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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyHighmark BCBS WNY timely-filing policy update | Op…
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    CurrentHighmark Blue Cross Blue Shield WnyPolicy G-06133

    Reimbursement Policy Proof of Timely Filing

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    This reimbursement policy governs the evidence and criteria Highmark BCBS WNY requires to reconsider claims denied for failure to meet timely filing requirements for applicable member programs (EP program noted). It affects providers submitting claims to Highmark BCBS WNY.

    Policy Summary
    PayerHighmark Blue Cross Blue Shield Wny
    PolicyProof of Timely Filing for Claims Reconsideration
    Policy CodePolicy G-06133
    Change TypeClarification / Administrative
    Effective Date10/23/2025
    Last ReviewOct 23, 2025
    Next Review Date
    Key ActionRequest reconsideration by providing acceptable proof of claim receipt and demonstrating Good Cause for the delay.
    SourceLink
    POLICY UPDATE CHANGES

    10/23/2025 Review approved and effective: no changes

    11/19/2021 policy title updated; policy language updated; clarified what is not considered proof of timely receipt (fax and hand delivery).

    10/23/2025effective and last approval date

    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.

    EP only
    EP program only
    6 examplesGood Cause reasons listed
    11 entriespolicy history bullets (2017-2025)

    Proof and Good Cause for Timely Filing Reconsideration

    Proof and Good Cause criteria

    Reconsideration of claims denied for late filing is allowed when the provider supplies acceptable proof of receipt and demonstrates Good Cause. Covered when ALL of the following are met:

    ALL of the following

    • Acceptable receipt evidence

      • Mailed submissions: official mailing service return receipt or delivery confirmation PLUS a mailed claims log identifying each claim in the submission.

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

      • Electronic submissions: clearinghouse-assigned receipt date from reconciliation reports.

    ALL of the following

    • Examples of circumstances that may establish Good Cause

      • Administrative error (incorrect or incomplete information furnished by official sources to the provider).
      • Retroactive enrollment (member subsequently received notification of enrollment effective retroactively to or before the date of service).
      • Incorrect information furnished by the member to the provider, resulting in erroneous filing with another health insurance plan, Original Medicare, or State Medicaid plan.
      • Unavoidable delay in securing required supporting claim documentation or evidence from one or more third parties, despite reasonable efforts by the provider to secure such documentation or evidence.
      • Unusual, unavoidable, or other 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 or unintentional oversight.

    ALL of the following

    • ANY of the following

      • Facsimile (fax) transmission.
      • Hand delivery documentation consisting of a claim log and a signed receipt.

    Coding Guidance and Required Mail Log Fields

    Coding guidancemixed
    No codes listed
    Required mailed claims log fields
    Name of claimantName of claimant
    Address of claimantAddress of claimant
    Telephone number of claimantTelephone number of claimant
    Claimant's federal tax identification numberClaimant's federal tax identification number
    Name of addresseeName of addressee
    Name of carrierName of carrier
    Designated addressDesignated address

    How to Request Reconsideration and Required Evidence

    Prior Authorization

    Reconsideration steps and required evidence for late-filed claims

    Request reconsideration of a claim denied for late filing by submitting acceptable proof of claim receipt and demonstrating Good Cause for the delay. For mailed claims provide an official mailing service return receipt or delivery confirmation plus a copy of the provider's mailed claims log; for electronic claims provide the clearinghouse assigned receipt date from reconciliation reports. Fax transmission and hand delivery (claim log and signed receipt) are not acceptable proof. If Good Cause is asserted, include an explanation and any supporting evidence — the plan may request clarification or additional information if the evidence raises doubt.

    • Mailed submissions: official mailing service return receipt or delivery confirmation AND a copy of the mailed claims log identifying each claim in the submission (log must include claimant name/address/phone, federal TIN, addressee, carrier, designated address, date of mailing, subscriber name/ID, member name, date(s) of service, total charge, and delivery method).
    • Electronic submissions: clearinghouse assigned receipt date from reconciliation reports.
    • Not accepted as proof: fax transmission or hand delivery (claim log and signed receipt).
    • Good Cause: provide an explanation and any supporting evidence; the plan will base its determination primarily on that statement/evidence and may request further clarification if needed.

    Definitions and Acceptable Documentation

    Definitions (general)
    Referenced definitionsGeneral Reimbursement Policy Definitions (see Definitions section)
    Policy scopeApplies to reconsideration of claims denied for failure to meet timely filing, subject to contract or regulatory overrides
    Provider responsibilityProviders must submit acceptable proof of receipt and, when required, demonstrate Good Cause for late filing
    Electronic proofClearinghouse assigned receipt date from reconciliation reports accepted as proof for electronic submissions
    Documentation of claim receipt
    Mailed submissions - acceptable proofOfficial mailing service return receipt or delivery confirmation plus a mailed claims log identifying each claim in the submission
    Policy Summary
    PayerHighmark Blue Cross Blue Shield Wny
    PolicyProof of Timely Filing for Claims Reconsideration
    Policy CodePolicy G-06133
    Change TypeClarification / Administrative
    Effective Date10/23/2025
    Last ReviewOct 23, 2025
    Next Review Date
    Key ActionRequest reconsideration by providing acceptable proof of claim receipt and demonstrating Good Cause for the delay.
    SourceLink
    On This Page
    Proof and Good Cause for Timely Filing ReconsiderationCoding Guidance and Required Mail Log FieldsHow to Request Reconsideration and Required EvidenceDefinitions and Acceptable Documentation
    Date of mailingDate of mailing
    Subscriber name / Subscriber ID number / Member's nameSubscriber name; Subscriber ID number; Member's name
    Date(s) of service, total charge, and delivery methodDate(s) of service/occurrence; total charge; delivery method
    Electronic submissions - acceptable proofClearinghouse assigned receipt date from reconciliation reports
    Not acceptable as proofFax transmission and hand delivery (claim log and signed receipt) are not considered proof of timely receipt
    Provider-maintained evidenceA claims log that identifies each claim included in the mailed submission is required
    Good Cause — definition and examples
    Good Cause definitionGood Cause is established by an explanation for the delay or other evidence; the health plan will evaluate the statement or evidence to determine Good Cause
    When plan may request more informationIf evidence leads to doubt, the health plan will contact the provider for clarification or additional information
    Administrative errorIncorrect or incomplete information furnished by official sources to the provider
    Retroactive enrollmentMember subsequently received notification of enrollment effective retroactively to or before the date of service
    Incorrect member informationIncorrect information furnished by the member resulting in erroneous filing with another plan or payer
    Third‑party documentation delayUnavoidable delay in securing required supporting documentation from third parties despite reasonable efforts by the provider
    Destruction or damage of recordsDestruction or other damage of provider records (unless caused by provider) may constitute Good Cause