(Medicare Claims Processing Manual)

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;   EXCEPTION FOR DURABLE MEDICAL EQUIPMENT REGIONAL CARRIERS (DMERCs):   Expendable items (disposable items such as blood glucose test strips and PEN nutrients) that will be used in a time frame that spans two calendar years and are required to be billed with appropriately spanned from and to dates of service may be process ed on a single claim line. For these types of items, DMERCs must base pricing and deductible calculations on the from date, since that is the date when the item was furnished.    A claim other than a DMERC claim that spans two calendar years where the from date of service is untimely but the to date of service is timely should be split and processed as follows:   1. Where the number of services on the claim is evenly divisible by the number of days spanned, assume that the number of services for each day is equal. Determine the number of services per day by dividing the number of services by the number of days spanned. Then split the claim into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.   2. Where the number of services on the claim is not evenly divisible by the number of days spanned and it is not otherwise possible to determine from the claim the dates of services, suspend and develop the claim in order to determine the dates of services. A fter determining the dates of services, split the claim accordingly into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.    A claim containing both assigned and unassigned charges. Split assigned and unassigned services from non- participating physicians/suppliers into separate assigned and unassigned claims for workload counts and processing;    Assigned claims from different physicians/suppliers (excluding group practices and persons or organizations to whom benefits may be reassigned). Process a separate claim for the services from each physician/supplier. Where the assigned claim is from a pers on or organization to which the physicians performing the services have reassigned their benefits, process all of the services as a single claim;    A claim where there is more than one beneficiary on a single claim. There can only be one beneficiary per claim; and   NOTE: Roster bills for covered immunization services furnished by mass immunizers may be submitted for multiple beneficiaries. You must create individual claims for each Medicare beneficiary based on the roster bill information.    Outpatient physical therapy services furnished on a cost basis by a physician-directed clinic cannot be processed when combined on the same claim with other charge -related services by the clinic. Process the cost related services as a separate claim.    If an unassigned claim includes services by an independent physical therapist together with other physician services, process the physical therapy services as a separate claim. Process an assigned claim from an independent physical therapist as a single cl aim.    A claim that is a duplicate of a claim previously denied is treated as a new claim if there is no indication that the claim is a resubmittal of a previous claim with additional information, or there is no indication on the second claim that the beneficiary  is protesting the previous determination.    In a claim containing services from physicians/suppliers covering more than one carrier jurisdiction, the carrier receiving the claim must split off the services to be forwarded to another contractor and count the material within the local jurisdiction as a claim. The carrier receiving the transferred material must also count it as a separate claim.    When services in a claim by the same physician/supplier can be identified as being both second/third opinion services and services not related to second/third opinion, the "opinion" services must be split off from the "non- opinion" services and counted as a separate claim. When one physician/supplier in an unassigned claim has provided the "opinion" service and another physician(s)/supplier(s) has provided the "non- opinion" services, the claim may not be split.    Claims containing any combination of the following types of services must be split to process each type of service as a separate claim. These services are:    --  Physical therapy by an independent practitioner, or      --  any services paid at l00 percent of reasonable charges.  (Any of these types of services may be combined on the same claim with any other type of service.)   Do not deviate from defining claims as described above. Split claims in accordance with the appropriate definition. Throughout the claims process count each of the separate claims, resulting from the split, as an individual claim.   70.8.2 - Replicating Claims for Processing  (Rev. 170, 05- 07-04)  There are no prescribed reasons other than those aforementioned for splitting claims and for counting additional claims into your workload.  However, claims are frequently split for other reasons that are dictated by the systems or the methods of processing them.  Such additional claims are labeled "Replicate Claims."  Tally and report all replicate claims (other than those aforementioned) separately.  Identify replicate claims and report them in the appropriate categories for claims.  Some examples of repl icate claims are:    Additional claims created because of a line item limitation (regardless of the methodology used for coding line items);    Extra claims created in making partial payments;    Claims created for carving out individual specialty types of services and    Extra claims created to apply special payment reductions (e.g., Gramm -Rudmann- Hollings) efficiently for applicable dates of service.   NOTE:  For budget requests and cost reports (CMS -l524, CMS -l528, CMS -l6l6, and CMS -2599), the workload must exclude the number of replicate claims produced.   