Anthem timely filing limit and claim dispute rules by state

Anthem filing, prior authorization and portal

Appeal levels

Top denials from Anthem

What is the Anthem timely filing limit?

Anthem does not have one national timely filing limit. Anthem Blue Cross and Blue Shield is a trade name, and the legal company behind it differs from state to state, so the filing limit, the dispute deadlines and the prior authorization lists follow the state and the product on the member's ID card.

Anthem's own bulletins reflect this. A June 2024 flier for Anthem Blue Cross commercial plans in California refers to "Anthem's timely filing limit" and tells providers to prove timely filing against it, without printing a number. A 2021 Connecticut commercial bulletin does the same. The number sits in the state manual or reimbursement policy for the member's product, so look it up per claim and do not carry one figure across states.

The footer of Anthem's June 2018 Connecticut bulletin shows how the entity changes by state. These are examples from that footer:

The same footer lists other states and says the entities are independent licensees of the Blue Cross and Blue Shield Association. That is why the Blue Cross Blue Shield guide applies when an Anthem member is treated outside Anthem's states, while this page applies when you contract with Anthem.

Look up the limit in four steps:

1. Read the state and the plan type from the card and from the eligibility response.
2. Open the Anthem provider manual or reimbursement policy for that state and product.
3. Note the limit for participating and nonparticipating providers, and how the manual says the clock starts.
4. Put the limit in your billing system by payer plan, not by the word Anthem.

Our timely filing calculator counts the days once you have the number, and the payer comparison covers other payers and Medicare.

Which portal or clearinghouse do I use to submit Anthem claims?

Availity Essentials is Anthem's provider portal for claims, eligibility and disputes. The June 2024 California commercial flier says to submit claims through the Claims and Payments application in Availity Essentials, or through your EDI vendor, and to check the primary carrier in Eligibility and Benefits Inquiry under the Patient Registration menu.

Attach documents at submission. The same flier says to use the attachment button in Claims and Payments, or to work with your EDI vendor on digital attachments, when Anthem is the secondary payer and needs the other carrier's EOB.

How does secondary billing affect Anthem timely filing?

When Anthem is the secondary payer, the filing clock is tied to the other carrier's response. The June 2024 flier for Anthem Blue Cross commercial plans in California gives two rules. The dated remittance advice or explanation of payments from the other carrier must show you submitted to the other insurer within Anthem's limit, and the claim and documentation must reach Anthem within the limit counted from the date of that remittance advice.

If the other carrier rejected the claim, send the denial letter with the claim. The flier says the letter must be dated and on letterhead, and the claim must reach Anthem within the limit counted from the letter date. Sending a claim to Anthem as primary when Anthem is secondary causes a denial, because Anthem has no EOB, and that delay can use up the time. The matching denial code is CO-22.

What are the Anthem appeal levels and deadlines?

Anthem's commercial claim payment disputes in Connecticut have two steps, and the second cannot start without the first. The October 2021 Connecticut commercial bulletin names them claim payment reconsideration and claim payment appeal, and says the dispute process applies after a claim is finalized and you disagree with the payment.

Once the appeal is submitted, the bulletin says the decision is final and the dispute may not be submitted again. It points providers to their state regulatory agency for more help and to their Provider Experience Consultant after both steps are complete.

The bulletin lists the disputes that belong here: manual processing errors, contract interpretation, reduced payments, code editing issues, other health insurance denials, eligibility issues and timely filing issues. Status questions, clinical appeals and requests for additional information are different processes.

In Availity, the bulletin gives the path: Help & Training, Find Help, then Overpayments and Appeals, then Dispute a Claim. You can upload supporting documents there and see the status and history of a dispute.

Can I still get paid when a claim denied for timely filing?

Yes, in two cases. The same bulletin says Anthem will consider reimbursement of a claim denied for failure to meet timely filing if you provide documentation that the claim was submitted within the timely filing requirements, or demonstrate that good cause exists. Build the documentation file the day the claim goes out: the clearinghouse acceptance report and, for secondary claims, the other carrier's dated remittance advice.

What about expedited and clinical appeals?

A June 2018 Connecticut bulletin describes the clinical track. An expedited appeal applies when services have not been provided and the standard timeframe could seriously jeopardize the member's life or health, harm the ability to regain maximum function, or leave the member in severe pain that cannot be managed without the service. Anthem said it would respond to qualifying expedited appeals within 72 hours, and the request is faxed with a letter of intent and supporting documentation. Administrative services only (ASO) members use the service number on the ID card to start an expedited appeal.

How do I check eligibility and submit prior authorization for Anthem members?

Prior authorization requirements follow the state and product, so look the service up for the member's state before you schedule a procedure or an admission. Start with eligibility and benefits in Availity Essentials to confirm the plan, the network status and the primary payer.

Run this check at scheduling, not at billing, because an authorization denial is much harder to repair than to prevent. Our prior authorization and eligibility verification services cover that front-end work.

How do I dispute an out-of-network underpayment from Anthem?

Anthem's claim payment dispute process is separate from the federal No Surprises Act process. Use the reconsideration and appeal steps above for processing errors, contract interpretation or reduced payments, and do not let them use up the No Surprises Act clock. The deadlines for open negotiation run from the federal rules, and out-of-network billing and IDR explains how we manage them.

Where can I get help with Anthem denials?

Nucleus Align works Anthem denials and disputes through denial management, and you can book a call to go through a specific claim.