What is the timeframe for submitting a claim adjustment?

Answer:
Part A providers may adjust claims, for the purpose of correcting clerical errors, within one year from the initial determination or within four years when good cause is supported.

While a contractor may choose to reopen a claim at any time under limited criteria, the Centers for Medicare & Medicaid Services (CMS) does not expect that a contractor would regularly grant reopening requests for older claims because its history may not be readily available. Both contractor and provider have a reasonable expectation to be timely in the administrative finality of their claims.

Third party payer error in making primary payment does not constitute good cause for the purpose of reopening a claim beyond one year of the initial determination or redetermination.  A contractor’s decision to reopen or not to reopen a claim, regardless of the reason for that decision, is not subject to appeal.

Adjustments to add services
If a provider fails to include a particular item or service on its initial bill, an adjustment request to include such item(s) or service(s) is not permitted after the expiration of the time limitation for filing a claim.

Hospital diagnosis related group (DRG) claim adjustments
Hospital adjustments to correct the diagnostic and procedure coding on their claim to a higher weighted DRG must be submitted within 60 days of the paid remittance.

Claim adjustments that result in a lower weighted DRG are not subject to the 60 days requirement.

Skilled nursing facility (SNF) health insurance prospective payment system (HIPPS) code adjustments
SNF adjustments to change a HIPPS code due to a minimum data set (MDS) correction must be completed within 120 days of the through date on the claim.

Provider requests for Medicare to grant a timely filing extension because a claim was canceled and/or revised and refiled after the one-year timely filing period due to the provider error; cannot be granted.

Time Limitations on Filing Adjustments

Reason For Adjustment
Time Limitation
(from Date of Service)
Adding additional items and services
1 Year
Incorrect bill type
1 Year
Third party error
1 Year
Correcting or supplementing information already billed
4 Years
Removing items and charges
4 Years
Adjustment for Inpatient PPS claims that result in a higher weighted Diagnostic Related Group (DRG)
60 days  - from Remittance Advice (RA) date on original claim
Adjustment to change Skilled Nursing Facility (SNF) Health Insurance Prospective Payment System (HIPPS) code
120 days - from “Through” date on claim

Please refer to CMS Internet-Only Manuals (IOM), Publication 100-04, Chapter 1 (PDF, 4.24 MB) Section 70.5 and Section 130; Chapter 34 (PDF, 97 KB), Sections 10.4 and 10.6.2.

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