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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyWellpoint Medicaid Timely Filing Update | OpenPaye…
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    CurrentWellpoint Maryland MedicaidPolicy G-06050

    Claims Timely Filing

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    This policy governs when Wellpoint Maryland Medicaid will consider reimbursement for initial claims and how timely filing limits are calculated for participating and nonparticipating providers and facilities, subject to applicable requirements.

    Policy Summary
    PayerWellpoint Maryland Medicaid
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 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.

    180 daysParticipating provider filing limit
    180 daysNonparticipating provider filing limit
    6 monthsSelf-referred claim limit
    Calendar daysFiling basis
    No reimbursement

    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.

    Late filing consequence
    Temporary waiverWaiver availability

    Timely Filing Reimbursement Criteria

    Timely Filing Reimbursement Criteria

    Reimbursement for the initial claim is considered when the claim is received and accepted within the applicable timely filing limit, subject to any provider, state, federal, or CMS contract or requirement that indicates otherwise. Claims filed outside the limit are not subject to reimbursement unless the provider documents that a clean claim was filed within the applicable limit; the health plan may also temporarily waive timely filing requirements after documented natural disasters or under applicable state guidance.

    Reimbursement consideration requires ALL of the following

    • At least ONE reimbursement pathway applies

      • The initial claim was received and accepted within the applicable timely filing limit.
      • The claim was filed outside the timely filing limit, but the provider presents documentation proving that a clean claim was filed within the applicable filing limit.
      • The health plan has temporarily waived the timely filing requirement following a documented natural disaster or under applicable state guidance.
    • No provider, state, federal, or CMS contract and/or requirement indicates that reimbursement should be handled otherwise.

    • The applicable timely filing limit is determined using ALL of the following rules

      • 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 federal or state mandate.
      • If no applicable federal or state mandate exists, compare the number of days with the health plan standard.
      • For services rendered on consecutive days, count the timely filing limit from the last day of service.
      • Count limits using calendar days unless otherwise specified.
      • 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).

      • The applicable health plan standard is ONE of the following

    Filing Limits and Coding Guidance

    Standard correct codingmixed
    No codes listed
    Participating provider or facility
    Participating provider or facility limit180 calendar days
    Filing basisCalculated from the date of service to the date the health plan receives the claim
    Consecutive-day servicesCount the limit from the last day of service
    Nonparticipating provider or facility
    Nonparticipating provider or facility limit180 calendar days
    Self-referred undisputed claimsSix months when the member has self-referred
    Filing basis

    Timely Filing Requirements

    Billing Rule

    Submit claims within the applicable filing limit

    Submit the initial claim so that it is received and accepted within the applicable timely filing limit, unless provider, state, federal, CMS, or contractual requirements indicate otherwise.

    • Participating providers and facilities: 180 days.
    • Nonparticipating providers and facilities: 180 days; six months for undisputed claims when the member self-refers.
    Billing Rule

    Calculate timely filing

    Calculate timely filing from the date of service to the date the health plan receives the claim. For services rendered on consecutive days, count the filing limit from the last day of service; limits are based on calendar days unless otherwise specified.

    Policy Summary
    PayerWellpoint Maryland Medicaid
    PolicyClaims Timely Filing
    Policy CodePolicy G-06050
    Change TypeNo material change
    Effective DateJun 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 Reimbursement CriteriaFiling Limits and Coding GuidanceTimely Filing Requirements
    Participating providers and facilities: the claim is received within 180 days of the date of service.180 days
  1. Nonparticipating providers and facilities: the claim is received within 180 days of the date of service; for undisputed claims where the member has self-referred, the limit is six months.180 days; six months for undisputed self-referred claims
    2. Calculated from the date of service to the date the health plan receives the claim
    Undisputed self-referred claims
    Undisputed self-referred claim limitSix months
    Provider typeNonparticipating provider or facility
    Claim conditionApplies when the member has self-referred and the claim is undisputed
    Other-insurance primary claims
    Timely filing start dateDate of the other carrier's Explanation of Payment (EOP)
    Applicable situationThe member has other health insurance that is primary
    Calculation methodCount timely filing from the other carrier's EOP date
    Billing Rule

    Apply other-insurance timing

    When another health insurance carrier is primary, calculate timely filing from the date of that carrier’s Explanation of Payment (EOP).

    Documentation Required

    Provide proof for late-filed claims

    If a claim is submitted outside the timely filing limit, provide documentation proving that a clean claim was filed within the applicable filing limit. Without that documentation, the claim will not be subject to reimbursement.

    Billing Rule

    Apply disaster or state-guidance waivers

    Timely filing requirements may be temporarily waived following a documented natural disaster or under applicable state guidance. Apply any waiver only when the circumstances and guidance support it.