Whether you are newly covered by Medicare, a long-time beneficiary, or a provider of covered Medicare Services, there is a lot to remember about your health insurance claims. Getting your bills paid is, after all, the reason for health insurance in the first place. In most situations, your doctor or provider's office will manage the claims submission process, but there may be some situations where this falls upon you.
Medicare’s framework is governed by laws and regulations about submitting claims and getting reimbursed. The timely filing limit is one of the most important things you can know about your Medicare coverage.
The meaning behind Medicare timely filing is a lot like what it sounds like. This is the policy regarding when Medicare claims have to be submitted for reimbursement. Medicare timely filing guidelines dictate when a healthcare provider, your doctor, for example, or, in some cases yourself, should bill Medicare for your healthcare services.
The Medicare timely filing guidelines require that all claims be submitted within 1 calendar year, that is 12 months, from the time you or your patient had the service. The timely filing limit will be shown on your Medicare claims as the “From” date.
The timely filing limits are the same even when Medicare is your secondary health insurance. If you have other health insurance Medicare will always pay as secondary. You or your provider will submit your claim to your primary insurance first. Once they have paid, you will submit the claim to Medicare as the secondary payer.
Medicare timely filing guidelines allow for one year from the date of a service or procedure for providers or beneficiaries to submit a claim. Whether Medicare is paying as your primary insurance or your secondary, or even tertiary, insurance, the claim must fall within the guidelines for Medicare timely filing.
The Centers for Medicare & Medicaid Services (CMS) allow for 4 exceptions to the Medicare timely filing guidelines. Only in these specific circumstances can you exceed requirements for timely filing for Medicare claims.
1. Administrative Error - If there is an error regarding your Medicare claim caused by an employee of CMS or your Medicare contractor, CMS will extend the timely filing limit by 6 months.
2. Retroactive Medicare Entitlement - If Social Security retroactively backdated your Medicare eligibility to before your date of service, you can request an extension under Medicare timely filing guidelines.
3. Retroactive Medicare Entitlement Involving Medicaid - If you are covered by your state’s Medicaid program on a date of service and then later learn that you were entitled to Medicare, Medicaid may ask your provider for the money back. In that scenario, CMS will provide you with a 6-month extension to allow for timely filing for Medicare.
4. Retroactive Disenrollment From MA or PACE Coverage - This occurs when, for a date of service, you are covered under a Medicare Advantage plan (MA) or the Program of All-inclusive Care for the Elderly (PACE) and later retroactively disenrolled from that coverage. In that situation, CMS may allow for an additional 6 months under Medicare timely filing.
While in many circumstances you or your provider can file an appeal when Medicare denies payment for services or supplies you feel should be covered, you may be asking if this includes a timely filing appeal? Unfortunately, this is not the case regarding the timely filing limit. There is no timely filing appeal under current Medicare guidelines.
If your situation, however, falls under one of the CMS exceptions noted above, you can submit a waiver to extend the Medicare timely filing period. If your Medicare claim is denied solely because of the claim being filed outside the 12-month limit, there is not a route to submit a timely filing appeal.
