With nearly 84% of physicians accepting Medicare patients, Medicare timely filing denials can affect almost any provider.
And with the Affordable Care Act (ACA) reducing the claims submittal period from between 15 and 27 months down to 12 months it’s become even tougher to meet the timely filing deadline.
So when submitting Medicare claims, it’s important to know the ins and outs of the timely filing rule, and what options you have when receiving this particular denial.
Determine the Claim Start/End Date
The start date for a particular Medicare claim is considered to be the date the service is provided to the patient or the “From” date recorded on the claim form. The end date for Medicare timely filing is exactly one full calendar year after the start date.
Claims must be received and time-stamped by the appropriate Medicare claims processing contractor before the end date. If a claim is sent prior to the end date but is received after, it will still be denied. Therefore, it’s best not to procrastinate.
Review Exceptions
Medicare timely filing claim denials can only be contested based on the following four exceptions:
Administrative Error
A claim can be appealed if the deadline was missed due to an error committed by an employee, Medicare contractor or another agent performing Medicare functions.
If successfully disputed, the end date will be extended to the last day of the sixth month after notice of an error correction was received.
Retroactive Medicare Entitlement
This applies if a patient receives notice of Medicare entitlement retroactive to the date service was provided. For example, a patient wasn’t covered at the time of treatment and the end date passes, but then the patient receives notice of Medicare entitlement with an effective date prior to the date treatment was rendered.
In this case, the Medicare timely filing deadline will be extended to the last day of the sixth month after the notice of entitlement was received.
Retroactive Medicare Entitlement Involving State Medicaid Agencies
In this situation, a State Medicare Agency recovers payment for a dually eligible beneficiary (Medicare and Medicaid) six months or more after the start date the claim.
This could happen if a patient was only entitled to Medicaid at the time of treatment, but receives notification of Medicare coverage effective retroactive to the date of treatment resulting in the recovery of the Medicaid payment. The timely filing deadline would then be extended to the last day of the sixth month after payment was recouped from the provider.
Retroactive Disenrollment from a MA Plan or PACE Provider Organization
It’s similar to the State Medicaid Agencies exception but involves Medicare Advantage plans and Program of All-Inclusive Care of the Elderly organizations. For instance, a patient receives treatment while eligible for one of the said programs, but later receives the notification of disenrollment retroactive to the date of the provided service, resulting in a payment recoup.
The Medicare timely filing deadline is then extended to the last day of the sixth month from the day payment is recalled.
File an Appeal
Medicare timely filing denials are not subject to a formal appeal. If your claim qualifies for one of the above exceptions, it can be opened for review by sending a request letter along with supporting documentation to the following address:
J15 — HHH CLAIMS
CGS Administrators, LLC
PO Box 20019
Nashville, TN 37202
As you can see, Medicare timely filing denials are not always final, but disputing a claim denial can prove difficult with so few possible exceptions. The best way to avoid them is by processing claims as quickly as possible.
If you’re practice is having trouble in this regard, it may be time to look into a practice management system that facilitates claims filing.
