Practice Management Alert

Question: In our office, we are normally very careful to submit our Medicare claims within the required one-year time period. Recently, however, we have been short-staffed, which has caused a few delays. Are there any exceptions to the timely filing requirements?

RCI Subscriber

Answer: Yes, there are a few exceptions to Medicare’s timely filing period.

According to Medicaid.gov, the Centers for Medicare & Medicaid Services (CMS) offers four exceptions in which you can request an extension on the time limit for your claims:

1. Administrative error, which may occur if the deadline was not met due to an error or misrepresentation of an employee, Medicare contractor, or agent of the department that was performing Medicare functions and acting within the scope of its authority.
2. Retroactive Medicare entitlement, which means a beneficiary is retroactively notified of their Medicare entitlement after the service was provided and beyond the timely filing period.
3. Retroactive Medicare entitlement involving state Medicaid agencies, which occurs whena a state Medicaid agency retrieves payment from a provider or supplier six months post-service to a beneficiary who later receives retroactive Medicare entitlement, preventing the provider from claiming from Medicare due to expired filing limit.
4. Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization: A beneficiary initially enrolled in an MA plan or PACE provider organization is retroactively disenrolled, leading to the organization recouping its payment from the provider or supplier six months post-service.

Make note: Not every insurance company adheres to the 12-month timely filing limit. Some private insurance companies may only provide a 60-day window after the date of service (DOS) for claim submission, while others may allow more than a year. Always stay up to date with the submission deadlines for each insurance company you bill. A practical method to manage multiple timely filing rules is to create a spreadsheet detailing each insurer’s submission deadline. If there’s a pile-up of claims in your office, sort them by individual payer. This way, you can refer to your chart to swiftly pinpoint the insurer with the shortest deadline and prioritize those claims.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC