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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyWellpoint Timely Filing Policy Update | OpenPayer
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    CurrentWellpointPolicy G-06133

    Reimbursement Policy Proof of Timely Filing

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    This policy governs when Wellpoint Iowa may reconsider claims rejected for failure to meet timely filing requirements and what documentation or good-cause evidence providers must submit. It applies to providers serving Iowa Health Link and Hawki members in Iowa.

    Policy Summary
    PayerWellpoint
    PolicyReimbursement Policy Proof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material changes
    Effective DateOctober 23, 2025
    Last ReviewOct 23, 2025
    Next Review DateNot specified
    Key ActionRequest reconsideration of an untimely claim by providing proof of timely receipt or demonstrating good cause.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Acceptable claim-submission methods
    2Insufficient proof methods
    6Good-cause circumstances
    14Required mailed-claims log elements
    3

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    Related policies and materials

    Timely Filing Reconsideration Criteria

    Reconsideration of claims rejected for untimely filing

    A claim rejected for failure to meet timely filing requirements may be reconsidered when the provider proves timely receipt or establishes good cause, unless applicable provider, state, federal, or CMS requirements indicate otherwise.

    ANY of the following

    • Proof of timely receipt

      • For mailed claims, provide the official mailing-service return receipt or delivery confirmation and a copy of the claim log identifying each claim included in the submission.
      • For electronic claims, provide the clearinghouse-assigned receipt date from reconciliation reports.
    • Good cause: Provide an explanation for the delay or other evidence establishing a qualifying reason for delayed filing. The health plan will determine good cause and may request clarification or additional information if the evidence raises doubts about the explanation.

    Qualifying good-cause circumstances

    Good cause may be found when the claim-filing delay resulted from one or more of the following circumstances.

    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 State Medicaid plan.
    • An 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 service provider's control demonstrating that the provider could not reasonably have been expected to be aware of the need to file timely.

    Coding and Billing Standards

    Standard correct coding appliesmixed
    No codes listed
    Permitted billing code systems identified in the disclaimermixed
    CPTCurrent Procedural Terminology codes used to report services and procedures
    HCPCSHealthcare Common Procedure Coding System codes used to report services and procedures
    Revenue codesRevenue codes used to report services and procedures

    Documentation and Submission Requirements

    Documentation Required

    Request Reconsideration of an Untimely Claim

    For a claim not accepted because it did not meet timely filing requirements, request reconsideration by providing either a claim receipt date that complies with applicable timely filing requirements or evidence establishing good cause, unless provider, state, federal, or CMS contracts or requirements provide otherwise.

    • Submit the reconsideration request with the applicable receipt-date documentation or good-cause evidence.
    Documentation Required

    Document Mailed Claim Receipt

    For mailed claims, provide official mailing-service return receipt or delivery confirmation as proof of receipt within the applicable timely filing period.

    • Also provide a copy of the claim log identifying each claim included in the mailed submission.
    Documentation Required

    Policy Definitions

    Definitions
    Definitions sourceGeneral Reimbursement Policy Definitions
    Policy Summary
    PayerWellpoint
    PolicyReimbursement Policy Proof of Timely Filing
    Policy CodePolicy G-06133
    Change TypeNo material changes
    Effective DateOctober 23, 2025
    Last ReviewOct 23, 2025
    Next Review DateNot specified
    Key ActionRequest reconsideration of an untimely claim by providing proof of timely receipt or demonstrating good cause.
    SourceLink
    On This Page
    Timely Filing Reconsideration CriteriaCoding and Billing StandardsDocumentation and Submission RequirementsPolicy Definitions
  1. Destruction or other damage to the provider's records, unless the destruction or damage was caused by the provider's willful act or unintentional oversight.

    2. Document Electronic Claim Receipt

    For electronic claims, provide the clearinghouse-assigned receipt date shown in reconciliation reports as proof that the claim was received within the applicable timely filing period.

    • Submit the relevant clearinghouse reconciliation report or extract showing the assigned receipt date.
    Denial Risk

    Avoid Insufficient Receipt Evidence

    Do not rely on facsimile transmission or hand-delivery documentation as proof of timely claim receipt.

    • Fax transmission is not acceptable proof.
    • A provider-maintained claim log identifying each hand-delivered claim, together with a copy of the signed receipt, is not acceptable proof.
    Documentation Required

    Maintain Complete Mailed-Claims Logs

    Maintain a complete mailed-claims log for each submission. The log must identify the claimant's and subscriber's information, mailing details, carrier, service information, charges, and delivery method.

    • Name of claimant
    • Address of claimant
    • Telephone number of claimant
    • Claimant's federal tax identification number
    • Name of addressee
    • Name of carrier
    • Designated address
    • Date of mailing
    • Subscriber name
    • Subscriber ID number
    • Member's name
    • Date(s) of service/occurrence and total charge
    • Delivery method
    Documentation Required

    Establish Good Cause

    To establish good cause, explain the reason for the filing delay in the claim or provide other supporting evidence. The health plan will evaluate the explanation or evidence and may request clarification or additional information if its validity is in doubt.

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

    Follow Compliant Billing and Documentation Requirements

    Follow proper billing and submission guidelines and use industry-standard, compliant codes on every claim submission. CPT, HCPCS, and/or revenue codes must accurately identify the services or procedures performed and be fully supported by the medical record and/or office notes; services must also satisfy applicable authorization and medical-necessity requirements.

    • Failure to follow applicable coding, billing, submission, or documentation requirements may result in claim rejection or denial.
    • The health plan may recover or recoup payment or adjust reimbursement to reflect the services and procedures actually performed.
    • Unless otherwise stated, the policy applies to participating and non-participating professional providers and facilities.
    • Provider, state, federal, or CMS contracts and requirements may supersede the policy.