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Timely Claim Filing Requirements

Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §70External PDF

Home health and hospice billing transactions, including, claims, and adjustments must be submitted no later than 12 months, or 1 calendar year, after the date the services were furnished. For example, a claim with dates of service 9/15/2015, must be received by 9/15/2016 for processing.

Important Notes for Home Health and Hospice Providers

  • The "Through" date on claims will be used to determine the timely filing date. Example: A claim has a From date of 7/1/2015 and a Through date of 7/31/2015. The claim must be received by 7/31/2016.
  • Per Medicare Learning Network® (MLN) Matters article MM7396External PDF, timely filing edits will be bypassed for any RAP for which the associated Home Health Prospective Payment System (HH PPS) final claim could still be timely under Section 6404 of the Affordable Care Act.
  • Notices of Election (NOEs)are not subject to the timely filing requirements indicated in Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §70External PDF. ¬†However, refer to the Change Request 8877 Web page for information requiring NOEs to be submitted and accepted within 5 calendar days after the hospice admission date.

As a reminder, a new receipt date is assigned to RAPs, claims, and adjustments that are corrected (F9d) from the Return to Provider (RTP) file. Therefore, it is important to ensure that your billing transactions are corrected from RTP (T B9997) status/location prior to the timely filing deadline.

When a Claim is Rejected

A claim that is rejected for being filed after the timely filing period is not subject to a formal appeal (i.e., redetermination). If one of the following exceptions apply, you may request that CGS review the reason the claim was rejected. Refer to the Untimely Filing section on the Reopenings web page for additional information.

Exceptions Allowing Extension of Time Limit

Exceptions to the 1 calendar year time limit for filing Medicare home health and hospice billing transactions are as follows:

  • Error or misrepresentation by an employee, Medicare contractor, or agent of the Department of Health and Human Services (HHS) that was performing Medicare functions and acting within the scope of its authority.
  • Retroactive Medicare entitlement to or before the date of the furnished service.
  • Retroactive Medicare entitlement where a State Medicaid Agency recoups money from a provider or supplier 6 months or more after the service was furnished.
  • A Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recoups money from a provider or supplier 6 months or more after the service was furnished to a beneficiary who was retroactively disenrolled to or before the date of the furnished service.

Refer to the Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 1, §70.7External PDF, for additional information about the exceptions. The conditions for meeting each exception, and a description of how filing extensions will be calculated, are described in sections 70.7.1 – 70.7.4.

Resources

Updated: 12.16.16


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