Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage

July 26th, 2019 - Namas
Categories:   Medicare   Medicare Advantage   Claims  

Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky.

In their notice, Anthem states:

"Effective for all commercial and Medicare Advantage Professional Claims submitted to the plan on or after Oct. 1, 2019, your Anthem Blue Cross and Blue Shield (Anthem) Provider Agreement(s) will be amended to require the submission of all commercial and Medicare Advantage professional claims within ninety (90) days of the date of service. This means all claims submitted on or after October 1, 2019 will be subject to a ninety (90) day timely filing requirement."
They further state:

"If you object to the enclosed amendment, you must provide us with written notice of your appeal within 30 days of receipt of this letter. If, after 30 days, we are unable to reach an agreement, your contract will terminate on or before October 1, 2019."

If you do not accept these terms, you can "object," according to Anthem's wording, but it's pretty clear that your contract with Anthem will terminate on October 1, 2019.
Click Here to view the letter we received from an AMBA member's Kentucky doctor.
Medicare allows 12 months on timely, right?

If you ask Medicare Advantage payers whether they follow Medicare rules and regulations, they will tell you that they do. But in fact, this is a classic example of Medicare Advantage payers NOT following Medicare regulations. We all already know this, but here is Medicare's rule regarding timely filing:
"Claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished."
Medicare Advantage Plans do not have to follow the same rules that Medicare Fee-for-Service plans must. Here are the regulations for Medicare Advantage Plans.
How Anthem and others (UHC, Aetna) get around the 12-month timely filing limitation
It's very simple - these payers have tied their timely filing policy to the provider's contract. If you are NOT contracted with Anthem, then you may have other remedies to rely on, such as your state law (Florida requires at least 6 months, Virginia requires at least 12 months). You should ensure you are benefitting from these longer deadlines if you are not contracted. It's only fair when most Medicare Advantage Plans are already using contracts to limit those providers to 90-day timely filing deadlines.
Here's a tip if you have passed the timely filing deadline: a Medicare Advantage patient can absolutely file a grievance with Anthem or any other Medicare Advantage payer and may be able to get the full 12 months allowed under Medicare regulations.
And here's another tip: an ERISA appeal may provide 12 months on plans that are subject to ERISA law (employer group plans that are not a church plan and not a Government plan).
Watch for more notifications from Anthem - there is a new prior authorization letter circulating and we will be talking about this as well as their new modifier -25 edits in the next few days.


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association