The newly enacted Patient Protection and Affordable Care Act amends the timely fling requirements on Medicare Fee for Service claims to one calendar year after the date of service.
The one-year filing deadline applies to any claims for services provided on or after January 1, 2010. Prior to PPACA, the regulations stated the service provider or supplier must submit claims for services furnished during the first nine months of the calendar year on or before December 31st of the following calendar year. For services rendered during the last quarter of the calendar year, the provider or supplier must submit the claim on or before December 31st of the second following year. Medicare contractors are adjusting (as necessary) their relevant system edits to ensure that:
- Claims with dates of service prior to October 1, 2009 will be subject to pre-PPACA timely filing rules and associated edits;
- Claims with dates of service October 1, 2009 through December 31, 2009 received after December 31, 2010 will be denied as being past the timely filing deadline and;
- Claims with dates of service January 1, 2010 and later received more than 1 calendar year beyond the date of service will be denied as being past the timely filing deadline.
Section 6404 of the Patient Protection and Affordable Care Act amends the filing requirement and permits CMS to make certain exceptions to the one-year filing deadline. No exceptions have been developed since the PPACA enactment. However, one exception found in the timely filing regulations at 42 CFR section 424.44(b)(1) covers 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.
Additional instructions regarding timely filing exceptions may be available from a provider’s claim intermediary, carrier or other specified claim processing agent. For example, WPS Insurance’s Medicare site gives specific instructions on how to file a waiver to extend the timely filing limit. The instructions state the following:
In rare cases, CMS permits Medicare contractors to extend the time limit for filing a claim beyond the usual deadline if the provider can show good cause for the delay in filing the claim. The CMS indicates that Medicare contractors could determine good cause exists when the delay is caused by an administrative error on the part of an official Medicare employee acting on behalf of the Medicare contractor within the scope of his or her authority. Circumstances such as backdated Medicare entitlement (which is often prompted by a Medicaid buy-in) may also qualify for an extension of the timely filing deadline. In such situations, providers must file the claim promptly after the error is corrected.
Providers who believe they have good cause for their delay in filing a timely claim must send a request to the WPS Medicare Claims Manager to extend the timely filing limit along with their claim for payment. It is important that the request for a waiver of timely filing and documentation supporting the request accompany the initial claim. Since claims denied for timely filing do not have appeal rights, the WPS Medicare Redeterminations unit cannot grant any waiver to the timely filing deadline after the claim is processed. Therefore, do not send it to WPS Medicare using the Redetermination form. (http://www.wpsmedicare.com/part_b/business/2009_1214_payreduction.shtml)
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