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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicySimply Healthcare Timely Filing Update | OpenPayer
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    CurrentSimply HealthcarePolicy G-06133

    Reimbursement Policy Proof of Timely Filing

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    This policy governs reconsideration of claims rejected for failure to meet timely filing requirements when providers can document timely receipt and establish good cause under applicable Florida Medicaid managed care and Florida Healthy Kids requirements.

    Policy Summary
    PayerSimply Healthcare
    PolicyProof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material change
    Effective DateOct 23, 2025
    Next Review DateNot specified
    Key ActionSubmit compliant claim-receipt evidence and documentation demonstrating good cause when requesting reconsideration of a late-filed claim.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Accepted proof methods
    2Unaccepted proof methods
    6Good-cause circumstances
    13Claims-log data elements

    Reconsideration Eligibility

    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.

    Reconsideration of claims rejected for untimely filing

    The plan will reconsider reimbursement of a claim rejected for failure to meet timely filing requirements when applicable contract requirements do not provide otherwise and the provider satisfies the receipt-date and good-cause requirements below.

    ALL of the following

    • Provider provides a claim receipt date compliant with applicable timely filing requirements.
    • Provider demonstrates good cause for the delayed filing.
    • No contrary provider, state, federal, or CMS contract or requirement controls.

    Acceptable proof of timely receipt

    • Mailed claim is supported by an official mailing-service return receipt or delivery confirmation and a claim log identifying each claim in the submission.
    • Electronic claim is supported by the clearinghouse-assigned receipt date from reconciliation reports.

    Good-cause circumstances

    • The delay resulted from administrative error involving incorrect or incomplete information from official sources.
    • The member was retroactively enrolled effective on or before the date of service.
    • Incorrect member information caused erroneous filing with another health insurance plan, Original Medicare, or a state Medicaid plan.
    • Required supporting documentation or evidence was unavoidably delayed despite reasonable provider efforts to obtain it from third parties.
    • Unusual, unavoidable, or other circumstances beyond the provider's control made timely filing reasonably unforeseeable.
    • Provider records were destroyed or damaged, unless caused by the provider's willful act or unintentional oversight.

    Standard Correct Coding

    Standard correct codingmixed
    No codes listed

    Submitting a Reconsideration Request

    Documentation Required

    Request reconsideration of a late-filed claim

    For a claim rejected because it failed to meet timely filing requirements, submit evidence of a claim receipt date that complies with applicable timely filing requirements and demonstrate that good cause exists for the delay. Reconsideration is subject to any contrary provider, state, federal, or CMS contract or requirement.

    Documentation Required

    Provide acceptable claim-receipt evidence

    Use an accepted method to establish timely receipt. For mailed claims, provide the official mailing-service return receipt or delivery confirmation and a copy of the claim log identifying each claim in the submission; for electronic claims, provide the clearinghouse-assigned receipt date from reconciliation reports.

    • Mailed claims: official mailing-service return receipt or delivery confirmation, plus the claim log.
    • Electronic claims: clearinghouse-assigned receipt date from reconciliation reports.
    Denial Risk

    Avoid unacceptable receipt evidence

    Do not rely on facsimile transmission or hand-delivery documentation to prove that a claim was received timely. A hand-delivery claim log identifying each claim and a signed receipt will not be considered proof of timely receipt.

    • Fax: facsimile transmission is not accepted.
    • Hand delivery: a claim log and signed receipt are not accepted.
    Documentation Required

    Maintain required mailed claims-log information

    Maintain a mailed claims log with all required information so each claim in a submission can be identified and supported.

    • Name of claimant
    • Address of claimant
    • Telephone number of claimant
    • Claimant’s federal tax identification number
    • Name of addressee
    • Name of carrier
    • Designated address
    • Date of mailing
    • Subscriber name
    • Subscriber ID number
    • Member’s name
    • Date(s) of service or occurrence
    • Total charge and delivery method
    Documentation Required

    Support a good-cause request

    Include an explanation for the filing delay or other evidence establishing the reason for it. The plan may contact the provider for clarification or additional information if the evidence creates doubt about the explanation’s validity.

    • Good cause may include administrative error involving incorrect or incomplete information from official sources.
    • Other circumstances may include retroactive enrollment, incorrect member information causing erroneous filing with another plan, unavoidable delay obtaining third-party documentation despite reasonable efforts, unusual or unavoidable circumstances beyond the provider’s control, or destruction or damage of provider records not caused by the provider’s willful act or unintentional oversight.

    Policy Definitions

    General Reimbursement Policy Definitions
    Related definitions sourceGeneral Reimbursement Policy Definitions
    Good Cause
    Basis for determinationGood Cause may be established by the provider’s explanation for the delay or other evidence that establishes the reason; the health plan determines Good Cause primarily from that statement or evidence.
    Plan reviewIf the evidence creates doubt about the validity of the explanation, the health plan may contact the provider for clarification or additional information needed to make a Good Cause determination.
    Potential qualifying circumstancesGood Cause may be found for administrative error, retroactive enrollment, incorrect member information, unavoidable delays obtaining required third-party documentation, unusual or unavoidable circumstances beyond the provider’s control, or destruction or damage of provider records not caused by the provider’s willful act or unintentional oversight.
    Policy Summary
    PayerSimply Healthcare
    PolicyProof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material change
    Effective DateOct 23, 2025
    Next Review DateNot specified
    Key ActionSubmit compliant claim-receipt evidence and documentation demonstrating good cause when requesting reconsideration of a late-filed claim.
    SourceLink
    On This Page
    Reconsideration EligibilityStandard Correct CodingSubmitting a Reconsideration RequestPolicy Definitions