(Medicare Claims Processing Manual)

70.7.1 - Administrative Error  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)  Medicare regulations at 42 CFR 424.44 allow that where Medicare program error causes the failure of the provider or supplier to file a claim for payment within the time limit in 70.1 above, the time limit will be extended through the last day of the 6th calendar month following the month in which the error is rectified by notification to either the provider, supplier, or beneficiary.  In order to avoid having two extension of time triggers, contractors must notify the beneficiary and the provider or supplier in writing about the correction of the error on the same day.  Administrative error may include misrepresentation, delay, mistake, or other action of Medicare, or its contractors.  Contractors will not accept requests for extensions for such errors that extend beyond 4 years from the date of service.   The administrative error that prevents timely filing of the claim may affect the provider or supplier directly or indirectly, i.e., by preventing the beneficiary or his or her representative from filing a timely request for payment.  Situations in which fa ilure to file within the usual time limit will be considered to have been caused by administrative error include but are not limited to the following:     The failure resulted from misinformation from an employee, Medicare contractor, or agent of the Department acting within the scope of its authority, e.g., that certain services were not covered under Part A or Part B, although in fact they were covered.    The failure resulted from excessive delay by Medicare, or the Medicare contractor in furnishing information necessary for the filing of the claim.    The failure resulted from advice by an employee, Medicare contractor, or agent of the Department acting within the scope of its authority that precluded the filing of a claim until the provider or supplier receives certain information from the Medicare con tractor (e.g., a hospital following manual instructions does not file a billing for outpatient services where the services are expected to be paid for by workmens compensation; but the hospital learns after the expiration of the time limit of the ultimate  denial of workmens compensation liability).    Any claim involving situations other than those listed above, where it appears that an extension of the time limit might be justified on the basis of administrative error, should be submitted by the appropriate Medicare claims processing contractor with a recommendation, before payment, to the appropriate CMS RO.  Contractors should consult with the appropriate RO.  ROs may in turn consult with CMS Central Office.   Where administrative error is alleged to be responsible for late filing, the necessary evidence would ordinarily include:    A statement from the beneficiary, his/her representative or the provider or supplier, depending on whom the error directly affected, as to how he/she learned of the error, and when it was corrected, and one of the following:    A written report by Medicare or the Medicare contractor describing how its error caused failure to file within the time limit; or    Copies of a CMS or Medicare contractor letter or other written notice reflecting the error, or    A written statement of an agency employee having personal knowledge of the error.   However, the statement of the beneficiary, his/her representative, or the provider or supplier is not essential if the other evidence establishes that his/her failure to file within the usual time limit resulted from administrative error, and that he/she f iled a claim within six months after the month in which he/she was notified that the error was corrected. There must be a clear and direct relationship between the administrative error and the late filing of the claim. Where the evidence is in the Medicare contractors own records, it should annotate the claims file to this effect.   If the claims processing contractor determines that a late claim should be honored because the facts support that an error or misrepresentation has caused the claim to be late, the provider, supplier, or beneficiary will have until the end of the 6th calendar month from the month in which the provider, supplier, or beneficiary received notification that the error or misrepresentation has been corrected.   70.7.2  Retroactive Medicare Entitlement  (Rev. 2477, Issued: 05- 25-12, Effective: 08 -27-12 Implementation: 08- 27-12)  The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:   (a) At the time the service was furnished the beneficiary was not entitled to Medicare.   (b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.   Thus, a provider or supplier may have furnished services to an individual who was not entitled to Medicare.  More than a year later, the individual receives notification from SSA that he or she is entitled to Medicare benefits retroactive to or before the date he or she received services from the provider or supplier.  In this situation, the provider or supplier may submit a request for a filing extension to the appropriate Medicare claims processing contractor, as long as the provider or supplier submits s upporting documentation that verifies that the conditions above are met.  If the beneficiary and the provider or supplier is notified on different days about the beneficiarys retroactive Medicare entitlement, there will be two extensions of time triggers.  One extension of time trigger is when the beneficiary is first notified about the beneficiarys retroactive Medicare entitlement and the other extension of time trigger is when the provider or supplier is the first party notified of the beneficiarys retroactive Medicare entitlement. If the beneficiary is submitting the claim,  the time to file the claim is based on the day the beneficiary is first notified of the retroactive Medicare entitlement.  If the provider or supplier is submitting the claim, the time to file the claim is based on the day the provider or supplier is firs t notified of the retroactive Medicare entitlement.   