Filing Claim Where General Time Limit Has Expired

As a general rule, where the contractor receives a late filed claim submitted by a provider or supplier with no explanation attached as to the circumstances surrounding the late filing, the contractor should assume that the provider or supplier accepts responsibility for the late filing.
Where it comes to the attention of a provider or supplier that health services that are or may be covered were furnished to a beneficiary but that the general time limit (defined in §70.1 above) on filing a claim for such services has expired, the provider or supplier should take the following action.

• Where the provider or supplier accepts responsibility for late filing, it should file a no-payment claim. (See Chapter 3 for no-payment bill processing instructions.)

Where the provider or supplier believes the beneficiary is responsible for late filing, it should contact the contractor and also file a no-payment claim and include a statement in the remarks field on the claim explaining the circumstances which led to the late filing and giving the reasons for believing that the beneficiary (or other person acting for him/her) is responsible for the late filing. If a paper claim is submitted, such a statement may be attached and, if practicable, may include the statement of the beneficiary as to the beneficiary’s view on these circumstances.

• Where the beneficiary does not agree with the determination that the claim was not filed timely or the determination that he/she is responsible for the late filing, the usual appeal rights are available to the beneficiary. Where the provider or supplier is protesting the denial of payment or the assignment of responsibility, no formal channels of appeal are available. However, the contractor may, at the request of the provider or supplier, informally review its initial determination.


Exceptions Allowing Extension of Time Limit

 the following exceptions to the 1 calendar year time limit for filing fee for service claims:

(1) Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority (See 70.7.1).

(2) Retroactive Medicare entitlement, 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 subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service (See 70.7.2).

(3) Retroactive Medicare entitlement involving State Medicaid Agencies, where a State Medicaid Agency recoups payment from a provider or supplier 6 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 retroactively 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 the timely filing limit has expired

(4) Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, 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 it payment from a provider or supplier 6 months or more after the date the service was furnished



Where the initial request for an exception to the timely filing limit is made by a provider or supplier, the Medicare contractor has responsibility for determining whether a late claim may be honored based on all pertinent documentation submitted by the provider or supplier, and for the exceptions described in sections 70.7.2 and 70.7.3, based on its review of the relevant information contained in the Common Working File (CWF) database. As explained in sections 70.7.1 – 70.7.4, the contractor will determine if the requirements for a particular exception are met. However, in certain circumstances, the contractor may contact the appropriate CMS regional office (RO) to ascertain whether it wants to participate in the review and decision-making of the specific exception request. In limited circumstances, the RO may conclude that the exception request should go to CMS Central Office for a final determination

Determining End Date of Timely Filing Period—Receipt Date

A submission, as defined above, is considered to be a filed claim for purposes of determining timely filing on the date that the submission is received by the appropriate Medicare claims processing contractor. At this point, the submission receives a permanent receipt date that remains part of the claim record. Once a submission (or claim) passes edits for completeness and validity described in §70.2 above, it is accepted into the Medicare claims processing system.

The receipt date has two functions. It is used for determining whether the claim was timely filed . The same date is also used as the receipt date for purposes of determining claims processing timeliness on the part of the intermediary.

Determination of Untimely Filing and Resulting Actions


Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished (i.e., generally, the “From” date, with the exception of the “Through” date for institutional claims that have span dates of services, as specified in §70.1). When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal.

Where the beneficiary request for payment was filed timely (or would have been filed the request timely had the provider taken action to obtain a request from the patient whom the provider knew or had reason to believe might be a beneficiary) but the provider is responsible for not filing a timely claim, the provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. In appropriate cases, such claims should be processed because of the spell-of-illness implications and/or in order to record the days, visits, cash and blood deductibles. The beneficiary is charged utilization days, if applicable for the type of services received.

Determining Start Date of Timely Filing Period -- Date of Service

In general, the start date for determining the 12 month timely filing period is the date of service or “From” date on the claim. For institutional claims (Form CMS-1450, the UB-04 and now the 837 I or its paper equivalent) that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim is used for determining the date of service for claims filing timeliness.


Certain claims for services require the reporting of a line item date of service. For professional claims (Form CMS-1500 and 837-P) submitted by physicians and other suppliers that include span dates of service, the line item “From” date is used for determining the date of service for claims filing timeliness. (This includes DME supplies and rental items.) If a line item “From” date is not timely but the “To” date is timely, contractors must split the line item and deny the untimely services as not timely filed. Claims having a date of service on February 29 must be filed by February 28 of the following year to be considered timely filed. What constitutes a claim is defined below.


Time Limitations for Filing Part A and Part B Claims

Medicare regulations at 42 CFR 424.44 define the timely filing period for Medicare fee for service claims. In general, such claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished. (See section §70.7 below for details of the exceptions to the 12 month timely filing limit.)

