Billing, Claims, and Appeals

Claim Submission Timeliness Calculator

 
 

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Timely Filing

As a result of the Patient Protection and Affordable Care Act (PPACA), all claims for services furnished on/after January 1, 2010, must be filed with your Medicare Administrative Contractor (MAC) no later than one calendar year (12 months) from the date of service (DOS) or Medicare will deny the claim.

  • In general, start date for determining 1-year timely filing period is DOS or "From" date on claim
    • Claims with a February 29 DOS must be filed by February 28 of following year to meet timely filing requirements

For a claim to be considered to have been filed timely in accordance with CMS instructions, it must not be considered to be unprocessable under the definition of an unprocessable claim found in the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.

Medicare claims must be submitted by certain dates to avoid a reduction in payment or denial. Electronic claims must be received before 5 p.m. ET to be collected in that day's file. Anything submitted after 5 p.m. will be included in the next business day. Also, when the end of the year falls on a weekend, in order to be filed within the current year, claims must be received before 5 p.m. ET on the last business day.

Effects of Time Limitations

Where a supplier accepts assignment within the time limit for filing and then delays submission of the claim until no payment can be made to the supplier or the beneficiary, the supplier cannot charge the beneficiary for the services shown on the bill except for the 20 percent coinsurance and any unmet part of the deductible.

Resources

  • CMS Change Request (CR) 6960 - Systems Changes Necessary to Implement the Patient Protection and Affordable Care Act (PPACA) Section 6404 - Maximum Period for Submission of Medicare Claims Reduced to Not More Than 12 Months
  • CMS CR7270 - Changes to the Time Limits for Filing Medicare Fee-For-Service Claims
  • CMS CR7834 - Modifying the Timely Filing Exceptions on Retroactive Medicare Entitlement and Retroactive Medicare Entitlement Involving State Medicaid Agencies

 

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