Medicare Timely Filing Extension

Timely Filing Requirements

Medicare will reject or deny claims which have not been filed within the time requirements specified by the program.

Claims filed after the timely filing period are typically not eligible for appeal.  Because the claim was filed after the timely filing period, Medicare does not make an "initial determination" on the claim.  Due to no "initial determination" being made, the denial is not appealable.

A redetermination request should not be filed in appeals for a timely filing denial.

In certain circumnstances, all is not lost.  There are times a timely filing extension can be granted.

Timely Filing Extension

There are 4 circumstances when a timely filing extension may be granted by Medicare:

1. Administrative Error by Medicare
2. Retroactive Benefit Entitlement
3. Retroactive Entitlement Due to State Medicaid
4. Retroactive Disenrollment from Medicare Advantage Plan or PACE program

Let's look at each of these scenarios.

Administrative Error by Medicare

• An error or misrepresentation by Medicare or Medicare Contractor.
• The filing deadline for the claim may be extended to the last day of the sixth month after notice of error being corrected.

Retractive Benefit Entitlement

• Notice is received that benefits were retroactive to before the date of service.
• The filing deadline for the claim may be extended to the last day of the sixth month after notice of entitlement for benefits was received. 

Retroactive Entitlement Due to State Medicaid

• A state Medicaid agency recoups their payment 6 months or more after the service was provided.  
• The filing deadline for the claim may be extended to the last day of the sixth month after the recoupment from the state Medicaid program.

Retroactive Disenrollment from Medicare Advantage Plan

• A beneficiary is disenrolled from a Medicare Advantage Plan or a Program of All-inclusive Care of the Elderly (PACE) Provider Organization. THe date of disenrollment is before the date of service and a recoupment from the MA or PACE provider has occurred six months after the date of service.
• The filing deadline for the claim may be extended to the last day of the sixth month after the recoupment from the Medicare Advantage or PACE program.

Written Request

When one or more of the aove scenarios are met, a written request for extension must be submitted.  The written request must include the following elements:

• Be in writing
• Written on company letterhead
• The address on the provider's company letterhead 
• 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)
• Include supporting evidence such as:
• Administrative Error Documentation
• Retroactive Entitlement Documentation
• Retroactive Dis-enrollment Documentation