Medicare Appeal time limit - Five level of appeal

When to file an appeal

Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.

Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.

The five levels of appeals, listed in order, are:

Appeal level Time limit for filing request Where to file an appeal


First level: Redetermination 120 days from the initial claim determination Medicare administrative contractor (MAC

Second level: Reconsideration 180 days from the redetermination decision Qualified independent contractor (QIC)

Third level: Administrative law judge hearing (ALJ) 60 days from the date of the reconsideration decision Office of Medicare Hearings and Appeals

Fourth level: Medicare Appeals Council 60 days from the date of the ALJ decision Departmental Appeals Board

Fifth level: Judicial review: 60 days from the date of the Medicare Federal District Court

Submit request by:

Monetary threshold for requests made on or after January 1, 2015: $1,460. For requests made on or after January 1, 2016, the threshold is $1,500.


Federal District Court

Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

Retroactive Medicare Entitlement - Medicare timely filing denial

The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:
(a) At the time the service was furnished the beneficiary was not entitled to Medicare.

(b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

Thus, a provider or supplier may have furnished services to an individual who was not entitled to Medicare. More than a year later, the individual receives notification from SSA that he or she is entitled to Medicare benefits retroactive to or before the date he or she received services from the provider or supplier. In this situation, the provider or supplier may submit a request for a filing extension to the appropriate Medicare claims processing contractor, as long as the provider or supplier submits supporting documentation that verifies that the conditions above are met.

If the beneficiary and the provider or supplier is notified on different days about the beneficiary’s retroactive Medicare entitlement, there will be two extensions of time triggers. One extension of time trigger is when the beneficiary is first notified about the beneficiary’s retroactive Medicare entitlement and the other extension of time trigger is when the provider or supplier is the first party notified of the beneficiary’s retroactive Medicare entitlement. If the beneficiary is submitting the claim, the time to file the claim is based on the day the beneficiary is first notified of the retroactive Medicare entitlement. If the provider or supplier is submitting the claim, the time to file the claim is based on the day the provider or supplier is first notified of the retroactive Medicare entitlement.
Where retroactive Medicare entitlement is alleged, the provider, supplier, or beneficiary will need to provide the contractor with the following information:

• an official Social Security Administration (SSA) letter notifying the beneficiary of Medicare entitlement and the effective date of the entitlement; and,

• documentation describing the service/s furnished to the beneficiary and the date of the furnished service/s.

If the provider, supplier, or beneficiary is unable to provide the contractor with an official SSA letter, the Medicare contractor shall check the Common Working File (CWF) database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s retroactive entitlement. For example, if the CWF indicates a Medicare entitlement date of March 1, 2008 and a date of accretion of December 14, 2010, then the contractor may interpret the CWF data to mean that the beneficiary was retroactively entitled to Medicare as of March 1, 2008 and that this data was added to the CWF database on December 14, 2010. If the contractor has any problems or concerns with respect to interpreting the CWF data, then the contractor should consult with the appropriate CMS regional office.

If the contractor determines that both of the conditions for meeting this exception described above are met, the time to file a claim will be extended through the last day of the 6th calendar month following the month in which either the beneficiary or the provider or supplier received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

Exceptions Allowing Extension of Time Limit

Medicare regulations at 42 C.F.R. §424.44(b) allow for the following exceptions to the 1 calendar year time limit for filing fee for service claims:

(1) Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority (See 70.7.1).

(2) Retroactive Medicare entitlement, 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 subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service (See 70.7.2).

(3) Retroactive Medicare entitlement involving State Medicaid Agencies, where a State Medicaid Agency recoups payment from a provider or supplier 6 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 retroactively 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 the timely filing limit has expired

Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, 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 it payment from a provider or supplier 6 months or more after the date the service was furnished

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.


Where the initial request for an exception to the timely filing limit is made by a provider or supplier, the Medicare contractor has responsibility for determining whether a late claim may be honored based on all pertinent documentation submitted by the provider or supplier, and for the exceptions described in sections 70.7.2 and 70.7.3, based on its review of the relevant information contained in the Common Working File (CWF) database. As explained in sections 70.7.1 – 70.7.4, the contractor will determine if the requirements for a particular exception are met. However, in certain circumstances, the contractor may contact the appropriate CMS regional office (RO) to ascertain whether it wants to participate in the review and decision-making of the specific exception request. In limited circumstances, the RO may conclude that the exception request should go to CMS Central Office for a final determination.

What we can do further if we receive timely filing denial

Filing Claim Where General Time Limit Has Expired


As a general rule, where the contractor receives a late filed claim submitted by a provider or supplier with no explanation attached as to the circumstances surrounding the late filing, the contractor should assume that the provider or supplier accepts responsibility for the late filing.

