Requesting an Exception to Timely Filing
Table of Contents
- Requesting an Exception to Timely Filing
- No Appeal Rights for Claims Denied Based on Timely Filing Limit
- Provider Liability
- Exceptions that May Allow the Time Limit to be Extended
- How to Request a Waiver to Extend the Timely Filing Requirement
- Addresses to Mail Your Request
Requesting an Exception to Timely Filing
Providers must file claims within a qualifying time limit to be eligible for Medicare reimbursement. The Patient Protection and ACA of 2010 amended the timely filing requirements to one calendar year after the date of service. This amendment applies to services furnished on or after 1/1/2010.
No Appeal Rights for Claims Denied Based on Timely Filing Limit
CMS requires Medicare contractors to deny claims submitted beyond the timely filing limit. CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, Section 70.4 states:
“When a claim is denied for having been filed after the timely filing period, such denial does not constitute an ‘initial determination.’ As such, the determination that a claim was not filed timely is not subject to appeal.”
Provider Liability
The provider may not charge the beneficiary for the services except for deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made.
Exceptions that May Allow the Time Limit to be Extended
CMS permits Medicare contractors to extend the time limit for filing a claim beyond one calendar year. This is outlined in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, Section 70.7.
CMS indicates Medicare contractors may determine certain situations allowing extension of the time limit.
See the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, for:
- Administrative error 70.7.1
- Retroactive Medicare entitlement 70.7.2
- Retroactive Medicare entitlement involving State Medicaid Agencies 70.7.3
- Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization 70.7.4
How to Request a Waiver to Extend the Timely Filing Requirement
Post Claim – claim(s) has been submitted and denied for timely
- Complete a Part B Reopening Request Form and attach the documentation with the reason(s) you qualify for the extension and mail to the address indicated on the bottom of the form.
Pre-Claim – no claim(s) have been submitted
A provider who believes they meet the qualifications for an extension of timely filing as outlined in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, Section 70.4 must submit the following to the NGS Claims Department Manager requesting a timely filing waiver:
- A completed CMS-1500 claim form, along with appropriate documentation required to process the claim
- A letter explaining the reason the claim is being filed beyond a year after the date of service
- Documentation to prove why an extension shall be granted for late filing (e.g., documentation verifying the beneficiary was retroactively entitled to Medicare on or before the date of the furnished service)
NGS will review the request with CMS to determine if an extension can be granted, as defined by CMS. The requesting provider will be notified of the outcome of their request in writing. Remember, since claims denied for timely filing have no appeal rights, the NGS Appeals Department is not able to grant timely filing waivers. Please do not send requests using the redeterminations form.
Addresses to Mail Your Request
| State(s) | Address |
|---|---|
| Connecticut | National Government Services, Inc. Attn: Claims Manager P.O. Box 6185 Indianapolis, IN 46206-6185 |
| Massachusetts, Maine, New Hampshire, New York (downstate counties), Rhode Island, Vermont |
National Government Services, Inc. Attn: Claims Manager P.O. Box 6178 Indianapolis, IN 46206-6178 |
| New York (Queens only) | National Government Services, Inc. Attn: Claims Manager P.O. Box 6239 Indianapolis, IN 46206-6239 |
| New York (upstate counties) | National Government Services, Inc. Attn: Claims Manager P.O. Box 6189 Indianapolis, IN 46206-6189 |
| Illinois, Minnesota, Wisconsin | National Government Services, Inc. Attn: Claims Manager P.O. Box 6475 Indianapolis, IN 46206-6475 |
Reviewed 8/28/2024