What are the timely filing requirements?
The timely filing period for both paper and electronic Medicare claims is no later than one calendar year after the date of service.

Section 6404 of the Affordable Care Act (ACA) amended the timely filing requirements to reduce the maximum time period for submission of all Medicare fee-for-service claims to one calendar year after the date of service. These amendments apply to services furnished on or after January 1, 2010. Additionally, this section mandates that all claims for services furnished prior to January 1, 2010, must be filed with the appropriate Medicare claims processing contractor no later than December 31, 2010.

Subsequent to Section 6404 of the ACA, the following Centers for Medicare & Medicaid Services (CMS) Change Requests (CRs) were issued:

  • CR 6960 – "Systems Changes Necessary to Implement the Patient Protection and Affordable Care Act (PPACA) Section 6404 Maximum Period for Submission of Medicare Claims Reduced to Not More Than 12 Months"
  • CR 7080 – "Timely Claims Filing: Additional Instructions"
  • CR 7270 – "Changes to the Time Limits for Filing Medicare Fee-for-Service Claims"

As such, claims for dates of service on or after January 1, 2010, must be submitted to Medicare within one calendar year from the date of service. For institutional claims that include span dates of service (i.e., a "From" and "Through" date span on the claim), the "Through" date, rather than the "From" date, will be used as the date of service for determining claims filing timeliness. Claims with a date of service on February 29 of any calendar year received on or after March 1 of the following calendar year will be denied as being past the timely filing deadline.

In accordance with Medicare guidelines, Medicare systems will reject/deny claims that are not received within the specified time requirements. 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. Therefore, providers should not submit a request for a redetermination to the Appeals department.

What happens if the claim is returned to provider (RTP)?
When a claim is returned for correction, the resubmission of the claim must be done within the specified time requirement. If the resubmission is not filed within the specified time requirement, the claim will be rejected/denied.

What happens if the claim was suspended?
Where a contractor has suspended a claim and allowed a period for submission of corrections, the timely filing requirements will have been met if the corrections are received within the allotted time.

Does an adjusted claim have to be submitted within the timely filing requirements?
If a provider fails to include a particular item or service on its initial claim, an adjustment submission to include such an item(s) or service(s) is not permitted after the expiration of the time limitation for filing of the initial claim.

What exceptions are made to extend the time limit?
Exceptions to the one calendar year time limit for filing Medicare claims are as follows:

  1. Error or misrepresentation by an employee, Medicare contractor, or agent of the Department of Health and Human Services who was performing Medicare functions and acting within the scope of its authority
  2. Retroactive Medicare entitlement to or before the date of the furnished service
  3. Retroactive Medicare entitlement where a state Medicaid agency recoups money from a provider or supplier six months or more after the service was furnished
  4. A Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recoups money from a provider or supplier six months or more after the service was furnished to a beneficiary who was retroactively disenrolled to or before the date of the furnished service

The Provider Outreach and Education department created the Checklist for Timely Filing Extension. Providers are encouraged to use this checklist to determine when they can request an extension on the time limit for claims.

References:
CMS Change Request 6960, Transmittal 697 (PDF, 73 KB) 
CMS Change Request 7080, Transmittal 734 (PDF, 49 KB)
CMS Change Request 7270, Transmittal 2140 (PDF, 439 KB)
Code of Federal Regulations, 42 CFR 424.44 (PDF, 145 KB)

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