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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicySimply Healthcare Timely Filing Update | OpenPayer
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    CurrentSimply Healthcare Plans, Inc.Policy G-06133

    Proof of Timely Filing

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    This policy governs when Simply will reconsider a claim rejected for failure to meet timely filing requirements and what evidence providers must submit to prove timely receipt or establish good cause. It applies to providers submitting claims to Simply Healthcare Plans, Inc. Medicare Advantage in Florida.

    Policy Summary
    PayerSimply Healthcare Plans, Inc.
    PolicyProof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeHistorical revisionno material changes in 2025 review
    Effective DateOct 23, 2025
    Last ReviewOct 23, 2025
    Next Review DateNot specified
    Key ActionRequest reconsideration of an untimely claim by providing a compliant claim receipt date or demonstrating good cause.
    SourceLink
    POLICY UPDATE CHANGES

    The 2021 policy revision removed documentation wording from the title, added exclusions for fax and hand-delivery evidence, and specified that the claim log applies to mailed claims.

    2Acceptable claim submission methods with specified proof
    2Submission methods not accepted as timely-filing proof
    13Required mailed-claims log data elements
    6

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    Circumstances that may establish good cause
    2025-10-23Current approval and effective date

    Timely Filing Reconsideration Criteria

    Timely Filing Reconsideration Criteria

    The health plan will reconsider reimbursement of a claim rejected for failure to meet timely filing requirements, unless applicable care provider, state, federal, or CMS contracts or requirements indicate otherwise, when the provider satisfies at least one of the following.

    ONE of the following

    • Provide proof of timely claim receipt

      • Claims submitted by mail

        • Provide official mailing-service return receipt or delivery confirmation.
        • Provide a copy of the claim log identifying each claim included in the submission. The log must include the claimant's name, address, telephone number, and federal tax identification number; addressee name; carrier name; designated address; date of mailing; subscriber name and ID number; member name; dates of service or occurrence; total charge; and delivery method.

      • Claims submitted electronically

        • Provide the clearinghouse-assigned receipt date from reconciliation reports.
    • Demonstrate that good cause exists for the delayed filing.

      Good-cause circumstances and determination requirements are detailed in the Good Cause Criteria group.

    Receipt evidence that is not accepted as proof of timely filing

    • Facsimile transmission for a claim submitted by fax.
    • A claim log identifying each claim included in a hand-delivered submission and a copy of the signed receipt.

    Good Cause Criteria

    Good cause may support reconsideration when the provider explains the delay or supplies other evidence establishing its reason. The health plan determines good cause primarily from that statement or evidence and may contact the provider for clarification or additional information when the evidence creates doubt about the statement's validity.

    Good-cause circumstances

    • Administrative error: incorrect or incomplete information was furnished by official sources to the provider.
    • Retroactive enrollment: the member subsequently received notification of enrollment effective retroactively to or before the date of service.
    • Incorrect information furnished by the member caused erroneous filing with another health insurance plan, Original Medicare, or a State Medicaid plan.
    • An unavoidable delay occurred in securing required supporting claim documentation or evidence from one or more third parties, despite the provider's reasonable efforts to obtain it.

    Coding Guidance

    Standard correct codingmixed
    No codes listed

    Submitting Reconsideration Support

    Denial Risk

    Request reconsideration of an untimely claim

    Request reconsideration of a claim rejected for failure to meet timely filing requirements by providing a claim receipt date that complies with applicable timely filing requirements or by demonstrating that good cause exists.

    Documentation Required

    Document claim receipt

    For a mailed claim, submit official mailing-service return receipt or delivery confirmation and a copy of the claim log identifying each claim included in the submission. The claim log must include the claimant’s name, address, telephone number and federal tax identification number; addressee, carrier and designated address; mailing date; subscriber name and ID; member name; date(s) of service or occurrence; total charge; and delivery method.

    Related Reimbursement Definitions

    Definitions
    Governing definitions referenceGeneral Reimbursement Policy Definitions
    PolicyG-06133
    ApplicabilitySimply Healthcare Plans, Inc. Medicare Advantage in Florida
    Policy Summary
    PayerSimply Healthcare Plans, Inc.
    PolicyProof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeHistorical revisionno material changes in 2025 review
    Effective DateOct 23, 2025
    Last ReviewOct 23, 2025
    Next Review DateNot specified
    Key ActionRequest reconsideration of an untimely claim by providing a compliant claim receipt date or demonstrating good cause.
    SourceLink
    On This Page
    Timely Filing Reconsideration CriteriaCoding GuidanceSubmitting Reconsideration SupportRelated Reimbursement Definitions
    Unusual, unavoidable, or other circumstances beyond the service provider's control demonstrate that the provider could not reasonably have been expected to know of the need to file timely.
  1. Destruction or other damage to the provider's records, unless the destruction or damage was caused by the provider's willful act or unintentional oversight.
    2. Denial Risk

    Avoid insufficient receipt evidence

    Do not rely on facsimile transmission or a hand-delivery claim log with a signed receipt as proof that the claim was received timely.

    Documentation Required

    Support a good-cause determination

    Explain the filing delay or submit other evidence establishing the reason for the delay. If the evidence creates doubt about the statement’s validity, the health plan may contact the provider for clarification or additional information needed to make a good-cause determination.

    • Good cause may involve administrative error involving incorrect or incomplete information from official sources.
    • Good cause may involve retroactive enrollment effective on or before the date of service.
    • Good cause may involve incorrect member information that resulted in filing with another health plan, Original Medicare or State Medicaid.
    • Good cause may involve an unavoidable delay obtaining required supporting documentation from third parties despite reasonable efforts.
    • Good cause may involve unusual, unavoidable or other circumstances beyond the provider’s control.
    • Good cause may involve destruction or other damage to provider records, unless caused by the provider’s willful act or unintentional oversight.