Quick Answer: BCBS Timely Filing Limit
The BCBS timely filing limit depends on the Blue Cross Blue Shield company, the memberโs product, your provider agreement, and the claim type. Published initial limits include 90, 95, 180, and 365 days. Confirm which event starts the clock and check separate rules for corrections, secondary claims, and appeals.
There is a claim which shows โsentโ in your billing system; however, the remittance shows CO-29. Before attempting any re-transmission or write-off, get the payerโs receipt document and check the rule for that particular product. Checking these two points should help you decide what action to takeโwhether to correct the reject or deny it, or whether there could be an exception case involved.
BCBS Timely Filing Limit Quick Reference Table
Blue Cross Blue Shield is an alliance of individual companies. You would need to start with the membershipโs product, their participation status, and the provider agreement covering the billing entity and location. Match the claim with the provider manual, relevant policy updates, and other federal or state rules. Terms of the agreement of the employer group or facility might be separate.
Examples published for specific products and provider agreements. Filing timeframes differ based on plan, state, contract, and claim. A cell labeled โverifyโ refers to the product manual, provider agreement, or denial message. The value of another cell may not refer to this process.
| BCBS plan or product | Initial claim | Corrected claim | Secondary claim or COB | Provider dispute or appeal |
|---|---|---|---|---|
| BCBS Massachusetts HMO/POS and PPO [2] | 90 days from service or discharge for authorized inpatient stays | 180 days from original denial for eligible replacements. Added charges follow the original limit. | 180 days from primary payment or 90 days from primary denial, subject to the planโs conditions. | If BCBSMA is primary and has no record of the claim, submit the timely filing appeal within 180 days from service. Check the Blue Book for other reviews. |
| BCBSTX commercial PPO [3] | 365 days from service. Institutional claims use the UB-04 Through field. | Applicable original filing deadline or governing contract terms. | Verify the productโs COB rule. The manual lists a separate exception when a member provides incorrect insurance information. | First claim dispute within 180 days of the applicable check, Explanation of Payment, or Provider Claims Summary. |
| BCBSTX commercial HMO products covered by its HMO manual [3] | 180 days from service. Institutional claims use the UB-04 Through field. | Applicable original filing deadline or governing contract terms. | Verify the HMO product rule and whether an exception applies. | First claim dispute within 180 days of the applicable check, Explanation of Payment, or Provider Claims Summary. |
| BCBSTX Medicaid and CHIP [4] | Standard 95 days from service for participating providers. Check the manual for facility and special situations. | Verify the applicable replacement rules in the program manual. | 95 days from the other carrierโs or programโs remittance or letter denying coverage. | 120 calendar days from receipt of the remittance advice. |
| BCBSTX Medicare Advantage PPO and HMO/D-SNP [5] | PPO: 90 days from service for participating providers. HMO/D-SNP: 180 days from service for participating physicians and professional providers. | Verify by product and provider type. | Verify the productโs secondary billing instructions. | Check the productโs provider dispute process and the notice. |
| BCBS Illinois commercial professional PPO networks [6] | 180 days from service for non-inpatient claims, or discharge or transfer for inpatient services. | Verify the applicable commercial policy and agreement. | 180 days from the participating providerโs receipt of the primary EOB. | Verify the productโs claim review rules. |
| Highmark Delaware, Pennsylvania, and West Virginia [7] | 365 days from the last service when the contract is silent under Highmarkโs standard policy. | 455 calendar days from original claim finalization for covered commercial, Medicare Advantage, and FEP corrections. BlueCard Home is excluded from this rule. | Same applicable window as when Highmark is primary, measured from the primary payerโs finalization or payment shown on the EOB. | Verify the review route and cutoff for the claim and issue. |
| Florida Blue participating providers [8] | Follow the participating provider agreement and applicable law. The manual describes 180 days where that guidance applies. | Verify the agreement and billing instructions for the product. | 90 days from primary final determination where the cited Florida insurance or HMO statute applies. | The general administrative appeal window runs to the remittance advice anniversary. The manual gives a separate 60-calendar-day rule for nonparticipating Medicare Advantage provider appeals. |
