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Timely Filing of Claims

Timely Filing of Claims

BCBSAZ asks providers to submit complete and accurate claims, preferably within 30 days of service, and require submission within one year of the date of service. BCBSAZ will deny any claims received more than one year after the date of service. Members are not liable to a BCBSAZ contracted provider for payment of a claim on which BCBSAZ denied payment for lack of timely filing. For the Federal Employee Program (FEP), the claim submission deadline is December 31 of the year immediately following the year in which service was rendered.

Proof of Claims Filing and Timeliness

For claims denied under timely filing provisions, providers may follow the provider grievance resolution process, and submit proof of timely filing. BCBSAZ will accept the following documentation as proof of timely claim submission:

  • For electronic claims
    • A copy of the BCBSAZ Custom Claims Acknowledgement Report (CCAR) showing receipt of a clean claim within one year of the date of service
  • For hard copy claims
    • A copy of a computer screen print showing that the claim was submitted within one year of the date of service, plus the following information:
      • Dates of timely follow-up conversations with a BCBSAZ staff member documenting date of call and person spoken to
      • Any previous contacts with BCBSAZ staff within the one year date of service time frame regarding this claim (i.e., copies of letters, etc.)

Resubmission of Requested Information Other Than Claims

To avoid delays in processing, BCBSAZ makes every effort to use information already available in its imaged records and files before sending a new records request to a provider. A provider who believes that BCBSAZ is requesting information that was previously submitted, should carefully review the request to assure that BCBSAZ is not seeking additional or different information.

After verifying that the requested information is identical to information previously submitted:

  • Contact the specific department requesting the information.
  • Provide as much information as possible about the prior transmittal, including the date the information was sent and the designated recipient.
  • Provide a copy of the transmittal if the information was faxed.

BCBSAZ will advise you if we have located the information or need you to resubmit it. If resubmission is required, BCBSAZ will give you verbal or written confirmation of receipt.

Adjustment of Adjudicated Claims

A provider may request reconsideration or adjustment of an adjudicated claim if the provider disagrees with the adjudication. BCBSAZ may also adjust an adjudicated claim if BCBSAZ determines that the claim was incorrectly paid or denied. Except for the situations listed below, both the provider and BCBSAZ must give written notice of a request for reconsideration or adjustment within one (1) year of the date of the denial, payment, or other notice of adjudication. When requesting reconsideration, the provider must do so in a manner that is reasonably sufficient to put BCBSAZ on notice of the provider's request. Refer also to the Provider Grievance Process and to Corrected Claims Information.

Adjustments beyond the one year period are allowed in the following circumstances:

  • Claims for services rendered to a member of the Federal Employee Program Service Benefit Plan 
  • Claims involving subrogation and coordination of benefits for self-funded groups not governed by state law
  • Claims involving "fraud" which means a claim that includes or is based on a misstatement or omission of material fact by a member or provider, resulting in incorrect adjudication of a claim, and includes, without limitation, failure to disclose other applicable coverage, use of CPT® codes that do not accurately reflect services provided, billing for services not rendered, billing for services under the name of a provider other than the provider who actually rendered the service
  • Claims where a longer period of time is required by applicable state or federal law, including, without limitation, adjustments required because of federally mandated changes in Medicare reimbursement rates, federal requirements that certain government payers be payer of last resort or secondary payer, and federal laws prohibiting providers from accepting more than the Medicare limiting charge
  • Claims where BCBSAZ is ordered to adjust a claim because a member or provider has prevailed on a health care appeal
  • Claims under a worker's compensation policy