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February 13, 2015

Medicare Timely Filing Guidelines

Background

The Patient Protection and Affordable Care Act (PPACA) signed into law on March 23, 2010, by President Obama included a provision which amended the time period for filing Medicare Fee-For-Service (FFS) claims. This provision was aimed at curbing fraud, waste, and abuse in the Medicare program. Under the law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year (12 months) after the “through” date of service on the claim.

Note: Adjustment claims (Type of Bill ending in XX7) submitted by the provider are also subject to the one calendar year timely filing limitation.  In addition, claims that have Returned to Provider (RTP’d) for corrections and resubmitted, are also subject to timely filing standards.

Exceptions

On January 21, 2011, the Centers for Medicare & Medicaid Services (CMS) announced four exceptions to the 12 month Medicare claim filing period. 

  • Administrative Error
    • Error or misrepresentation of an employee, the Medicare Contractor or agent of the Department of Health and Human Services (DHHS) that was performing Medicare functions and acting within the scope of its authority
    • Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider or supplier received notice that an error or misrepresentation was corrected
  • Retroactive Medicare Entitlement
    • Beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished
    • Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider or supplier received notification of Medicare entitlement retroactive to or before the date of the furnished service
  • Retroactive Medicare Entitlement Involving State Medicaid Agencies
    • A state Medicaid agency recoups payment from a provider or supplier six months or more after the date the service was furnished to a dually eligible beneficiary
    • Medicare will extend the timely filing limit through the last day of the sixth month following the month in which a state Medicaid agency recovered Medicaid payment from a provider or supplier
  • Retroactive Disenrollment from a Medicare Advantage (MA) Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization
    • A beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups its payment from a provider or supplier six months or more after the date the service was furnished
    • In these cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the MA plan or PACE provider organization recovered its payment from a provider or supplier

Phone or Written Requests for Exceptions

  • Providers may contact the J15 Part A Provider Contact Center (PCC) by phone at 866.590.6703 for questions and assistance.
  • Please note Customer Service Representatives are unable to manually process a claim through the Fiscal Intermediary Standard System (FISS) in order to ensure a claim complies with timely filing standards. If it is determined that documentation is required to overturn timely filing (based on the four exceptions listed above), the telephone representative will inform the caller that a written request for exception must be submitted to:  

    J15 Part A Provider Contact Center
    P.O. Box 20200
    Nashville, TN 37202

The written request for exception for claim(s) sent to CGS must contain the following elements:

  1. Be in writing
  2. Be on company letterhead
  3. The address on the company letterhead must match the 'Master Address' in the provider's Medicare enrollment record
  4. The provider's six-digit Provider Transaction Access Number (PTAN)
  5. The provider's National Provider Identifier (NPI)
  6. The last five digits of the provider's Federal Tax Identification (ID) number
  7. Beneficiary's name
  8. Beneficiary’s Medicare number
  9. Beneficiary’s date of birth
  10. Dates of service for the claim(s) in question
  11. Include supporting evidence (see below for examples)

Note: A written request for exception may take up to 45 business days for research and a response.

Supporting Evidence/Documentation

Administrative Error

  • A written report by the agency (Medicare, Social Security Administration (SSA), or Medicare Administrative Contractor (MAC)) based on agency records, describing how its error caused failure to file within the usual time limit
  • Copies of an agency (Medicare, SSA,  or MAC) letter reflecting an error
  • A written statement of an agency (Medicare, SSA,  or MAC) employee having personal knowledge of the error
  • CGS Claims Processing Issues Log (CPIL) showing the system error
    Note: The provider must demonstrate that they submitted the claim within six months after the month in which they were notified that the system error was corrected. In addition, there must be a clear and direct relationship between the system error and the late filing of the claim(s).

Retroactive Medicare Entitlement

  • Copies of a SSA letter reflecting retroactive Medicare entitlement
  • Dated screen prints of the Common Working File (CWF) showing no Medicare eligibility at the time the claim was originally submitted and dated screen prints of CWF showing the retroactive Medicare eligibility

Retroactive Medicare Entitlement Involving State Medicaid Agencies

  • Copy of a state Medicaid agency letter reflecting recoupment
  • Proof of Medicaid recoupment of a claim

Retroactive Disenrollment from a MA Plan or PACE Provider Organization

  • Copies of an MA plan or PACE provider organization letter reflecting retroactive disenrollment
  • Dated screen prints of the CWF showing MA plan or PACE provider organization eligibility at the time the claim was originally submitted
  • Proof of MA plan or PACE provider organization recoupment of a claim

Note: Each provider request for exception will be evaluated individually based on the evidence submitted with the request.

References:


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