Asking for a Claim Reopening for a Medicare Denied Claim Not Filed Within the Time Limits
Providers often ask Medicare contractors to reopen claims denied for timely filing when the delay was caused by another insurer recouping their previous payment. The Centers for Medicare & Medicaid Services (CMS) does not accept errors caused by incorrect third party payment as justification for not submitting timely claims to Medicare. The CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 34, Section 10.11 
, states the following:
"Third party payer error in making a primary payment determination does not constitute good cause for the purposes of reopening an initial determination or redetermination when Medicare processed the claim in accordance with the information in its system of records or on the claim form. Contractors may only reopen for third party payer error under the 'within one year for any reason' standard. This is true for both contractor-initiated reopenings as well as reopenings requested by a party. All providers and suppliers have a legal obligation to determine the correct primary payer when billing Medicare. Failure to do so, regardless of third party payer error, does not constitute 'good cause' that will permit reopening beyond one year. Information regarding such error does not constitute 'new and material evidence'."
Page Last Updated: Thursday, 18-Mar-2010 05:56:29 CDT
