Timely Filing Matters

Each year, professional and institutional providers are required to write-off a portion of their expected payment because of untimely filing of healthcare claims. Whether your contract is with a commercial payer, Medicare, or Medicaid, knowing what is required to submit a timely claim can result in fewer losses and more efficient processing and payment of each claim.

As you probably know by now, the statutory time limit for filing Medicare claims has been adjusted as part of implementing the Affordable Care Act. At one time, providers were given anywhere from fifteen to twenty-seven months to submit a claim for payment, depending on the date services were rendered. However, effective January 1st of 2010, the timely filing period was reduced to a maximum of twelve months from the date of service.

The new filing deadline seems straightforward at first, but there are several details our agencies need to be aware of. There are certain situations in which the timely filing limit may be sooner or later than twelve months from the service date. Knowing the criteria for these exceptions will help your agency fight for accurate reimbursement of any claims erroneously denied for timely filing.

For professional providers billing for services rendered over a specific time span, Medicare will determine timely filing based on the “from” date of service. This ruling prevents Medicare claims processors from issuing line-item denials within the claim, provided it has been submitted within twelve months of the initial treatment date. Alternatively, if the claim’s submission date falls after the twelve months following the first service date, Medicare will split the claim by line item detail and issue individual denials for each date that was not filed timely.

Specific exceptions to the timely filing rule pertain to administrative and patient eligibility issues. In the event of an administrative error on the part of Medicare or its representatives, the timely filing limit is extended to six months from the date that the provider received notice of the error, to allow sufficient time to submit the claim. Additionally, providers are given six additional months to file when patient becomes retroactively eligible for Medicare and services were provided during the retroactive coverage period. If a patient is eligible for Medicaid at the time treatment is rendered, and later becomes retroactively entitled to Medicare, the provider is given six additional months from the time that Medicaid recoups its initial payment to submit a claim. This also applies if the patient is retroactively dis-enrolled from a Medicare managed care plan and the managed care carrier recoups its initial payment.

It’s a good idea to verify the accuracy of all denials you receive from Medicare, as there are instances in which your agency may still be able to recover payment of a denied claim. In the event of a timely filing rejection, check to be certain that none of these special situations apply to your claim. You may be surprised to learn that a simple appeal with adequate documentation can result in payment of a claim that might otherwise be abandoned.

For more information on this topic, visit www.cms.gov.