Timely Filing Requirements
The Medicare regulations at 42 C.F.R. §424.44 and the CMS Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 1, §70 specify the time limits for filing Part A and Part B fee-for- service claims.
Important Notes for Providers
- The "Through" date on a claim is used to determine the timely filing date. For example, if the "From" date of service is 7.1.2021 and the "Through" date of service is 7.31.2021, the claim must be received by 7.31.2022.
- Claims that Return to Provider (RTP) for correction that are resubmitted and adjustment claims (Type of Bill XX7) are also subject to the one calendar year timely filing limitation.
- If a beneficiary indicates another insurer is primary over Medicare, bill the primary insurer prior to submitting a claim to Medicare. Once payment is received from the primary insurer, submit a Medicare Secondary Payer (MSP) claim to Medicare, even if no payment is expected. This will allow you to adjust the MSP claim if the primary insurer later recoups their money.
Filing a claim after you find out Medicare is primary is not a valid reason to waive the timely filing deadline. MSP and tertiary payer situations do not change or extend Medicare's timely filing requirements.
- When a claim denies because it was received after the timely filing period, such denial does not constitute an "initial determination" and, therefore, is not subject to appeal.
Exceptions Allowing Extension of the Time Limit
The Centers for Medicare & Medicaid Services have established the following exceptions to the one calendar year time limit:
- 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.
Required Documentation for Timely Filing Exception Request
Administrative Error
- Copies of an agency (Medicare, Social Security Administration or Medicare Administrative Contractor) letter reflecting an error
- A written statement of an agency (Medicare, SSA, or MAC) employee with personal knowledge of the error
- CGS Claims Processing Issues Log (CPIL) showing a system error
- A written report by an agency (Medicare, SSA or MAC) based on agency records, describing how its error caused failure to file within the usual time limit
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.
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
- Proof of MA plan or PACE provider organization recoupment of a claim
- Dated screen prints of the CWF showing MA plan or PACE provider organization eligibility at the time the claim was originally submitted
When a Claim Rejects for Untimely Filing (Reason Code 39011)
If one of the above exceptions apply, you may request that CGS review the reason the claim was rejected. Providers can submit a hardcopy UB-04 adjustment or a reopening request if one of the exceptions apply.
Reviewed: 12.01.22