Where retroactive Medicare entitlement is alleged, the provider, supplier, or beneficiary will need to provide the contractor with the following information:    an official Social Security Administration (SSA) letter notifying the beneficiary of Medicare entitlement and the effective date of the entitlement; and,    documentation describing the service/s furnished to the beneficiary and the date of the furnished service/s.  If the provider, supplier, or beneficiary is unable to provide the contractor with an official SSA letter, the Medicare contractor shall check the Common Working File (CWF) database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiarys retroactive entitlement.  For example, if the CWF indicates a Medicare entitlement date of March 1, 2008 and a date of accretion of December 14, 2010, then the contractor may interpret the CWF da ta to mean that the beneficiary was retroactively entitled to Medicare as of March 1, 2008 and that this data was added to the CWF database on December 14, 2010.  If the contractor has any problems or concerns with respect to interpreting the CWF data, the n the contractor should consult with the appropriate CMS regional office.   If the contractor determines that both of the conditions for meeting this exception described above are met, the time to file a claim will be extended through the last day of the 6th calendar month following the month in which either the beneficiary or the provider or supplier received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.   70.7.3  Retroactive Medicare Entitlement Involving State Medicaid Agencies  (Rev. 2477, Issued: 05- 25-12, Effective: 08 -27-12 Implementation: 08- 27-12)  The time for filing a claim will be extended if CMS or one of its contractors determines that failure to meet the filing deadline is caused by all of the following conditions:   (a) At the time the service was furnished the beneficiary was not entitled to Medicare.   (b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.   (c) A State Medicaid Agency recovered the Medicaid payment for the furnished service from a provider or supplier 6 months or more after the date of the furnished service.   In these situations, at the time services were furnished the beneficiary was entitled to Medicaid but not to Medicare.  After the date of the furnished services, the beneficiary is then notified that he or she is entitled to Medicare.  Finally, sometime af ter the date of the furnished service, the State Medicaid Agency recoups the money it paid the provider or supplier.  If the State Medicaid Agency recoups the money it paid the provider or supplier 6 months or more after the date the service was furnished, the provider or supplier may be given an extension to have those claims filed to Medicare.   In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with the following information:    documentation verifying the date that the State Medicaid Agency recouped money from the provider/supplier;    documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (e.g., an official SSA letter to the beneficiary, or if an official SSA letter is not available, the contractor shall check t he CWF database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiarys retroactive entitlement; see the example in section 70.7.2 above concerning the CWF for additional detail s regarding this contractor verification process); and,   documentation verifying the service/s furnished to the beneficiary and the date of the furnished service/s.   If the contractor determines that all of the conditions described above for meeting this exception are met, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the State Medicaid Agency recovered its money.   70.7.4 - Retroactive Disenrollment from a Medicare Advantage plan or Program of All- inclusive Care for the Elderly (PACE) Provider Organization  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)  The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:   (a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All- inclusive Care for the Elderly (PACE) provider organization. (b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All -inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.  (c) The Medicare Advantage plan or Program of All- inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.  There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization.  And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.    In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:    prior enrollment of the beneficiary in an MA plan or PACE provider organization;    the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;    the effective date of the disenrollment; and,    the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.  If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.  70.8 - Filing Request for Payment to Carriers Medicare Part B  (Rev. 2140, Issued: 01- 21-11, Effective: 01-01-10, Implementation: 02-22-11)  Medicare regulations at 42 CFR 424.44 define the timely filing period for Medicare fee-for-service claims.  Such claims must be filed no later than 12 months (or 1 calendar year) after the date the services were furnished.   70.8.1  Splitting Claims for Processing  (Rev. 3389, Issued: 10- 30-15, Effective: 01-01-14, Implementation: 04-04-16)   There are a number of prescribed situations where a claim is received for certain services that require the splitting of the single claim into one or more additional claims. The splitting of such a claim is necessary for various reasons such as proper reco rding of deductibles, separating expenses payable on a cost basis from those paid on a charge basis, or for accounting and statistical purposes. Split a claim for processing in the following situations:    Expenses incurred in different calendar years cannot be processed as a single claim. A separate claim is required for the expenses incurred in each calendar year;