| Anthem BCBS New York Medicaid [9] | 90 days from service for participating providers and facilities. Verify the separate nonparticipating rule. | Verify the state programโs correction rules. | For the policyโs applicable window, count from the other carrierโs Explanation of Payment when that carrier is primary. | Check the New York Medicaid dispute policy and notice. |
| BCBS Rhode Island commercial [10] | 180 days from service or inpatient discharge under the published commercial policy. | 180 days from a denial disposition. Paid claims follow a separate adjustment window. | 180 days from the primary insurerโs processing date. | 60 days from the original BCBSRI remittance for filing-limit appeals. |
| Premera Blue Cross, Washington provider guidance [11] | Verify the contract and product. The onboarding page says 365 days from service, while the medical manual says 90 days. | Verify the applicable filing rule. The medical manual explains the replacement format. | Verify with Premera for the product. | Level I provider appeal within 365 days of the action when that process applies. The manual excludes FEP, BlueCard Home, and Medicare Supplement. |
Anthem, Florida Blue, and Plans with Similar Names
Anthem: Pull the state and line of business manual. Anthem New Hampshire points out 90 days for participating Medicare Advantage professional claims and provides commercial providers with their participating agreements. New Yorkโs Medicaid policy is a separate document with a participation split. Keep the policy with the payer record so another biller can check it against the claim in front of them.
Florida Blue: Read your participating agreement and the section on prompt claims processing/timely filing limits. The manual states a 180 day time frame when applicable. Floridaโs Insurance and HMO laws state a different time frame when applying to primary claims. The laws state that it is of import the service or discharge was provided to the provider and the correct name and address of the insurer. The laws state that notice by mail or electronically applies to the time frame. Have the provider service unit state what law applies when the agreement, manual, and instructions to the claim point to different laws.
Medicare Advantage, Medicaid, and Federal Employee Coverage
This example from Texas shows differences in product lines. The participating commercial PPO manual states 365 days, the participating Medicare Advantage PPO rule states 90 days, and the Standard Medicaid and CHIP states 95 days. CMSโs guidance for Original Medicare states its own filing period and directs providers to the appropriate Medicare Administrative Contractors. For a BCBS Medicare Advantage Claim, use the productโs provider guidance and requirements.
For the Federal Employee Program (FEP), who is filing will depend on a variety of factors. The U.S. Office of Personnel Managementโs Service Benefit Plan brochure gives information on claim filing and request for review. Also, check the administering Blue planโs provider instructions. BCBS Nebraskaโs published policy states that it has applied its own standard 120-day window to the FEP plan and is subject to the applicable agreement. Verify the provider rule for filing a commercial or member claim.
Add the deadline to the event named by the payer
- Identify the type of claim. Confirm the program ID, payer ID, the billing NPI or tax ID, and the type of claim (professional, 837P, or CMS 1500, vs. institutional, 837I or UB-04). Confirm the providerโs participation for the service rendered. Keep in mind, a single payer name in the practice management system can represent multiple contracts and products.
- Identify the action. Is this the first clean claim, a replacement for a processed claim, a secondary claim, a response to a payer request, or a dispute? Pull the policy for that action. For example, in Texas, the PPO and HMO manuals specify a distinct response window when the plan returns a claim for additional information. That window begins when the plan mails its request.
- Identify the trigger. Use the service, discharge, or event named in the policy. That may include primary payer processing, receipt of the primary EOB, finalization of the original claim, or the applicable remittance. If the payer measures from receipt, keep evidence of receipt. If it measures from the service or event printed on the document, record that.
- Confirm and calculate. Use the specified unit, and days when specified. A 365 day count may differ from a rule tied to an anniversary. Verify any exceptions for weekend or holidays. Keep an internal submission target with enough time to work a rejection and confirm receipt.
If you cannot locate the governing rule on your own, you may ask the Provider Services department for assistance with the policy, the triggering event, the final filing cutoff, and the means to submit. Keep the reference number for the call, and attach the written guidance, portal response, or other communication to the payer record. This will help your team if a different member gives a different response.