Where it comes to the attention of a provider or supplier that health services that are or may be covered were furnished to a beneficiary but that the general time limit (defined in §70.1 above) on filing a claim for such services has expired, the provider or supplier should take the following action.

• Where the provider or supplier accepts responsibility for late filing, it should file a no-payment claim. (See Chapter 3 for no-payment bill processing instructions.) Where the provider or supplier believes the beneficiary is responsible for late filing, it should contact the contractor and also file a no-payment claim and include a statement in the remarks field on the claim explaining the circumstances which led to the late filing and giving the reasons for believing that the beneficiary (or other person acting for him/her) is responsible for the late filing. If a paper claim is submitted, such a statement may be attached and, if practicable, may include the statement of the beneficiary as to the beneficiary’s view on these circumstances.

• Where the beneficiary does not agree with the determination that the claim was not filed timely or the determination that he/she is responsible for the late filing, the usual appeal rights are available to the beneficiary. Where the provider or supplier is protesting the denial of payment or the assignment of responsibility, no formal channels of appeal are available. However, the contractor may, at the request of the provider or supplier, informally review its initial determination.

Can we bill patient when Medicare claim denied as timely filing?

Medicare document says yes but only limited to Deductible and coins.


Determination of Untimely Filing and Resulting Actions


Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished (i.e., generally, the “From” date, with the exception of the “Through” date for institutional claims that have span dates of services, as specified in §70.1). When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal.


Where the beneficiary request for payment was filed timely (or would have been filed the request timely had the provider taken action to obtain a request from the patient whom the provider knew or had reason to believe might be a beneficiary) but the provider is responsible for not filing a timely claim, the provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. In appropriate cases, such claims should be processed because of the spell-of-illness implications and/or in order to record the days, visits, cash and blood deductibles. The beneficiary is charged utilization days, if applicable for the type of services received.

What is the time limit when DOS has different from and TO date

Determining Start Date of Timely Filing Period -- Date of Service

In general, the start date for determining the 12 month timely filing period is the date of service or “From” date on the claim. For institutional claims (Form CMS-1450, the UB-04 and now the 837 I or its paper equivalent) that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim is used for determining the date of service for claims filing timeliness. Certain claims for services require the reporting of a line item date of service. For professional claims (Form CMS-1500 and 837-P) submitted by physicians and other suppliers that include span dates of service, the line item “From” date is used for determining the date of service for claims filing timeliness. (This includes DME supplies and rental items.) If a line item “From” date is not timely but the “To” date is timely, contractors must split the line item and deny the untimely services as not timely filed. Claims having a date of service on February 29 must be filed by February 28 of the following year to be considered timely filed. What constitutes a claim is defined below.


Time Limitations for Filing Part A and Part B Claims

Medicare regulations at 42 CFR 424.44 define the timely filing period for Medicare fee for service claims. In general, such claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished. (See section §70.7 below for details of the exceptions to the 12 month timely filing limit.)

Appropriate Medicare Contractor

Submissions for services must be filed with the appropriate Medicare contractor. It is the provider’s or supplier’s responsibility to submit each claim to the appropriate contractor. Medicare contractors may attempt to re-route claims appropriately if they have enough information to do so. In the case of re-routed claims, services submitted for payment are not considered claims under Medicare regulations until received by the appropriate Medicare contractor.

Can we submit the claim if patient has provided the backdated card , what is the time limit for secondary claims

Backdated Medicaid Cards 

If a member receives a backdated medical card and the provider wishes to accept it and bill Medicaid for services that occurred over a year ago, the claims must be billed within one year of the issuance of the card.  Claims must be billed on paper with a copy of the medical card or letter of eligibility and mailed to Provider Relations address at PO Box 2002, Charleston, WV 25327-2002.  

Example:  Services rendered by a physician on 3/1/2012; on 6/1/2012, member‟s Medicaid eligibility is granted effective 3/1/2012.  All services previously rendered after 3/1/2012 can be billed to Medicaid, and considered for reimbursement if claims are received by 6/1/2013.


MCO‟s and Timely Filing 

Molina does not reimburse for any services the provider does not bill timely to the MCO. If the MCO denial is due to the member not being covered under the MCO and the provider determines that the member was covered with WV Medicaid at the time services were rendered, Molina may be responsible.  In this case, Molina will accept MCO Medicaid remits as proof of timely filing as long as the date of the denial is not over a year from the date of service. Please Note: The MCO must be one of the MCO‟s that are contracted with WV Medicaid and not an MCO that has a private insurance policy for the member.

To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service. The year is counted from the date of receipt to the “from date” on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit. (See exceptions below for Medicare primary claims and backdated medical card.)

The original claim must have had the following valid information:
•   Valid provider number
•   Valid member number
•   Valid date of service
•   Valid type of bill

Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement.

This policy is applicable to reversal/replacement claims.  If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV 25327-2002. You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing.

