Reimbursement Policy Claims Timely Filing
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This policy governs when Wellpoint New Jersey Medicaid will consider reimbursement for initial claims based on timely receipt and acceptance. It applies to participating and nonparticipating providers and facilities, subject to applicable provider, state, federal, CMS, and contractual requirements.
No material clinical or coverage changes in this revision.
Claims Timely Filing Criteria
Claims Timely Filing Reimbursement Criteria
An initial claim is considered for reimbursement when it is received and accepted within the applicable timely filing limit. Claims filed outside the limit are not subject to reimbursement unless a qualifying exception applies.
ALL of the following
ALL of the following
- The initial claim must be received and accepted within the applicable timely filing limit.
- Determine the applicable limit by applying provider, state, federal, CMS, contractual, or other controlling requirements before applying the health plan standard.
- If no controlling requirement applies, use the health plan standard of 180 calendar days from the last date of service in the course of treatment for both participating and nonparticipating providers and facilities.180 calendar days
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