Timely Filing of Claims - Important Notice About Claim Denials
Recently, WPS Medicare began seeing a dramatic increase in the number of providers experiencing claim denials when the provider submits claims past the timely filing limit for submitting claims. Although WPS Medicare recognizes that many providers must submit claims after Medicare's timely filing limit due to circumstances beyond their control, WPS Medicare must deny any claim submitted after the time limit for filing the claim expires.
To be eligible for Medicare reimbursement, providers and suppliers must file claims within a qualifying time limit. Providers must file claims with Medicare by the end of the calendar year following the Fiscal Year, which runs from October 1 to September 30, in which the provider performs the service or Medicare denies the claim. To summarize, providers have at least 15 months from the date of service to file claims.
Patient Responsibility
The provider cannot collect the actual charge for the service from the patient when Medicare denies an assigned claim for late filing. When the provider accepts assignment but fails to submit a valid claim within the filing limit, the provider may only charge the patient 20 percent of Medicare's approved amount.
Claims Subject to the 10 Percent Payment Reduction
Providers may submit claims for up to 12 months after the date of service without penalty. Claims submitted more than 12 months beyond the date of service are subject to a 10 percent reduction in the Medicare payment. The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM), Publication 100-04, Chapter 1, section 70.8.6, states if an assigned service is filed after the time limits specified in this section, Medicare may waive the 10 percent payment reduction in the case of an administrative error only.
Claims Denied Past the Timely Filing Limit Cannot be Appealed
The CMS requires Medicare contractors to deny claims submitted after the end of the calendar year following the fiscal year in which the services were provided. In addition, the CMS IOM Publication 100-04, Chapter 1, section 70.4 states, "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."
How to File a Waiver to Extend the Timely Filing Limit
In rare cases, CMS permits Medicare contractors to extend the time limit for filing a claim beyond the usual deadline if the provider can show good cause for the delay in filing the claim. The CMS indicates that Medicare contractors could determine good cause exists when the delay is caused by an administrative error on the part of an official Medicare employee acting on behalf of the Medicare contractor within the scope of his or her authority. Circumstances such as backdated Medicare entitlement (which is often prompted by a Medicaid buy-in) may also qualify for an extension of the timely filing deadline. In such situations, providers must file the claim promptly after the error is corrected.
Providers who believe they have good cause for their delay in filing a timely claim must send a request to the WPS Medicare Claims Manager to extend the timely filing limit along with their claim for payment. It is important that the request for a waiver of timely filing and documentation supporting the request accompany the initial claim. Since claims denied for timely filing do not have appeal rights, the WPS Medicare Redeterminations unit cannot grant any waiver to the timely filing deadline after the claim is processed. Therefore, do not send it to WPS Medicare using the Redetermination form.
For more information about the requirements for extending the time limitation for filing a Medicare Part B claim, please see the CMS IOM, Publication 100-04, Chapter 1, Sections 70.7.1 and 70.8.9 through 70.8.14 
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Page Last Updated: Thursday, 18-Mar-2010 05:56:29 CDT
