely filing limit will not be reimbursed unless the provider submits documentation proving a clean claim was filed within the applicable filing limit.
The health plan may temporarily waive timely filing requirements following documented natural disasters or under applicable state guidance.

Definitions

DefinitionsGeneral Reimbursement Policy Definitions (see policy for full list).

ScopeApplies to reimbursement related to timely submission of initial claims for the Highmark BCBS WNY Essential Plan.

Reference materialsSee related policies: Corrected Claims; Eligible Billed Charges; Proof of Timely Filing.