Thursday, April 16, 2015

Timely Filing Requirements and exception cases


This article is intended for physicians and non-physician practitioners who submit claims for payment to the Medicare Part B Program.

Key Points/Instruction/What You Need To Know


•    In general, Medicare fee-for-service claims must be filed to the Medicare claims processing contractor no later than 12 months, or 1 calendar year, from the date the services were furnished. For example, if a patient was seen on 07/19/2013, a claim must be filed by 07/19/2014.

•    To determine the 12 month timely filing period, we use the “From” date on the claim.

•    Professional claims submitted by physicians and other suppliers that include span dates of service, the line item “From” date will be used to determine the date of service and filing timeliness.

o    Note: If a line item “From” date is not timely, but the “To” date is timely, we will split the line item and deny untimely services as not timely filed.

•    Claims having a date of service of February 29th must be filed by February 28th of the following year to be considered as timely filed. If the date of service is February 29th of any year and is received on or after March 1st of the following year, the claim will be denied as untimely.

•    Claims received after 12 months from the date of service will be denied with reason code 438 (non-assigned and assigned claims) time limit for filing has expired. The beneficiary is liable for the entire billed amount up to the limiting charge for non- assigned claims.

•    The exception is outpatient psychiatric claims. If the billed amount is over $300.00 take the psychiatric reduction prior to the 20% coinsurance based on the allowed amount. The beneficiary is responsible for the difference between the allowed amount and the psychiatric plus the 20% assuming the deductible had been met. For amounts under $300, take the psychiatric reduction of the billed amount prior to the 20% for the coinsurance.  The psychiatric reduction is 75% for 2012 dates, 81.25% for 2013 dates and no reduction after 2013.

•    If there is no documentation attached to the claim indicating why the claim is late, we will assume you accept responsibility for the late claim. In this instance, you may only charge the beneficiary for deductible or coinsurance amounts that would have been applied if Medicare payment had been made.

•    We realize there are times when you do not get the correct insurance information from the patient. Best practice is to obtain ALL medical insurance cards from the Medicare beneficiary. You may believe that not knowing a patient had Medicare or not knowing that Medicare should have been primary is grounds to waive timely filing. Well, it’s not. You must ask the patient if they are entitled to Medicare and if Medicare is primary or secondary. This is true for all Medicare claims both facility and physicians claims.

•    If the beneficiary says that Medicare is secondary, submit the claim to the primary insurer first. Then, once you receive the primary insurer remittance, submit the claim to Medicare as secondary, even if you do not expect Medicare to make a payment. Doing this will alleviate any issues if, at a later date, the primary insurer notifies you that an error was made. Filing a claim after you find out that Medicare is primary is not a valid reason to waive timely filing. However, if you initially submit a claim to Medicare as secondary and the primary insurer notifies you of an error and recoups their payment, you can adjust the Medicare secondary payer claim.

o    Note: There are no appeal rights for untimely claim denials unless it falls under one of the following exceptions.

Exceptions to Timely Filing
The CMS allows four exceptions to timely filing. Let’s discuss each of the four exceptions.

•    The first exception is Administrative Error. This occurs when an error or misrepresentation is provided by an employee, the Medicare contractor, or agent of the Department. In these cases, timely filing will be extended six months following the month in which you or the beneficiary received notice that an error or misrepresentation was corrected.

o    An error or misrepresentation may be advice that certain services were not covered under Part A or Part B, when, in fact, they were covered; excessive delay by Medicare providing information necessary for filing a claim; advice by an employee, Medicare contractor, or agent of the Department that delayed the filing of a claim until you received certain information from the contractor; any claim where it appears that an extension of the time limit might be justified based on administrative error.

o    If you believe an administrative error lead to the untimely filing of a claim, please provide a statement from the beneficiary, their representative or yourself as to how the error was known, when it was corrected, and a written report by Medicare or the Medicare contractor describing how its error caused failure to file within the time limit; or copies of a CMS or Medicare contractor letter or other written notice reflecting the error. There must be a clear and direct relationship between the administrative error and the late filing of the claim.

•    The second exception is Retroactive Medicare entitlement. This occurs when services are rendered to an individual not entitled to Medicare and later the individual is notified by the Social Security Administration that he or she is entitled to Medicare benefits retroactive to a date on or before your date of service. In this situation, you may request a filing extension as long as you submit supporting documentation that verifies retroactive Medicare entitlement. The supporting documentation should include the letter from the Social Security Administration notifying the beneficiary of Medicare entitlement and the effective date of the entitlement, a description of the service or services rendered and the date of the service.

o    When this exception is met, timely filing will be extended six months following the month in which you or the beneficiary received notification of retroactive Medicare entitlement.

•    The third exception is Retroactive Medicare Entitlement Involving State Medicaid Agencies. This occurs when, at the time services were rendered, the beneficiary was entitled to Medicaid, not Medicare and later is notified that he or she is entitled to Medicare. If the State Medicaid Agency recoups the money it paid you six months or more after the date of service, you may be given an extension to file claims to Medicare.

o    To qualify for this exception, you must provide documentation verifying the date the State Medicaid Agency recouped money from you; that the beneficiary was retroactively entitled to Medicare on or before the date of service; and the service or services rendered and the date of the service.

o    When this exception is met, timely filing will be extended six months from the month in which the State Medicaid Agency recouped its money.

•    The fourth exception is Retroactive Disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization. This occurs when a beneficiary is enrolled in a MA plan or PACE provider organization, later becomes disenrolled and the MA plan or PACE recoups their payment. If the MA plan or PACE recoups their money six months or more after the date of service, you may be granted an exception to file claims to Medicare.

o    To qualify for this exception, you must provide documentation that verifies prior enrollment in an MA plan or PACE; you were notified that the beneficiary is no longer enrolled in the MA plan or PACE; the effective date of the disenrollment; and the MA plan or PACE recouped money from you for services rendered to the beneficiary.

o    When this exception is met, timely filing will be extended six months from the month in which the MA plan or PACE recouped its money.

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