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Last Modified: 5/24/2018 Location: FL Business: Part A

Documentation needed to qualify for timely filing limit exceptions

Section 6404 of the Patient Protection and Affordable Care Act (the Affordable Care Act or ACA) reduced the maximum period for submission of all Medicare fee-for-service claims to no more than 12 months -- one calendar year -- after the date of service. This policy is effective for services furnished on or after January 1, 2010; claims for services furnished prior to that date were required to be submitted no later than December 31, 2010.
Effective on/after January 1, 2016, providers must utilize the new reopening process (TOB XXQ) when the need for correction is discovered beyond the claim timely filing limit; an adjustment bill (TOB XX7) is not allowed.
In an effort to streamline and standardize the process for claim reopening with the ‘Q” frequency code and adjustment reason codes (ARC), the Centers for Medicare & Medicaid Services (CMS) issued MLN MattersŪ article MM8581 external pdf file.
CMS released special edition MLN MattersŪ article SE1426 external pdf file to assist providers with coding instructions and billing scenarios for submitting requests to reopen claims that are beyond the claim filing timeframe.
(NOTE: The Administrative Billing Errors category is being removed from the process below, you must utilize the new reopening process to correct claims with dates of service beyond the timely filing limit. Please refer to the MLN Matters referenced above for complete information on the new reopening process.)
The following exceptions apply to the time limit for filing initial Medicare claims:
Retroactive Medicare entitlement
Retroactive Medicare entitlement involving state Medicaid agencies
Retroactive disenrollment from a Medicare Advantage plan or program of all-inclusive care for the elderly (PACE) provider organization
Retroactive Medicare entitlement
An official 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), or
If an official Social Security Administration (SSA) letter cannot be provided, First Coast Service Options, Inc. (First Coast) will 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 retroactive Medicare entitlement.
Retroactive Medicare entitlement involving state Medicaid agencies (state buy-in)
Documentation showing the date that the state Medicaid agency recouped money from the provider/supplier, and
Documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (i.e., the official letter to the beneficiary), and
Documentation verifying the service/s furnished to the beneficiary and the date of the furnished service(s).
Retroactive disenrollment from a Medicare Advantage plan or PACE provider organization
Evidence of prior enrollment of the beneficiary in an MA plan or PACE provider organization, and
Evidence that the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization, and
The effective date of the disenrollment; and
Documentation showing the date the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.
Click here for information on submitting an appeal.

Customer service process for time limit exceptions

First Coast has undertaken an initiative to provide an easier mechanism for handling requests from providers to extend the timely filing requirement on claims that exceed the provision. Effective January 1, 2016, as previously mentioned, the Administrative Billing Errors category has been removed from the process listed below. The following guidelines remain the same for all other requests from providers to extend the timely filing extension on their claims:
Medicare providers must complete the Request for Telephone Claim Override Timeliness Form for Part A, attach the appropriate documentation and a brief explanation of the reason for delayed filing. A limit of one form can be submitted per fax request. Fax the request to 904-361-0693. Click here to access the form pdf file. Note: If any part of the form is not legible, the timely filing limit for your claim(s) will not be overridden.
First Coast’s written inquiry representatives will retrieve the documentation, review it, and issue an approval or disapproval letter to the provider in response to the timely filing request. The approval or disapproval response will be mailed to the provider’s mailing address listed on our internal files. Be advised that this process could take up to 45 business days to complete. Please do not call the contact center.
If a claim filing extension is granted, the approval letter will instruct the provider to file a new claim. The unique approval number, provided in the approval letter, and the date of the approval letter must be included in the remark section of the claim.
Additionally, the approval letter will include a date by which the new claim must be filed. Once the claim is filed, the approval number entered on the remark line and the receipt date of the claim will be compared to the list of approved numbers. If this information matches, the claims timely filing edit will then be overridden on the applicable claim. It is important to note that other edits may fail on the claim which may require that providers correct their billing and resubmit the claims.
If a claim filing extension is not granted, the reason for not granting the extension will be outlined in the letter.
It is important that the above outlined process be followed in its entirety as any deviations could result in documentation being returned and added delays in approvals.

Access the timely filing request form pdf file

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.