Timely Filing of Claims – Important Notice About Claim Denials

Recently, WPS Medicare began seeing a dramatic increase in the number of providers experiencing claim denials when the provider submits claims past the timely filing limit for submitting claims. Although WPS Medicare recognizes that many providers must submit claims after Medicare’s timely filing limit due to circumstances beyond their control, WPS Medicare must deny any claim submitted after the time limit for filing the claim expires.

To be eligible for Medicare reimbursement, providers and suppliers must file claims within a qualifying time limit. Providers must file claims with Medicare by the end of the calendar year following the Fiscal Year, which runs from October 1 to September 30, in which the provider performs the service or Medicare denies the claim. To summarize, providers have at least 15 months from the date of service to file claims.

Patient Responsibility

The provider cannot collect the actual charge for the service from the patient when Medicare denies an assigned claim for late filing. When the provider accepts assignment but fails to submit a valid claim within the filing limit, the provider may only charge the patient 20 percent of Medicare’s approved amount.

Claims Subject to the 10 Percent Payment Reduction

Providers may submit claims for up to 12 months after the date of service without penalty. Claims submitted more than 12 months beyond the date of service are subject to a 10 percent reduction in the Medicare payment.

Claims Denied Past the Timely Filing Limit Cannot be Appealed

CMS requires Medicare contractors to deny claims submitted after the end of the calendar year following the fiscal year in which the services were provided.

How to File a Waiver to Extend the Timely Filing Limit

In rare cases, CMS permits Medicare contractors to extend the time limit for filing a claim beyond the usual deadline if the provider can show good cause for the delay in filing the claim. Providers who believe they have good cause for their delay in filing a timely claim must send a request to the WPS Medicare Claims Manager to extend the timely filing limit along with their claim for payment. It is important that the request for a waiver of timely filing and documentation supporting the request accompany the initial claim. Since claims denied for timely filing do not have appeal rights, the WPS Medicare Redeterminations unit cannot grant any waiver to the timely filing deadline after the claim is processed. Therefore, do not send it to WPS Medicare using the Redetermination form.