CurrentWellpointPolicy G-06133

Proof of Timely Filing

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This policy governs when Wellpoint will reconsider a claim denied for failure to meet timely filing requirements and what documentation providers must submit to prove timely receipt or establish Good Cause. It applies to provider claim submissions unless provider, state, federal, or CMS requirements indicate otherwise.

Policy Summary

PayerWellpoint

PolicyProof of Timely Filing

Policy CodePolicy G-06133

Change TypeAdministrative and documentation clarification

Effective DateNov 19, 2021

Last ReviewNov 19, 2021

Next Review DateNot specified

Key ActionRequest reconsideration of a timely filing denial by providing a compliant claim receipt date or demonstrating Good Cause.

SourceLink

POLICY UPDATE CHANGES

The policy history states that the 2021 review updated the policy title and language and added requirements addressing faxed and hand-delivered claims and mailed claim logs.

The policy history states that United States mail return-receipt language was updated and the term provider replaced physician.

2Accepted proof pathways

2Unaccepted proof methods

6Good Cause circumstances

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CurrentWellpointPolicy G-06133

Proof of Timely Filing

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Sign up for wellpoint Policy G-06133 alerts

Get alerted when Policy G-06133 changes without checking for updates manually.

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Policy Summary

PayerWellpoint

PolicyProof of Timely Filing

Policy CodePolicy G-06133

Change TypeAdministrative and documentation clarification

Effective DateNov 19, 2021

Last ReviewNov 19, 2021

Next Review DateNot specified

Key ActionRequest reconsideration of a timely filing denial by providing a compliant claim receipt date or demonstrating Good Cause.

SourceLink

POLICY UPDATE CHANGES

The policy history states that the 2021 review updated the policy title and language and added requirements addressing faxed and hand-delivered claims and mailed claim logs.

The policy history states that United States mail return-receipt language was updated and the term provider replaced physician.

2Accepted proof pathways

2Unaccepted proof methods

6Good Cause circumstances

Reconsideration of timely filing denial

Wellpoint will reconsider a timely filing denial when the provider supplies compliant proof of receipt or demonstrates Good Cause, subject to applicable provider, state, federal, or CMS requirements.

ALL of the following

Claim was denied for failure to meet timely filing requirements
ANY of the following
- ALL of the following
  - Provider provides a date of claim receipt compliant with applicable timely filing requirements
  - ANY of the following
    Mailed claim is supported by official mailing-service return receipt or delivery confirmation and a claim log identifying each claim included in the submission
    Electronic claim is supported by the clearinghouse-assigned receipt date from reconciliation reports
- Provider demonstrates that Good Cause exists for the filing delay

Unacceptable proof of timely receipt

The following methods are not considered proof that a claim was received timely.

ANY of the following

Claim submitted by fax, with facsimile transmission as the evidence
Claim submitted by hand delivery, with a claim log identifying each claim included in the delivery and a copy of the signed receipt as the evidence

Good Cause circumstances

Good Cause may be established when the filing delay resulted from a recognized circumstance and the provider supplies an explanation or other evidence establishing the reason for the delay.

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 or with the member's 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

How to Request Reconsideration

Denial Risk

Request reconsideration of a timely filing denial

For a claim denied for failure to meet timely filing requirements, request reconsideration by providing a date of claim receipt that complies with applicable timely filing requirements or by demonstrating Good Cause.

Documentation Required

Submit acceptable proof of claim receipt

Submit documentation appropriate to the submission method to establish that the claim was received within the applicable timely filing period.

Mailed claims: Provide the official mailing-service return receipt or delivery confirmation and a claim log identifying each claim included in the submission.
The mailed-claims log must include the claimant’s name, address, telephone number, federal tax identification number, addressee, carrier, designated address, date of mailing, subscriber name and ID number, member’s name, dates of service or occurrence, total charge, and delivery method.
Electronic claims: Provide the clearinghouse-assigned receipt date from the reconciliation reports.

Denial Risk

Avoid unacceptable proof methods

Do not rely on facsimile transmission or a hand-delivery claim log and signed receipt as proof that a claim was received timely. These methods will not be considered acceptable proof of timely receipt.

Faxed claims: Facsimile transmission is not accepted as proof.
Hand-delivered claims: A claim log and copy of the signed receipt are not accepted as proof.

Documentation Required

Document Good Cause

When timely filing was delayed, provide an explanation or other evidence establishing the reason for the delay. Wellpoint will determine Good Cause primarily from that information and may request clarification or additional information if the evidence creates doubt about the statement.

Potential Good Cause circumstances include administrative error, retroactive enrollment, incorrect member information that caused erroneous filing with another plan, an unavoidable delay obtaining required third-party documentation despite reasonable efforts, 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 negligence.

Key Term

Good Cause

Establishing Good CauseProvide an explanation for the filing delay or other evidence establishing the reason; Wellpoint determines Good Cause primarily from that statement or evidence.

Clarification requestsIf the evidence creates doubt about the validity of the statement, Wellpoint may contact the provider for clarification or additional information.

Recognized circumstancesGood Cause may apply to 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 of provider records not caused by the provider’s willful act or negligence.

Proof of Timely Filing

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Proof of Timely Filing

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Timely Filing Reconsideration Criteria

Coding Guidance

How to Request Reconsideration

Key Term