Written Statement of Intent to Claim Medicare Benefits
Purpose of a Statement of Intent
The purpose of a SOI is to extend the timely filing period for the submission of an initial claim. A SOI, by itself, does not constitute a claim, but rather is used as a placeholder for filing a timely and proper claim. Medicare regulations at 42 CFR §§424.32 and at 424.44 require that Medicare claims be filed on Medicare designated claim forms pursuant to Medicare instructions by the end of the year following the year in which the service/s are furnished (services furnished in the last 3 months of a calendar year are deemed to be furnished in the subsequent year). The timely filing period to file a specific Medicare claim may be extended when a valid SOI, with respect to that claim, is furnished to the appropriate Medicare carrier or intermediary (i.e., the one that will be responsible for processing the claim), or regional office (RO) serving the area of the beneficiary's residence within the timely filing period.A SOI to claim Medicare benefits must be postmarked on or before, or received by the appropriate RO or contractor, no later than the last day of the timely filing period that pertains to the service/s covered by the SOI. (See §3305.3 of the MIM .) If someone wishes to simultaneously submit more than one SOI to a RO, then he or she must sort them by Medicare contractor before submitting them. If a SOI contains the necessary information for some services, but not for others, then the SOI will be accepted only for those services for which the necessary information has been submitted.
After a valid SOI has been filed, a completed claim that meets the requirements of 42 CFR §424.32(a), §§3005-3005.4 of the MCM, and §§3605.2-3605.3 of the MIM, must be submitted to the appropriate Medicare contractor within 6 months after the month in which the contractor notifies the party who submitted the SOI that a claim may be filed, or by the end of the applicable timely filing period, whichever is later. (The month in which the contractor notifies the party is determined by the date of the contractor's notification letter, unless the recipient of the notice can establish by a preponderance of the evidence that the notice was sent on a materially different date. Also, "party" and "parties" are used herein in their generic sense, and are not meant to imply that an individual or entity that submits a SOI to file has standing to file a claim or pursue an appeal of a denied claim.) In order to ensure that a filed claim, which purportedly has been protected by a previously submitted SOI (and, which would be untimely if not so protected), does in fact relate back to the SOI, a SOI must be for an "identified beneficiary" and for "specified services." (See 42 CFR §424 .45(b).)
NOTE: The filing of an invalid SOI does not extend the timely filing period, so that if a party submits an invalid SOI prior to the end of the timely filing period, and the contractor or the RO does not discover the invalidity and alert the submitter of the invalidity until shortly before, or even after the timely filing period has expired, the party may not correct or resubmit the SOI after the timely filing period has expired. In this regard, a party that submits an invalid SOI bears the full risk that he or she may be unable to resubmit a valid SOI within the applicable timely filing period.
Medicare contractors are not required to develop a claim under the SOI procedures. All claims for services must meet Medicare's timely filing requirements. (See 42 CFR §424.44.) Timely filing requirements are further discussed in §3004 of the MCM and in §§3307 - 3312.5 of the MIM.
Who Can Submit Statements of Intent
Only the following parties may submit a SOI to claim Medicare benefits:- Providers, as defined in 42 CFR §400.202, and parties to whom they may assign their payment per 42 CFR §424.73, for items or services they have furnished or are entitled to bill Medicare.
- Suppliers, as defined in 42 CFR §400.202, and parties to whom they can reassign payment per 42 CFR §424.80, for items or services they have furnished or are entitled to bill Medicare.
- Medicaid State agencies and parties authorized to act on behalf of Medicaid State agencies, with respect to items and services rendered to dually eligible beneficiaries.
- Beneficiaries and their authorized representatives, but only where the SOI relates to (1) a claim for services furnished by a nonparticipating hospital that has elected not to claim payment for emergency services, or (2) a claim for services for which a physician or other supplier, or proper resignee, was required to file a claim under §1848(g)(4) of the Act but has not done so.
Contents of a Valid Statement of Intent
A SOI must be signed, and the person signing must indicate the capacity in which he or she is signing (e.g., beneficiary or beneficiary's authorized representative, provider, supplier, Medicaid State agency official, or party authorized to act on behalf of the Medicaid State agency).For a SOI to be considered valid, it must be submitted to the appropriate contractor, and if a provider or supplier (or the party to whom payment can be assigned), or Medicaid State agency (or a party authorized to act on its behalf) submits a SOI, then the following information must be submitted with the SOI:
- Beneficiary name;
- Medicare Health Insurance Claim (HIC) number;
- Name, address, and Medicare billing number of provider/physician/supplier at time of service;
- Dates of service for which a specific claim will be filed (dates must be reported in a manner that comports with Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form); and,
- Applicable revenue, DRG, CPT, HCPCS or other applicable code, and appropriate modifiers for each service. (Codes must be reported in a manner consistent with the reporting of the codes on the Medicare claim form. Diagnosis codes by themselves are not acceptable.)
In order for a SOI that is submitted to a RO to be valid, the SOI must include all of the above information and must also include the correct name and address of the Medicare contractor that will be responsible for processing the subsequent claim or claims.
If a beneficiary or authorized representative submits a SOI, it must be submitted to the appropriate contractor and must include all of the information listed below.
- Beneficiary name;
- Medicare Health Insurance Claim (HIC) number;
- Name, address, and if available, the Medicare billing number of the provider / physician / supplier at time of service;
- Date(s) of service for which a specific claim will be filed (dates must be reported in a manner that comports with Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim); and,
- Item(s) or service(s) received.
In order for a SOI that is submitted to a RO by a beneficiary or a beneficiary's authorized representative to be valid, it must include the information listed above and must also include the name and address of the Medicare contractor that will be responsible for processing the subsequent claim or claims.
Service and Filing Dates
| Service Dates | Late File By |
| 10/01/01-09/30/02 | 12/31/03 |
| 10/01/02-09/30/03 | 12/31/04 |
| 10/01/03-09/30/04 | 12/31/05 |
Submitters may obtain the name and address of the appropriate Medicare contractor (i.e., Medicare carrier or fiscal intermediary) at the following web site: http://www.cms.hhs.gov/apps/contacts/incardir.asp?.
Page Last Updated: Tuesday, 04-Dec-2007 13:19:18 CST
