Medicare Part B 101 Manual

Payment Floor Standards

The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail or otherwise finalize the initial determination on a clean claim. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be made.

The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.

The payment floor does not apply to: no-payment claims, RAPs submitted by HHAs, and claims for PIP payments.

There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. For the purpose of implementing the payment floor, the following definitions apply:

• An “electronic claim” is a claim submitted via CPU to CPU transmission, tape, direct data entry, direct wire or personal computer upload or download. A claim that is submitted via digital fax/OCR, diskette or touch-tone telephone is not considered an electronic claim.
• A “paper claim” is submitted and received on paper, including fax printouts. This also includes a claim that the contractor receives on paper and then reads electronically with OCR technology.

Based on the waiting periods, the payment floor dates are as follows:

Related Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.2.1.2

Reviewed 10/15/2024