CurrentWellpointPolicy G-06050

Claims Timely Filing

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Applies to participating and nonparticipating providers and facilities submitting initial claims to Wellpoint Tennessee Medicaid.

Policy Summary

PayerWellpoint

PolicyClaims Timely Filing

Policy CodePolicy G-06050

Change TypeAdministrative template update

Effective DateDecember 27, 2022

Next Review DateNot specified

Key ActionSubmit the initial claim within the applicable federal, state-mandated, or Wellpoint timely filing limit.

SourceLink

POLICY UPDATE CHANGES

The December 27, 2022 review updated the policy template.

120 daysStandard timely filing limit

365 daysSchool-based services limit

No limitIDD claims limit

Calendar daysFiling calculation basis

Timely Filing Reimbursement Criteria

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CurrentWellpointPolicy G-06050

Claims Timely Filing

Customize your policy alerts

Sign up for wellpoint Policy G-06050 alerts

Get alerted when Policy G-06050 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Applies to participating and nonparticipating providers and facilities submitting initial claims to Wellpoint Tennessee Medicaid.

Policy Summary

PayerWellpoint

PolicyClaims Timely Filing

Policy CodePolicy G-06050

Change TypeAdministrative template update

Effective DateDecember 27, 2022

Next Review DateNot specified

Key ActionSubmit the initial claim within the applicable federal, state-mandated, or Wellpoint timely filing limit.

SourceLink

POLICY UPDATE CHANGES

The December 27, 2022 review updated the policy template.

120 daysStandard timely filing limit

365 daysSchool-based services limit

No limitIDD claims limit

Calendar daysFiling calculation basis

Timely Filing Reimbursement Criteria

ALL of the following

The initial claim meets the applicable filing requirement
- The initial claim is received and accepted by Wellpoint within the applicable timely filing limit.
- Timely filing is determined by subtracting the date of service from the date Wellpoint receives the claim and comparing the number of days with the applicable federal or state mandate. If no federal or state mandate applies, compare the days with the applicable Wellpoint standard.
  Limits are based on calendar days unless otherwise specified.
- For services rendered on consecutive days, such as during a hospital confinement, the timely filing period is counted from the last day of service.
- If another health insurance plan is primary, timely filing is counted from the date of the other carrier's Explanation of Payment.
The applicable filing standard or exception is met
- The claim is filed within 120 days for participating or nonparticipating providers and facilities.
  Wellpoint standard when no controlling federal or state mandate applies.
- The claim is for school-based services and is filed within 365 days for participating or nonparticipating providers and facilities.
  Wellpoint standard when no controlling federal or state mandate applies.
- The claim is for Intellectual Developmental Disabilities (IDD) services.
  There is no timely filing limit for IDD claims for participating or nonparticipating providers and facilities.
- A different federal or state-mandated timely filing requirement applies, and the claim meets that requirement.
If a claim was filed beyond the applicable federal, state-mandated, or Wellpoint standard timely filing limit, the claim is denied as outside the timely filing limit.
Services denied for failure to meet timely filing requirements are not subject to reimbursement unless the provider presents documentation proving that a clean claim was filed within the applicable filing limit.
Wellpoint may temporarily waive timely filing requirements following a documented natural disaster or under applicable state guidance.
The waiver is discretionary and applies only when the qualifying circumstances are documented.

Filing Limits and Coding Requirements

Standard correct codingmixed

CPT	Current Procedural Terminology codes
HCPCS	Healthcare Common Procedure Coding System codes
Revenue codes	Revenue codes used to report services and procedures

Standard timely filing limit

Standard timely filing limit120 days for participating and nonparticipating providers and facilities

School-based services timely filing limit

School-based services limit365 days for participating and nonparticipating providers and facilities

IDD claims timely filing limit

IDD claims limitNo timely filing limit for Intellectual Developmental Disabilities (IDD) claims for participating and nonparticipating providers and facilities

Provider Submission and Documentation Actions

Billing Rule

Submit claims within the timely filing limit

Submit the initial claim within the applicable federal, state-mandated, or Wellpoint timely filing limit. Claims filed beyond the applicable limit will be denied as outside the timely filing limit.

Standard limit: 120 calendar days for participating and nonparticipating providers and facilities.
School-based services: 365 days for participating and nonparticipating providers and facilities.
Intellectual Developmental Disabilities (IDD) claims: no timely filing limit.

Documentation Required

Document timely filing when challenged

If a claim is denied for untimely filing, provide documentation proving that a clean claim was filed within the applicable filing limit. Services denied for failure to meet timely filing requirements are not subject to reimbursement unless this documentation is provided.

A clean claim is filed within the applicable filing limit and supported by documentation when timely filing is challenged.

Billing Rule

Use compliant codes and support billed services

Use industry-standard, compliant codes on all claim submissions, and ensure billed services are fully supported by the medical record and/or office notes. Failure to follow coding and billing guidelines may result in claim rejection or denial, payment recovery or recoupment, or adjusted reimbursement.

Use Current Procedural Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes, and/or revenue codes.
Billed codes must denote the services or procedures performed and be fully supported in the medical record and/or office notes.

Reimbursement Policy Definitions

General Reimbursement Policy Definitions

DefinitionGeneral reimbursement policy definitions apply.

Timely filing

CalculationSubtract the date of service from the date Wellpoint receives the claim and compare the resulting number of days with the applicable federal or state mandate. If no mandate applies, compare the number of days with the Wellpoint standard.

Consecutive-day servicesFor services rendered on consecutive days, such as a hospital confinement, count the limit from the last day of service.

Other insuranceIf another health insurance carrier is primary, count timely filing from the date of that carrier’s Explanation of Payment.

Clean claim

DefinitionA clean claim is a claim filed within the applicable filing limit and supported by documentation when timely filing is challenged.

Documentation requirementIf services are denied for failure to meet timely filing requirements, the provider must present documentation proving that a clean claim was filed within the applicable filing limit.

Reimbursement effectServices denied for failure to meet timely filing requirements are not subject to reimbursement unless the provider presents the required documentation.