Identify any weaknesses in your filing process
If you have BCBS deadlines documented in multiple spreadsheets and email inboxes, we can assist your billing department with reviewing payer guidelines and workflow process documentation.
BlueCard Claims and Out-of-State Members
Follow the host or local Blue planโs filing instructions for regular BlueCard professional and facility claims. The home plan is the Blue company with which the member is covered. The local plan can usually take the claim and route it. Use the complete member ID (including the three-character prefix, if any) and check product, eligibility and payer ID. BCBSTXโs BlueCard guidance, for example, sends claims for members of other participating Blue plans to BCBSTX for local processing.
Confirm the deadline and dispute process as two separate questions. According to BCBS Nebraska, for non-Nebraska Blue members, certain adjustments and exceptions follow the member planโs deadlines. Highmark states it handles BlueCard provider appeals through Highmark. Arkansas Blue Cross states certain disputes related to another planโs coverage or payment determination should be directed to the home plan. Ask the local plan to identify the rule and/or review process for your type of claim.
Example: The Texas practice might encounter a patient with a Blue PPO card from another state. In such case, the biller would check the alpha prefix and the product of this card through the local BlueCard system, and submit the claim to the Texas insurance with the right payer ID. Also, it will be necessary to establish what is the timely filing limit and where the providerโs claim disputes should be directed.
The answer may differ based on a particular state and a particular plan product, particularly when the billing system is set up to handle a different Texas commercial PPO plan. If the specimens are handled independently and sent to a separate laboratory, the latter will have to verify its own claim routing rules. According to BlueCard manuals, the independent laboratory claims could be routed according to the referring physicianโs service area.
Effective medical billing services maintain a separate file for the payers for local commercial claims, BlueCard claims, federal plans, Medicare Advantage, and Medicaid. Even when the claims are processed through one clearinghouse system, the products should maintain their own routing and timely filing rules.
BCBS Timely Filing Limit for Corrected Claims
Generally, you would always start with the original claim status. A claim may be rejected by the clearinghouse or payer prior to adjudication. In this case, address the rejection and send the claim in accordance with the payerโs original submission instructions. If the claim is pending adjudication, check the status to see if itโs been processed before sending a replacement. A replacement claim is allowable for a documented billing error if the payer has accepted the original claim. Documented errors may include mistyping, a transposition, or an omission. A replacement is allowable even if the error resulted in an incorrect unit or quantity. If a claim was submitted accurately and the payer denied payment, a replacement is allowable and may be preceded with the policy or appeal procedure to explain the reason for the replacement and why the submitted claim was correct.
Three scenarios illustrate when a correction should have its own rule in the billing system:
- BCBSTX: The commercial PPO and HMO manuals state that correction claims are subject to the applicable filing deadline.
- BCBS Massachusetts: Timely Filing Guidelines state an eligible replacement may be filed within 180 days of the original denial. New charges or services added to that replacement claim must also abide by the original filing rules.
ย ย ย ย ย Verify that the appropriate process is followed if the claim was paid. If a payerโs adjudication is being challenged, follow the process outlined in Section 17.0 of the Highmark guide.
- Highmark: The rule published by Highmark for covered corrections provides a time period of 455 calendar days from the finalization of the original claim. Highmark processed. BlueCard Home is excluded. An original submission or receipt date is useful evidence, but the finalization date should be used to determine the time period for filing a correction.
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Payer rules vary. Some require a complete replacement. Other payers instruct to carry forward valid lines on the corrected claim along with the corrected lines and supply the original claim control number. The payer may specify an appropriate replacement frequency code to use, which may be 7 or 8.
Some payer plans direct the use of frequency codes 4, 5 or 6 for corrected claims. Highmark allows specific late charge and correction replacement codes. BCBSTXโs CPCP025 warns against the use of frequency code 5 for corrected claims. For further instructions, contact the payer.
Example. After finalization of a Texas commercial PPO claim, the billing company finds that the billed units do not match the units on the signed record. Assuming the filing period has not lapsed, the company may submit a complete corrected claim and use the original claim number assigned by the payer. Incorrect payment for an otherwise correct claim would be considered a payment dispute.
