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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicySimply Healthcare Timely Filing Update | OpenPayer
    Ask Trek AI about this page
    CurrentSimply HealthcarePolicy G-06050

    Claims Timely Filing

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    Governs when initial claims are considered for reimbursement based on timely receipt and acceptance for participating and nonparticipating providers and facilities serving Florida Medicaid managed care and Florida Healthy Kids members.

    Policy Summary
    PayerSimply Healthcare
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeClarificationno material change
    Effective DateJune 3, 2025
    Last ReviewJun 3, 2025
    Next Review DateNot specified
    Key ActionSubmit the initial claim within the applicable timely filing limit and ensure it is received and accepted by the health plan.
    SourceLink
    POLICY UPDATE CHANGES

    Existing timely filing limits were clarified.

    Prior administrative template and policy-language updates were recorded.

    180 daysParticipating provider filing limit
    365 daysNonparticipating provider filing limit
    Clean claim proofLate-claim support
    Waiver possibleTemporary disaster relief

    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.

    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, subject to controlling provider, state, federal, CMS, and documented waiver requirements.

    ALL of the following

    • The claim is an initial claim for the services rendered.
    • The claim is received by the health plan within the applicable timely filing limit.
    • The claim is accepted by the health plan within the applicable timely filing limit.

    • The applicable filing limit is determined by

      • An applicable federal or state mandate, when one exists.

        The federal or state mandate controls over the health plan standard.

      • When no applicable federal or state mandate exists

        • The provider or facility is participating.180 days

          The standard timely filing limit is 180 days from the date of service to receipt of the claim.

        • The provider or facility is nonparticipating.365 days

          The standard timely filing limit is 365 days from the date of service to receipt of the claim.

    • Timely filing is calculated by subtracting the date of service from the date the health plan receives the claim and comparing the resulting number of days with the applicable filing limit.
    • For services rendered on consecutive days, timely filing is determined as otherwise specified by the applicable requirement or contract.
    • If the member has other health insurance that is primary, timely filing is counted from the date of the other carrier's Explanation of Payment (EOP).

    Controlling exceptions

    • A provider, state, federal, or CMS contract and/or requirement specifies a different timely filing requirement.

      The controlling contract or requirement governs reimbursement.

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

      The waiver is subject to health plan determination and the applicable guidance.

    A claim filed outside the applicable timely filing limit is not eligible for reimbursement unless the provider presents documentation proving that a clean claim was filed within the applicable filing limit.

    Documentation must establish that the clean claim was timely filed.

    Coding and Filing Limits

    Standard correct coding and claim submissionmixed
    CPTCurrent Procedural Terminology codes used to bill services and procedures
    HCPCSHealthcare Common Procedure Coding System codes used to bill services and procedures
    RevenueRevenue codes used to bill services and procedures
    Timely Filing Limits
    Participating provider or facility180 days
    Timely Filing Limits
    Nonparticipating provider or facility365 days
    Timely Filing Starting Point
    Other health insurance is primaryCount timely filing from the date of the other carrier's Explanation of Payment (EOP)

    Provider Responsibilities

    Billing Rule

    Submit claims on time

    Submit the initial claim within the applicable timely filing limit and ensure that the health plan receives and accepts it.

    Billing Rule

    Calculate the filing period

    Calculate timely filing by subtracting the date of service from the date the health plan receives the claim. Compare the resulting number of days first with any applicable federal or state mandate; if none applies, compare it with the health plan standard.

    Billing Rule

    Use the other carrier’s EOP date

    When another health insurer is primary, count timely filing from the date of the other carrier’s Explanation of Payment (EOP).

    Policy Summary
    PayerSimply Healthcare
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeClarificationno material change
    Effective DateJune 3, 2025
    Last ReviewJun 3, 2025
    Next Review DateNot specified
    Key ActionSubmit the initial claim within the applicable timely filing limit and ensure it is received and accepted by the health plan.
    SourceLink
    On This Page
    Timely Filing Reimbursement CriteriaCoding and Filing LimitsProvider Responsibilities
    Documentation Required

    Provide proof of timely filing

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

    Denial Risk

    Avoid late-filing denial

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

    Documentation Required

    Submit compliant claim coding

    Use proper billing and submission guidelines and industry-standard, compliant codes on all claim submissions. Bill services with CPT, HCPCS, and/or revenue codes, and ensure the billed services are fully supported in the medical record and/or office notes.

    • Use Current Procedural Terminology (CPT) codes.
    • Use Healthcare Common Procedure Coding System (HCPCS) codes.
    • Use revenue codes when applicable.
    • Ensure billed services and procedures are supported by the medical record and/or office notes.