Checklist for Timely Filing Extension

In accordance with Medicare guidelines, Medicare systems will reject or deny claims that are not received within the specified time requirements. 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. Therefore, providers should not submit a request for a redetermination to the appeals department.

According to Change Request (CR) 7270 (PDF, 103 KB), there are four exceptions where providers can request an extension on the time limit for claims.

Administrative Error

• Error or misrepresentation of an employee, the Medicare contractor or agent of the Department of Health and Human Services (DHHS) who was performing Medicare functions and acting within the scope of its authority
• Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider or supplier received notice that an error or misrepresentation was corrected

Retroactive Medicare Entitlement

• Beneficiary or provider receives notification of Medicare entitlement retroactive to or before the date the service was furnished
• Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider or supplier received notification of Medicare entitlement retroactive to or before the date of the furnished service

Retroactive Medicare Entitlement Involving State Medicaid Agencies

• A state Medicaid agency recoups payment from a provider or supplier six months or more after the date the service was furnished to a dually eligible beneficiary
• Medicare will extend the timely filing limit through the last day of the sixth month following the month in which a state Medicaid agency recovered Medicaid payment from a provider or supplier

Retroactive Disenrollment from a Medicare Advantage (MA) Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization

• A beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups its payment from a provider or supplier six months or more after the date the service was furnished
• In these cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the MA plan or PACE provider organization recovered its payment from a provider or supplier

Written Request
Palmetto GBA is able to honor a timely filing request if both the claim and a written request is received within six (6) months of the recoupment date or the date of accretion (DOA) update with supporting evidence. Please note: The claim must include remarks when billed outside of the one (1) year from the date of service limitation.

When one of the above criteria exists, providers may submit a written request for an extension. Providers are required to file a written request along with supporting evidence of their claim’s exception to timely filing requirements. 

Where to Submit a Written Request

A written request for exception for claim(s) sent to Palmetto GBA must contain the following:

• Be in writing
• Written on company letterhead
• The address on the company letterhead must match the Master Address in the provider’s Medicare enrollment record
• The provider’s six-digit Provider Transaction Access Number (PTAN)
• The provider’s National Provider Identifier (NPI)
• The last five digits of the provider’s Federal Tax Identification (EIN) number
• Beneficiary’s name
• Beneficiary’s Medicare number
• Beneficiary’s date of birth
• Dates of service for the claim(s) in question
• Include supporting evidence (see below for examples)

Examples of Supporting Documentation

• Administrative Error Documentation
  • A written report by the agency — Medicare, Social Security Administration (SSA), fiscal intermediary (FI), carrier or Medicare Administrative Contractor (MAC) — based on agency records, describing how its error caused failure to file within the usual time limit or
  • Copy of an agency (Medicare, SSA, FI, carrier or MAC) letter reflecting the error or
  • A written statement of an agency (Medicare, SSA, FI, carrier or MAC) employee having personal knowledge of the error or
  • Palmetto GBA Claims Processing Issues Log (CPIL) showing the system error

Note: The provider must demonstrate that they submitted the claim within six months after the month in which they were notified that the system error was corrected. In addition, there must be a clear and direct relationship between the system error and the late filing of the claim(s).

• Retroactive Medicare Entitlement Notification Documentation
  • Copies of an SSA letter reflecting retroactive Medicare entitlement; or
  • Registration form from a recent patient encounter; or
  • Claim recoupment notice from the previous payer of the service; or
  • Remittance Advice from other insurance where claim adjusted to deny; or
  • Letter from the beneficiary to the provider advising retroactive Medicare entitlement; or
  • Any other document that is clearly dated demonstrating notification
• Retroactive Medicare Entitlement Notification Documentation Involving State Medicaid Agencies
  • Copy of a state Medicaid agency letter reflecting recoupment
  • Proof of Medicaid recoupment of a claim
• Retroactive Disenrollment Notification from a MA Plan or PACE Provider Organization
  • Copies of an MA plan or PACE provider organization letter reflecting retroactive disenrollment; or
  • Dated screen prints of the CWF showing MA plan or PACE provider organization eligibility at the time the claim was originally submitted; or
  • Proof of MA plan or PACE provider organization recoupment of a claim

Note: Each provider request for exception will be evaluated individually based on the evidence submitted with the request.

References

• Change Request 7270 
• Change Request 7080 
• Change Request 6960 
• The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70.7.1 (PDF, 1.62 MB)