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Medicare offers some extensions to claim filing deadline

February 25, 2011

Medicare now requires all fee-for-services Part A and Part B claims be filed within 12 months, or one calendar year, from the date on which services were furnished. However, the U.S. Centers for Medicare & Medicaid Services (CMS) last month announced it will allow exceptions in the following cases:

  • Administrative error: This is where the failure to meet the filing deadline was caused by error or misrepresentation of an employee, the Medicare contractor, or an agent of the department that was performing Medicare functions and acting within the scope of its authority. In these cases, 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: This is where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary receives notification of Medicare entitlement effective retroactive to or before the date of the furnished service. In these cases, 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: This is where 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. For example, at the time the service was furnished the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactive to or before the date of the furnished service. The state Medicaid agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the timely filing limit has expired. In these cases, 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: This is where 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.

The one-year Medicare claim filing deadline was imposed under last year’s health care reform legislation and took effect Jan. 1, 2010. A Medicare Leaning Network article on the exceptions can be accessed on the CMS Web site at www.cms.gov/MLNMattersArticles/Downloads/MM7270.pdf.

The official instructions to Medicare claim processing contractors (CR 7270) can be accessed at www.cms.gov/transmittals/downloads/R2140CP.pdf.

Health care practitioners with questions about time limits for claim filing should contact their carriers, durable medical equipment Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs), Part A or Part B Medicare administrative contractors (A/B MACs), or Regional Home Health Hospice Intermediary (RHHI) at their toll-free numbers, which may be found on the CMS Web site (www.cms.gov).

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