Medicare's Claim Timeliness Requirements and Criteria for a Timeliness Extension

All claims must be filed with your Medicare contractor within one year (12 months) from the date of service listed on the claim. Medicare will deny payment on all claims that are not submitted timely. 

How is timeliness measured?

In general, Medicare uses the date of service on the claim to calculate the 12-month time frame for timeliness. Claims submitted with date of service March 31 of one year must be received by Medicare on or before March 31st of the following year. 

Whenever the last day for filing a claim falls on a Saturday, Sunday, federal non-workday or legal holiday, the claim will be considered timely if it is filed on the next workday.

How is timeliness calculated for span dates?

Claims for services that span multiple dates are measured for timeliness as indicated below:

• Institutional Claims: For institutional claims that include span dates of service (i.e., a "From" and "Through" date on the claim), the "Through" date on the claim is used for determining timeliness of the claim.
• Physician and Supplier Claims: For claims submitted by physicians and other suppliers that include span dates of service, the "From" date on each line is used to calculate timeliness for that item or service.

Note: The same time limit applies for filing Medicare Secondary Payer (MSP) claims. We strongly recommend that you file MSP claims timely, even if you do not expect Medicare to make additional (secondary) payment. 

Can timeliness denials be appealed?

Claims that are denied for exceeding the time limit are not considered "initial determinations." They are stopped in processing before they go through any system edits and audits to determine coverage. Because no initial determination has been done, claims that deny for timely filing are not eligible for a redetermination (the first level of appeal). Providers should not submit appeal requests on untimely claims.

Exceptions to the Medicare Timeliness Limit

According to Medicare’s regulations, there are four situations that would allow providers to request an extension on the time limit for claims.

1. 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

2. 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

3. 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

4. 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

How to Request a Timeliness Extension on a Claim

Palmetto GBA can honor a timely filing extension request if both the claim and a written request for extension is received within six (6) months of the date the patient met the criteria for an extension. (Please read the details in each of the 4 timeliness extension situations listed above.) To be considered for an extension, providers must send in supporting evidence to show that the criteria to extend timeliness has been met.

Note: The claim must include remarks explaining the reason for an extension when submitted to Medicare after the one-year time limit has expired. 

Where to Submit a Written Request

What should be included with a request for an extension?

A request for a timeliness exception must be written on company letterhead. The address on the company letterhead must match the Master Address in the provider’s Medicare enrollment record. The request must contain the following information:

• 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
• Supporting evidence to show that the criteria to extend timeliness has been met (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.

Reference: The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70 (PDF)