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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyWellpoint NJ Timely Filing Policy Update | OpenPay…
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    CurrentWellpointPolicy G-06133

    Proof of Timely Filing

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    This policy governs when Wellpoint New Jersey Medicaid will reconsider reimbursement for claims rejected for failure to meet timely filing requirements. It applies to providers who can document timely receipt or demonstrate good cause for the late filing.

    Policy Summary
    PayerWellpoint
    PolicyProof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material change
    Effective DateOct 23, 2025
    Last ReviewOct 23, 2025
    Next Review DateNot specified
    Key ActionProvide compliant receipt evidence or demonstrate good cause when requesting reconsideration of a claim rejected for untimely filing.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Acceptable claim submission methods with specified receipt evidence
    2Submission methods excluded as proof of timely receipt
    13Required data elements for a mailed claims log
    6Examples of circumstances that may establish good cause

    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.

    0
    Changes in the October 23, 2025 policy review

    Proof of Timely Filing and Good Cause

    Reconsideration of claims rejected for untimely filing

    The health plan may reconsider reimbursement of a claim rejected for failure to meet timely filing requirements when the provider supplies compliant receipt evidence or establishes good cause, unless applicable contracts or requirements provide otherwise.

    ALL of the following

    • ONE of

      • Provider provides a claim receipt date compliant with applicable timely filing requirements.

      • ALL of the following

        • Provider demonstrates good cause for the filing delay.
        • Provider submits an explanation or other evidence supporting the reason for the delay.

    Acceptable proof of claim receipt

    Acceptable proof depends on the claim submission method.

    ANY of the following

    • ALL of the following

      • Claim was submitted by mail.
      • Provider supplies an official mailing service return receipt or delivery confirmation.
      • Provider supplies a copy of the claim log identifying each claim included in the submission.

    • ALL of the following

      • Claim was submitted electronically.

    Good cause circumstances

    Good cause may be found when the delay resulted from circumstances such as the following.

    ANY of the following

    • Administrative error involving incorrect or incomplete information furnished by official sources to the provider.
    • Retroactive enrollment, when the member subsequently received notification of enrollment effective retroactively to or before the date of service.
    • Incorrect information furnished by the member to the provider, resulting in erroneous filing with another health insurance plan, Original Medicare, or a State Medicaid plan.
    • Unavoidable delay in securing required supporting claim documentation or evidence from one or more third parties, despite reasonable efforts by the provider to secure the documentation or evidence.
    • Unusual, unavoidable, or other circumstances beyond the provider's control that demonstrate the provider could not reasonably have been expected to be aware of the need to file timely.

    Standard Coding

    Standard correct codingmixed
    No codes listed

    How to Request Reconsideration

    Documentation Required

    Request reconsideration of a late-filed claim

    For a claim rejected for failure to meet timely filing requirements, request reconsideration by providing a claim receipt date compliant with applicable timely filing requirements or demonstrating that good cause exists for the delay.

    Documentation Required

    Document mailed claim receipt

    For a claim submitted by mail, provide the official mailing service return receipt or delivery confirmation and a copy of the claim log identifying each claim included in the submission.

    • The mailed claims log must include claimant, addressee, carrier, mailing, subscriber, member, service, charge, and delivery-method information.
    • Required entries include the date of mailing, subscriber ID number, member’s name, date(s) of service or occurrence, total charge, and delivery method.

    Applicable Definitions

    General Reimbursement Policy Definitions
    Applicable definitionsRefer to the General Reimbursement Policy Definitions for applicable definitions.
    Good Cause
    Evaluation basisGood Cause is determined primarily from the provider's explanation for the filing delay or other supporting evidence.
    ClarificationIf the evidence raises doubt about the statement's validity, the health plan will contact the provider for clarification or additional information.
    Potential circumstancesGood Cause may be found for administrative error, retroactive enrollment, incorrect member information, unavoidable delays obtaining third-party documentation, unusual or unavoidable circumstances beyond the provider's control, or destruction or damage to provider records not caused by the provider's willful act or unintentional oversight.
    Policy Summary
    PayerWellpoint
    PolicyProof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material change
    Effective DateOct 23, 2025
    Last ReviewOct 23, 2025
    Next Review DateNot specified
    Key ActionProvide compliant receipt evidence or demonstrate good cause when requesting reconsideration of a claim rejected for untimely filing.
    SourceLink
    On This Page
    Proof of Timely Filing and Good CauseStandard CodingHow to Request ReconsiderationApplicable Definitions
    Provider supplies the clearinghouse-assigned receipt date from reconciliation reports.
  1. Destruction or other damage to the provider's records, unless caused by the provider's willful act or unintentional oversight.
    2. Documentation Required

    Document electronic claim receipt

    For a claim submitted electronically, provide the clearinghouse-assigned receipt date from the reconciliation reports as evidence of timely receipt.

    Denial Risk

    Avoid insufficient receipt evidence

    Do not rely on facsimile transmission as proof of timely receipt. For hand-delivered claims, a claim log identifying each claim and a copy of the signed receipt will not be considered proof that the claim was received timely.

    Documentation Required

    Support a good-cause request

    When asserting good cause, include an explanation for the filing delay or other evidence establishing the reason. The health plan may request clarification or additional information if the evidence raises doubts about the statement’s validity.

    • Good cause may be found for administrative error, retroactive enrollment, incorrect member information, unavoidable difficulty obtaining third-party documentation, circumstances beyond the provider’s control, or destruction or damage of provider records not caused by the provider’s willful act or unintentional oversight.