Secondary Claims and Coordination of Benefits
Obtain the explanation of benefits (EOB) or electronic remittance advice (ERA) from the primary payer to determine the event that the secondary payer uses as their start date. In Illinois, the look-back period begins with the receipt of the primary EOB. In Rhode Island, the look-back period is from the date the primary payer processed the claim.
Massachusetts requires that primary payments and primary denials be reported as part of their secondary filing procedures. You will need both the primary payerโs payment and evidence supporting the secondary filing.
Transmit the COB or EOB data, post the primary payerโs allowed amount, and make payment adjustments, if any, as required by the secondary plan. If the primary payer denies coverage, retain the actual denial. Some policies use the denial to determine whether the filing cutoff has been met and to verify if the primary claim was submitted in a timely fashion. If Medicare is primary and you expect an automatic crossover, confirm the receiving plan has the claim, check for rejection or missing data, and then send the duplicate.
Example. A participating Illinois professional PPO provider receives the primary EOB. The poster files the EOB and creates a secondary billing task using BCBSILโs 180-day rule. A coworker handles a Rhode Island commercial claim the same way at first, then checks the policy and uses the processing information on the primary EOB. If the Rhode Island claim had been processed from the EOB arrival, the practiceโs tracker would show an earlier cutoff than what the payerโs rule allows.
If the primary payer hasnโt processed the claim, assign an owner to follow up and keep proof of the primary submission. Track to see if coverage was verified, the primary claim was accepted, and a payment, denial, or crossover was recorded.
An account waiting on another payer can fall out of the original claims queue even though the secondary claim still needs to be processed.
CO-29 Denials and Proof of Timely Filing
On an electronic remittance, CO is the contractual obligation adjustment group. X12โs claim adjustment reason code 29 indicates that the filing limit expired. Review any remittance advice remark codes, the payer claim number, and the recorded receipt before deciding what to send. A late receipt, a missing submission record, and a claim filed to the wrong destination can all leave you investigating the same denial.ย
Check where the claim stopped
| Evidence in the account | What to check next |
|---|---|
| โSentโ in the billing system | Find the matching clearinghouse transaction and confirm where the claim was routed. |
| 999 acknowledgment or batch acceptance | Check the sender and whether the acknowledgment covers the file or transaction set. Pull the individual claim response to verify its status. |
| 277CA or comparable claim-level response | Check whether the individual claim was accepted or rejected, who generated the response, and whether it matches the member, provider, and service on the denied claim. |
| Payer acceptance, portal history, or a payer control number | Check the payerโs receipt information and trace it to the same claim. Download or retain the supporting record in the approved system. |
| Paper claim submitted through an allowed channel | Pair the mailing or delivery record with an itemized claim log. Check the planโs rules for what it accepts as evidence. |
Checking Medicare Claim Status manual from CMS describes the relationship between 999 and 277CA within the context of electronic claim acknowledgment process. For a BCBS appeal, use the documentation that is acceptable for the particular plan. BCBSTX provides Availity Electronic Batch Response documents, and in addition to the certified mail, asks for Texas Department of Insurance mail log. BCBS Massachusetts also provides several options, like the Optum Timely Filing Report, for example, and states that unsuccessful or rejected transmission is not enough.
Claim receipt record included in a report enables reviewer to associate the original transmission with a denied claim. In case of disagreement between payer portal and clearinghouse, ask the latter to find the particular claim for the payer who received it. Verify the payer id and match the claim identifiers before including a report. Even clearinghouse report from the right batch may relate to some other claim in that batch.
Process the Provider Dispute Through the Right Channel
- Recognize the Type of Review and Deadline. Locate the Provider Payment Dispute, Administrative Reconsideration, or Timely Filing Appeals processes for the product. Identify the relevant event. Time limits for Texas commercial PPOs and HMOs are 180 days from the date of the payment or claim summary record. BCBSTX Medicaid and CHIP allow 120 calendar days from the date of the Remittance Advice for their Provider Appeals.
