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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyWellpoint TN Timely Filing Policy Update | OpenPay…
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    CurrentWellpoint Tennessee MedicaidPolicy G-06133

    Reimbursement Policy Proof of Timely Filing

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    This policy governs when Wellpoint Tennessee Medicaid may reconsider claims rejected for failure to meet timely filing requirements when providers document timely receipt and establish good cause.

    Policy Summary
    PayerWellpoint Tennessee Medicaid
    PolicyReimbursement Policy Proof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material change
    Effective DateOct 23, 2025
    Last ReviewOct 23, 2025
    Next Review DateNot specified
    Key ActionSubmit acceptable proof of claim receipt and documentation establishing good cause when requesting reconsideration of a timely filing rejection.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Accepted proof methods
    6Good-cause circumstances
    14Mailed claim-log fields
    2Unacceptable methods

    Timely Filing Reconsideration Criteria

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    Timely Filing Reconsideration

    A claim rejected for failure to meet timely filing requirements may be reconsidered when all applicable requirements are satisfied.

    ALL of the following

    • Provider supplies a claim receipt date demonstrating compliance with applicable timely filing requirements.
    • Provider demonstrates good cause for the filing delay.
    • No provider, state, federal, or CMS contract or requirement indicates otherwise.

    Potential Good-Cause Circumstances

    Good cause may be established by the provider's explanation or other evidence and may include the following circumstances.

    ANY of the following

    • Administrative error involving incorrect or incomplete information from official sources.
    • Retroactive member enrollment effective on or before the date of service.
    • Incorrect member information caused erroneous filing with another health plan, Original Medicare, or a state Medicaid plan.
    • Unavoidable delay obtaining required supporting claim documentation or evidence from a third party despite reasonable efforts.
    • Unusual, unavoidable, or other circumstances beyond the provider's control that made timely filing not reasonably knowable.
    • Destruction or other damage to provider records, unless caused by the provider's willful act or unintentional oversight.

    Standard Correct Coding

    Standard correct codingmixed
    No codes listed

    Reconsideration Submission Requirements

    Documentation Required

    Requirements for Reconsideration

    A claim denied for failure to meet timely filing requirements may be reconsidered when applicable provider, state, federal, or CMS contracts and requirements do not indicate otherwise. The provider must establish both compliant claim receipt and good cause for the filing delay.

    • Provide a claim receipt date that complies with applicable timely filing requirements.
    • Demonstrate that good cause exists for the late filing.
    Documentation Required

    Acceptable Proof of Claim Receipt

    Proof of timely claim receipt depends on the submission method. Mailed claims require official mailing-service return receipt or delivery confirmation plus a claim log identifying every claim in the submission; electronic claims require the clearinghouse-assigned receipt date from reconciliation reports.

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

    Unacceptable Proof of Timely Receipt

    The health plan will not accept facsimile transmission or hand-delivery records as proof that a claim was received within the timely filing period.

    • Fax: Facsimile transmission is not acceptable proof of timely receipt.
    • Hand delivery: A claim log identifying each delivered claim together with a copy of the signed receipt is not acceptable proof of timely receipt.
    Documentation Required

    Supporting Good-Cause Documentation

    Good cause may be established when the provider submits an explanation for the delay or other evidence showing the reason. The health plan will base its determination primarily on that statement or evidence and may contact the provider for clarification or additional information if validity is in doubt.

    • Good cause may apply when the delay resulted from administrative error involving incorrect or incomplete information from official sources.
    • Good cause may apply when the member was retroactively enrolled effective on or before the date of service.
    • Good cause may apply when incorrect member information caused erroneous filing with another health insurance plan, Original Medicare, or a state Medicaid plan.
    • Good cause may apply when required supporting claim documentation or evidence from one or more third parties could not be obtained despite reasonable provider efforts.
    • Good cause may apply for unusual, unavoidable, or other circumstances beyond the provider's control when the provider could not reasonably have been expected to know that timely filing was required.
    • Good cause may apply when provider records were destroyed or damaged, unless caused by the provider's willful act or unintentional oversight.

    Policy Definitions and References

    General Reimbursement Policy Definitions
    Referenced policyGeneral Reimbursement Policy Definitions
    UseRefer to the General Reimbursement Policy Definitions for applicable policy definitions.
    Policy contextWellpoint Tennessee Medicaid Policy G-06133
    Good Cause
    Evaluation basisGood cause is determined primarily from the provider's explanation for the filing delay or other supporting evidence.
    Additional informationThe health plan may contact the provider for clarification or additional information when the evidence raises doubt about the explanation's validity.
    Potential circumstancesGood cause may include administrative error, retroactive enrollment, incorrect 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 unintentional oversight.
    Policy Summary
    PayerWellpoint Tennessee Medicaid
    PolicyReimbursement Policy Proof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material change
    Effective DateOct 23, 2025
    Last ReviewOct 23, 2025
    Next Review DateNot specified
    Key ActionSubmit acceptable proof of claim receipt and documentation establishing good cause when requesting reconsideration of a timely filing rejection.
    SourceLink
    On This Page
    Timely Filing Reconsideration CriteriaStandard Correct CodingReconsideration Submission RequirementsPolicy Definitions and References