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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyWellpoint Claims Timely Filing Policy Update | Ope…
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    CurrentWellpointPolicy G-06050

    Reimbursement Policy Claims Timely Filing

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    This policy governs when Wellpoint Medicare Advantage claims must be received and accepted to qualify for reimbursement, including different limits for participating and nonparticipating providers and facilities in applicable Wellpoint states.

    Policy Summary
    PayerWellpoint
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material changes
    Effective DateJune 3, 2025
    Last ReviewJun 3, 2025
    Next Review DateNot specified
    Key ActionSubmit the initial claim so that it is received and accepted within the applicable timely filing limit.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 daysParticipating provider timely filing limit
    12 monthsNonparticipating provider timely filing limit
    Calendar daysFiling basis
    Last dayConsecutive-day service start
    Natural disastersTemporary waiver circumstance
    Policy Summary
    PayerWellpoint
    PolicyReimbursement Policy Claims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material changes
    Effective DateJune 3, 2025
    Last ReviewJun 3, 2025
    Next Review DateNot specified
    Key ActionSubmit the initial claim so that it is received and accepted within the applicable timely filing limit.
    SourceLink
    On This Page
    Timely Filing Requirements and ExceptionsFiling Limits and Related CodingSubmitting and Supporting Claims

    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 Requirements and Exceptions

    Initial Claim Timely Filing

    The health plan will consider reimbursement for an initial claim only when it is received and accepted within the applicable timely filing limit, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

    ALL of the following

    • The initial claim is received and accepted within the applicable timely filing limit.

    • The applicable standard is based on the provider or facility status

      • Participating provider or facility: the claim is filed within 90 days.
      • Nonparticipating provider or facility: the claim is filed within 12 months.
    • Any applicable provider, state, federal, or CMS contract or requirement is applied when it establishes a different filing limit.

      Claims filed outside the applicable timely filing limit will not be subject to reimbursement unless an exception applies.

    Exceptions to Timely Filing Denial

    A late claim may be considered only when the provider establishes a qualifying exception with supporting documentation.

    ONE of the following documented circumstances

    • The provider presents documentation proving that a clean claim was filed within the applicable timely filing limit.

      Documentation must establish that the clean claim was filed on time.

    • A documented natural disaster supports a temporary waiver of the timely filing requirement.

      The health plan reserves the right to waive timely filing requirements temporarily.

    • Applicable state guidance supports a temporary waiver or other exception to the timely filing requirement.

      The waiver or exception is subject to the applicable state guidance.

    Filing-Period Calculation

    Timely filing is calculated using calendar days unless otherwise specified and is measured against the applicable federal or state mandate before the health plan standard.

    ALL of the following calculation rules apply

    • Subtract the date of service from the date the health plan receives the claim and compare the resulting number of days with the applicable filing limit.
    • If an applicable federal or state mandate exists, compare the filing period with that mandate; if no such mandate exists, compare it with the health plan standard.

      Provider, state, federal, and CMS contracts or requirements may establish the applicable limit.

    • For services rendered on consecutive days, count the filing limit from the last day of service.
    • Count the filing period in calendar days unless otherwise specified.

    Filing Limits and Related Coding

    Related Codingmixed
    No codes listed
    Participating provider or facility timely filing
    Standard limit90 calendar days for participating providers and facilities
    Applicable qualificationUse a different limit when an applicable federal or state mandate, provider requirement, or contract indicates otherwise
    Calculation basisCompare the number of calendar days between the date of service and the date the claim is received
    Nonparticipating provider or facility timely filing
    Standard limit12 months for nonparticipating providers and facilities
    Applicable qualificationUse a different limit when an applicable federal or state mandate, provider requirement, or contract indicates otherwise

    Submitting and Supporting Claims

    Billing Rule

    Submit Claims Within the Filing Limit

    Submit the initial claim so it is received and accepted within the applicable timely filing limit. Unless provider, state, federal, or CMS requirements specify otherwise, Wellpoint’s standard is measured in calendar days from the date of service (or the last day of service when services occur on consecutive days).

    • Participating providers and facilities: 90 days.
    • Nonparticipating providers and facilities: 12 months.
    • Compare the date of receipt with the applicable federal or state mandate; if none applies, use the applicable Wellpoint standard.
    Documentation Required

    Support Late-Filed Claims

    If the member has other health insurance that is primary, count timely filing from the date of the other carrier's Explanation of Payment (EOP).
    Calculation basisCompare the number of calendar days between the date of service and the date the claim is received
    Consecutive-day service calculation
    Starting pointCount the timely filing limit from the last day of service
    Applies toServices rendered on consecutive days
    Time basisLimits are based on calendar days unless otherwise specified
    Other health insurance primary calculation
    Starting pointCount timely filing from the other carrier's Explanation of Payment (EOP) date
    Applies whenThe member has other health insurance that is primary
    Filing calculationCompare the applicable timely filing period with the number of calendar days from the EOP date to the date the claim is received

    Claims submitted outside the timely filing limit are not reimbursable unless you provide documentation proving that a clean claim was filed within the applicable filing limit.

    • Retain submission and acceptance documentation that establishes the date the clean claim was timely filed.
    • Wellpoint may temporarily waive timely filing requirements after a documented natural disaster or under applicable state guidance.
    Billing Rule

    Use the Other Carrier’s EOP Date

    When another insurer is primary, calculate timely filing from the other carrier’s Explanation of Payment (EOP) date, rather than solely from the date of service.

    • Apply the applicable filing limit to the EOP date when submitting the claim to Wellpoint.
    Denial Risk

    Meet All Reimbursement Requirements

    Timely filing is only one reimbursement requirement. Services must also satisfy applicable authorization and medical necessity guidelines, and claims must follow compliant billing and submission requirements.

    • Use industry-standard, compliant CPT, HCPCS, and/or revenue codes supported by the medical record or office notes.
    • Failure to follow applicable authorization, medical necessity, coding, billing, or other reimbursement requirements may result in claim rejection or denial, payment recovery or recoupment, or adjustment of reimbursement.
    • Provider, state, federal, and CMS contracts or requirements may supersede this policy.