- Reconstruct the Claim Record. Examine the original claim, transmission, and acknowledgment records. Analyze the payer claim number and the denial. Include the primary Explanation of Benefits (EOB) or the planโs request for information if they document the relevant filing requirement.
- State what you want the plan to do. Provide documentation showing the payer received the filing, describe the denied claim, and reference the filing provision. Ask the plan to review the timely filing determination and, in the affirmative, to process the claim.
- Complete the correct form or process through the correct portal. Access the payerโs dispute process workflow through Availity Essentials (or the payerโs Provider Portal). Use the approved, secure method for transmitting claim records and attachments. Save the submission confirmation and record the case number.
- Track the Claim. Check the status of the claim to see when the payer acknowledges receipt of the dispute. The denial may have been final. If so, check the denial for next level review, if any, and the deadline to request that level review.
worked denial scenario. An accepted office claim with verified 90-day filing window by the payer was on day 84. A later search on the portal by the biller showed CO-29 for a duplicate claim that was sent on day 96. Both records by the biller were matched based on member, provider, date of service and charges. The biller contacted the payer to locate the original claim and confirm its status. The payer adjudicating the original claim as correct would allow the biller to resolve the duplicate claim in the practice management system. However, if the payer adjudicates the original claim as denied, then the biller would take the original payer acceptance record and the original claim number through the provider dispute process to avoid the provider appealing a duplicate claim.
Change one fact and the action changes. If the claim was rejected due to an invalid member ID on day 84 and the first accepted claim was received by the correct payer on day 96, then the rejection of the claim filing document the attempt at filing. Review the planโs exception policy to see what kinds of documentation is needed to address cases outside the planโs rules. In general, account requests are looking for evidence different from what is requested in a dispute of an originally accepted claim.
Dispute language sample. โPlease review the timely filing denial for claim [payer claim number]. The attached claim-level acknowledgment identifies the original submission and shows the payer accepted it within the window as specified in [policy or agreement section]. Please confirm the original receipt and reprocess the claim if the filing requirement was satisfied.โ
Use the dispute language sample if evidence is found to warrant the request. If the exception is due to a COB trigger, a payer request or some other documented exception, identify that exception and include the appropriate evidence.
Filing Exceptions and Patient Balances
Distinguish an error in how the payer determined the deadline from a request for a waiver of the deadline. In general, an earlier receipt or a primary EOB would show the claim was filed within the applicable time period. If the claim was filed outside the applicable time period, find a documented exception such as a retroactive enrollment, incorrect plan information, or a published emergency waiver. The Healthy Blue of North Carolina Proof of Timely Filing policy gives examples of documented good cause and the evidence they would accept.
Anthemโs New York Medicaid policy provides information on types of temporary waivers that may occur as a result of a documented disaster or at the request of the state.
Exceptions are documented. For retroactive coverage, retain the eligibility or enrollment notice as well as the claim receipt. If there is a system outage, obtain a payer bulletin or approved exception, and retain the incident report, affected transmission records. If there is an issue with the insurance information, retain the eligibility check, records of coverage verification attempts, and the payer remittance. Contact the plan to ask if a form is required, if a claim should be filed first, or if a request should be made separately after a denial. A staffing backlog belongs in the internal review of why the claim was missed. For instance, Nebraskaโs policy excludes provider delays as reasons to grant an override.
Retain patient statements while liability is determined. BCBS Illinois and the BCBSTX commercial manuals exclude participating providers from shifting a missed filing balance to the member in situations described in their manuals. Adjust the patient payment in accordance with the remittance and the provider agreement, and apply the governing rules before transferring any amount to the patient responsibility. If the provider is determined to be liable, adjust the patient payment in accordance with the planโs instructions.
Avoid Late Filing in Your Billing Queue
Work queues where a claim may appear complete though it still needs further action may include charge description entry where the claim is still waiting to be coded, or a claim that is still awaiting a signed note. Also included may be a claim that has been unsuccessfully transmitted to the clearinghouse. An ERA that is successfully posted may not reflect rejection of the Secondary Claim.
