Last Modified: 10/10/2016 Location: FL, PR, USVI Business: Part B
Good cause for extension of the time limit for filing appeals
The time limit for filing a request for redetermination may be extended in certain situations. Generally, providers, physicians, or other suppliers are expected to file appeal requests on a timely basis. A request from the provider, physician, or other supplier to extend the period for filing the request for redetermination would not be routinely granted.
Note: A finding by the contractor that good cause exists for late filing for the redetermination does not mean that the party is then excused from the timely filing rules for the reconsideration.
Good cause may be found when the record clearly shows, or the beneficiary alleges, that the delay in filing was due to one of the following:
• Circumstances beyond the beneficiary’s control, including mental or physical impairment (e.g., disability, extended illness) or significant communication difficulties;
• Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (the Centers for Medicare & Medicaid (CMS), the contractor, or the Social Security Administration) to the beneficiary (e.g., a party is not notified of her appeal rights or a party receives inaccurate information regarding a filing deadline);
Note: Whenever a beneficiary is not notified of his/her appeal rights or of the time limits for filing, good cause must be found.
• Delay resulting from efforts by the beneficiary to secure supporting evidence, where the beneficiary did not realize that the evidence could be submitted after filing the request;
• When destruction of or other damage to the beneficiary’s records was responsible for the delay in filing (e.g., a fire, natural disaster);
• Unusual or unavoidable circumstances, the nature of which demonstrates that the beneficiary could not reasonably be expected to have been aware of the need to file timely;
• Serious illness which prevented the party from contacting the contractor in person, in writing, or through a friend, relative, or other person;
• A death or serious illness in his or her immediate family; or
• A request was sent to a government agency in good faith within the time limit, and the request did not reach the appropriate contractor until after the time period to file a request expired.
Note: Failure of a billing company or other consultant (that the provider, physician, or other supplier has retained) to timely submit appeals or other information is not grounds for finding good cause for late filing. Also, good cause does not exist where the provider, physician, or other supplier claims that lack of business office management skills or expertise caused the late filing.
Instructions on the time limits and good cause process may be found in the Medicare Claims Processing Manual, Chapter 29, Section 240 .
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