Medicare Primary Claims/Secondary Claims 

Timely filing requirement for Medicare primary claims is one year from the EOMB date. Did you know that secondary claims can be submitted electronically? For more information, please call our EDI help desk at 888-483-0793, option 6.

claims not submitted within the time limit - exceptional scenrio

Exceptions to the 12-Month Time Limit

Exceptions to the 12-month claim submission time limit may be allowed if the claim meets one or more of the following conditions:

·  New clean claim submitted within six months of the date of the void of the original claim payment date;
·  Court or hearing decision;
·  Delay in recipient eligibility determination;
·  Medicaid delay in updating eligibility file;
·  Court ordered or statutory action; or
·  System error on a claim that was originally filed within 12 months from the date of service.

Any claim filed more than 12 months from the date of service that meets an exception must be sent to the area Medicaid office for processing, not to the fiscal agent. Each of these exceptions is discussed below.

Original Payment is Voided

When an original Medicaid claim is voided, the provider may submit a new claim and a written request for assistance to the area Medicaid office no later than six  months from the void date.

Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court decision, there is no time limit for the submission of a claim.

Delay in Recipient Eligibility Determination

An exception may be granted when there is a delay in the determination of an individual’s Medicaid eligibility by the Department of Children and Families or the Social Security Administration. The provider must send in specific documentation to the area Medicaid office no later than 12 months from the date the recipient’s eligibility is updated on FMMIS. The claim submission must
include:
·  A clean claim,
·  A copy of the recipient’s proof of eligibility, and
·  Documentation of the reason for late submission.

Medicaid Delay in Updating Eligibility File

If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid Management Information System (FMMIS), an exception may be granted. The provider must submit the related clean claims to the area Medicaid office no later than 12 months from the date the recipient’s eligibility file was updated.

Court Ordered or Statutory Action

If the Medicaid office takes corrective action due to a court order or due to final agency action taken under Chapter 120, Florida Statutes, there is no time limit for claim submission.

System Error

If a clean claim is denied due to a system error or any error that is the fault of Medicaid or the fiscal agent, an exception may be granted if the provider submits another clean claim along with documentation of the denial to the area Medicaid office no later than 12 months from the date of the original denial.

Evaluate the Claim

The provider must evaluate any claim that is denied and determine if the claim fits any of the conditions for an exception to the 12-month filing limit.

Medicaid - clean claim, time limit for secondary claim and claim received date

Timely Claim Submission

Medicaid providers should submit claims immediately after providing services so that any problems with a claim can be corrected and the claim resubmitted before the filing deadline.

A clean claim for services rendered must be received by the Medicaid office or its fiscal agent no later than 12 months from the date of service

Clean Claim 

In order for a claim to be paid, it must be a clean claim. A clean claim is a Medicaid claim that:

·  Has been accurately and fully completed according to Medicaid billing guidelines.

·  Is accompanied by all necessary documentation.

·  Can be processed and adjudicated by the fiscal agent without obtaining additional information from the provider.


Date Received Determined

The date stamped on the claim by any Medicaid office or by the Medicaid fiscal agent is the recorded date of receipt for a paper claim. The fiscal agent date stamps the claim the date that it is received in the fiscal agent’s mailroom.

The date electronically coded on the provider’s electronic transmission by the Medicaid fiscal agent is the recorded date of receipt for an electronic claim.

Third Party Payer and Medicare Insurance Claims

Claims for recipients who have Medicare or other insurance must be submitted to a third party payer prior to sending the claim to Medicaid.

For non-Medicare claims, the claim must be received by Medicaid or the Medicaid fiscal agent no later than 12 months from the date of service or six months from the date of the other insurance payment or denial.

The filing limit for Medicare claims crossing over to Medicaid is the greater of 36 months from the date of discharge or 12 months from Medicare’s adjudication date.

Timely Filing Requirements for Medicare Fee-For-Service Claims

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service (FFS) claims as one of many provisions aimed at curbing fraud, waste, and abuse in the Medicare program.
 
The time period for filing Medicare FFS claims is specified in Sections 1814(a), 1835(a)(1), and 1842(b)(3) of the Social Security Act and in the Code of Federal Regulations (CFR), 42 CFR Section 424.44.  Section 6404 of the PPACA amended the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to one calendar year after the date of service. 
Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service.  In addition, Section 6404 mandates that claims for services furnished before January 1, 2010, must be filed no later than December 31, 2010.  The following rules apply to claims with dates of service prior to January 1, 2010.  Claims with dates of service before October 1, 2009, must follow the pre-PPACA timely filing rules.  Claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010. 

Section 6404 of the PPACA also permits the Secretary to make certain exceptions to the one-year filing deadline.  At this time, no exceptions have been established.  However, proposals for exceptions will be specified in future proposed rulemaking.