Establish an owner for each handoff and define what evidence closes it.
- Maintain a payer grid by product and claim type. Include the affiliate, product, provider participation, professional or facility, original filing limit, trigger, correction rule, COB rule, dispute cutoff, submission channel and source. Separate provider contracts by billing entity or location, if the terms differ.
- Reconcile signed encounters against accepted claims. Compare signed visits and completed charges against claims that reached the payers. Follow up on missing charges, outstanding documentation, rejections, and accepted claims with no status record. A batch count alone can mask claims that dropped out.
- Work rejections on each billing cycle. Assign registration and payer ID errors to the correct team. Send routing errors to a team member to check the clearinghouse and payer setup. Confirm acceptance after rework so the claim leaves the exception queue for the correct reason.
- Prioritize claims based on remaining filing room. Show which claims are the most urgent based on their filing or dispute cutoff. Use dollar value to prioritize among similar claims. A lower dollar value claim, for example, would be more pressing than a higher dollar claim that has more time to follow up.
- Keep secondary claims and disputes visible. Allow primary EOB posting its own secondary billing task. Open the dispute task when the denial posts, and enter the required form, the cutoff and evidence owner in the task.
- Examine each filing write-off to determine the cause. Indicate if the problem began in charge capture, eligibility, provider enrollment, payer routing, rejection follow-up, COB, or dispute resolution. If the same problem occurs repeatedly, change the handoff or system rule that allowed it.
The practical approach would be to select a random selection of claims and then ask another biller to retrieve the payer receipt and filing policy without consulting the biller who initially sent the claim. In case of both being readily accessible and the next step clearly defined, the claim is eligible for further processing. However, if the biller has to refer to the emails to reconstruct the claimโs history, you should establish a central storage for all successfully filed claims along with the corresponding documentation that your Denial Management Services will require to solve the problems related to filings.
Get a Billing Audit for Repeated BCBS Denials
Our Billing Team is able to track down the recurring denials to the point of claim submission, check the payer policy your office follows, and find the open accounts with items to investigate.
Frequently Asked Questions
Is the BCBS timely filing limit 90, 180, or 365 days?
It depends on the product and provider agreement. BCBS Massachusetts publishes 90 days for standard HMO/POS and PPO claims. BCBSTX publishes 180 days for the commercial products covered by its HMO manual and 365 days for its commercial PPO. Texas Medicaid and CHIP generally uses 95 days.ย
Which event starts the BCBS filing clock?
For initial claims, check the service, discharge, or facility Through field specified by the payer. Corrections can run from the original service or claim disposition. Secondary claims may use primary payer processing, payment, denial, or EOB receipt. Use the event named for your claim.ย
Can I send a corrected BCBS claim after the initial filing window?
Some products allow it. Highmark gives covered corrections 455 calendar days from original claim finalization, with BlueCard Home excluded. BCBSTX commercial generally requires corrections within the applicable claims filing deadline. Confirm the productโs correction rule and any separate limit for adding new charges.ย
Where do I file an out-of-state BlueCard claim?
Start with the local Blue planโs BlueCard instructions and use the full member ID. Ask which filing window and dispute channel apply to the product. Ancillary services and certain products can follow special routing rules, so verify before submitting.ย
Can I appeal a CO-29 denial if the clearinghouse shows I sent the claim?
You can request review when the planโs process allows it. Find the claim-specific receipt or acceptance record and check what the payer recognizes as proof. If the report shows a rejection, review the exception rules and gather the evidence for any provision that applies.ย
Can I bill the patient when BCBS denies a claim for late filing?
Check the remittance, contract, and applicable law before releasing a statement. Many participating provider rules assign missed-filing amounts to the provider. BCBS Illinois and BCBSTX expressly prohibit billing the member for amounts denied for untimely filing under the cited rules.ย
Closing the Claim
Prior to dismissing a CO-29 claim or resubmission, compare the payerโs receipt with BCBSโ timely filing requirement for that product and action. Retain the document with the file. Should there be consistent errors with filing in subsequent claims, correct the issue within the department responsible for the initial handoff.
