Effective date and retrospective billing

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Last Modified: 4/25/2025 Location: FL, PR, USVI Business: Part B

Effective date and retrospective billing

Q: What is the difference between the effective date and retrospective billing date?

A: The effective date is the later of the following two dates:

• The filing date of an enrollment application that was subsequently approved, or

• The date the provider first began furnishing services at a new practice location.

The provider may bill retrospectively for services when:

• The supplier has met all program requirements, including state licensure requirements, and

• The services were provided at the enrolled practice location for up to

1. 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or

2. 90 days prior to their effective date if a presidentially-declared disaster precluded enrollment in advance of providing services to Medicare beneficiaries.

Example:

Suppose that a non-Medicare enrolled physician began furnishing services to beneficiaries at her office March 1. She submitted the CMS-855I initial enrollment application May 1, and the application was approved June 1. The physician’s effective date of enrollment would be May 1, which is the later of: (1) the date of filing, and (2) the date she began furnishing services. The retrospective billing date is April 1 (or 30 days prior to the effective date of enrollment).

Source: CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 10, section 10.6.2 external pdf file

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