70.8.3 - Methods of Claiming Benefits for Services by Physicians and Suppliers  (Rev. 170, 05- 07-04)  The method of claiming Part B benefits depends upon whether the patient is claiming payment or is assigning benefit payments to his/her source of medical treatment or services.   As a rule, beneficiaries do not submit claims for reimbursement.  However, if there is reason for a beneficiary to submit a claim for reimbursement, the beneficiary uses the CMS -1490S.  For covered services furnished on or after September 1, 1990, physicia ns and suppliers must complete and submit in accordance with SSA 1848(g)(4)(A) all Part B claims whether assigned or unassigned for beneficiaries who desire Medicare benefit payment determinations.   The physician/supplier (or the facility or organization to which the physician may reassign benefits, claims the payment.  The patient or his representative agrees to assign the benefits and the physician/supplier agreeing to the assignment accepts the Medicare reasonable charge determination as the full charge for the services.  (See 3045ff. about specific assignment procedures and the nature and effect of assignments.)   70.8.4 - Claims Forms CMS -1490S and CMS -1500 (Rev.: 4388; Issued: 09- 06-19; Effective: 10 -07-19; Implementation: 10 -07-19)  A number of  prescribed claims forms have been developed for use when requesting payment for Part B Medicare services.  Many are printed and distributed nationally free of cost through CMSs Printing and Publications Branch.  (See NOTE below for exception.)   In order to maintain control over the content and format of the forms, private printing of a Government form is not routinely permitted.  However, if you or another organization wishes to independently print a prescribed claims form, the reproduction of a claims form must be in accordance with 422.527 of Title 20, Chapter III, Part 422 of the Code of Federal Regulations.  Obtain CMS approval for printing a prescribed form.  Route the written request for approval through the RO.  Include the following:    The reason or need for such reproduction;    The intended user of the form;    The proposed modifications or format changes, with printing or other specifications (such as realignment of data or line designations);    The type of automatic data processing machinery, if any, for which the form is designed; and   Estimates of printing quantity, cost per thousand, and annual usage.   NOTE:  This procedure does not apply to the Form CMS -1500, Health Insurance Claim Form.  A/B MACs (B), physicians and suppliers are responsible for purchasing their own forms.  This form can be bought in single, multipart snap- out sets or in continuous pin- feed format.  Medicare accepts any version.  Forms can be obtained from local printers or printed in- house as long as it follows the CMS approved specifications developed by the National Uniform Claim Committee.   The Form CMS -l490 was formerly the basic Part B claims form.  It was replaced by Form CMS -l500 for claims completed by physicians and suppliers (except ambulance suppliers), and Form CMS -l490S for claims from beneficiaries.  You must, however, continue to accept and process claims received on Form CMS -1490 form after conversion to Forms CMS -l500 and CMS -l490S.   The Form CMS -1500 (Health Insurance Claim Form) is the prescribed form for claims prepared and submitted by physicians or suppliers (except for ambulance services), whether or not the claims are assigned.  It can be purchased in any version required i.e., single sheet, snap- out, continuous, etc.  The forms described below are printed and distributed to contractors by CMS and are available in single sheets, multipart snap -out sets, or in pin- feed format.   The Form CMS -1490S (Patient's Request for Medical Payment) form is used only by beneficiaries (or their representatives) who complete and file their own claims.  It contains the patients comparable items of data that are on the Form CMS -1500.  When the Fo rm CMS -1490S is used, an itemized bill must be submitted with the claim.  Social Security Offices use the Form CMS -1490S when assisting beneficiaries in filing Part B Medicare claims.  For Medicare covered services received on or after September 1, 1990, the Form CMS -1490S is used by beneficiaries to submit Part B claims only if the service provider refuses to do so.  Inasmuch as the Form CMS -1490S has no provision for a diagnosis code, the diagnosis code is not required at the time of claim submission.   CMS implemented a new version of the Form CMS -1490S effective January 1, 2019. The revised form is version 01/18, OMB control number 0938- 1197. The revised form will replace the previous version of the form 01/05, OMB control number 0938- 0999.   The term, Form CMS -1490S refers to the form generically, independent of a given version.  Medicare will conduct a dual -use period (January 1, 2019 through March 31, 2019) during which Beneficiaries (or their representatives) can send Medicare claims on either the old or the revised form. When the dual -use period is over, Medicare will accept beneficiary paper claims on only the revised Form CMS -1490S, version 01/18.   The Form CMS -1556 (Prepayment Plan for Group Practices Dealing Through An A/B MAC (B)) is used by plans which, for Medicare purposes are, both Group Practice Prepayment Plans, and are paid on the basis of reasonable charges related to their costs for furni shing services to their subscribers.   70.8.5  Photocopies  (Rev. 170, 05- 07-04)  Some enrollees may want to keep the original itemized physician and supplier bills for income tax or complementary insurance purposes.  Photocopies of itemized bills are acceptable for Medicare deductible and payment purposes if there is no evidence of alteration.   70.8.6  Penalty for Filing Claims after One Year  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)