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 institutional claims that include span DOS (i.e., a "From" and "Through" date on claim), "Through" date on claim is used for determining DOS for claims filing timeliness
  • For claims submitted by physicians and other suppliers that include span DOS, line item "From" date is used for determining date of service for claims filing timeliness

Reopening Claims Beyond Claim Filing Timeframes

When the need for a correction is discovered beyond the claims timely filing limit, an adjustment bill is not allowed and a provider must utilize the reopening process to remedy the error. The reopening request (TOB xxxQ) should only be utilized when the submission falls outside of the period to submit an adjustment bill. Providers are reminded that submission of adjustment bills (TOB xxx7) or reopening requests (TOB xxxQ) in response to claim denials resulting from review of medical records (including failure to submit medical records in response to a request for records) is not appropriate. Providers must submit appeal requests for such denials.

Coding Requirements

  1. Type of Bill xxxQ
  2. An applicable Condition Code R1-R9
    • R1=Mathematical or computational mistake
    • R2=Inaccurate data entry
    • R3=Misapplication of a fee schedule
    • R4=Computer Errors
    • R5=Incorrectly Identified Duplicate
    • R6=Other Clerical Error or Minor Error or Omission (Failure to bill for services is not consider a considered a minor error
    • R7=Correction other than Clerical Error
    • R8=New and material evidence is available
    • R9=Faulty evidence (Initial determination was based on faulty evidence)
  3. A Condition Code to identify what was changed (if appropriate):
    • D0=Changes in service date
    • D1= Changes to charges
    • D2=Changes in Revenue Code/HCPCS/HIPPS Rate Codes
    • D4=Change in Clinical Codes (ICD) for Diagnosis and/or Procedure codes
    • D9=Change in Condition Codes, Occurrence Codes, Occurrence Span Codes, Provider ID, Modifiers and other changes
    • E0=Change in patient status
  4. A Condition Code W2=Duplicate of an original bill. When a provider uses this code they are attesting that they are reopening a bill already sent to the Medicare program and that there is no Appeal in Process. A provider cannot reopen a bill and appeal the same bill simultaneously.
  5. (For DDE claims only) An “Adjustment Reason Code” from the reopening subset below on claim page 3 (MAP1713)
    • R1 = < 1 yr Initial Determination (from Remittance Advice date)
    • R2 = 1 - 4 yr Initial Determination (from Remittance Advice date)
    • R3 = > 4 yr Initial Determination (from Remittance Advice date)
  6. Reopenings that require “Good Cause” to be documented must have a Remark/Note from the provider. Remarks/notes should be formatted as shown below without the parenthetical explanation (this is not an exhaustive list) and a narrative explanation after the word “because”. If the change or addition affects a line item (shown as bold) instead of a claim item, please indicate which lines are being changed in the remark/note. The first fifteen (15) characters of the remark/note must match exactly as shown below.
    • GOOD CAUSE- C-A CC (CHANGED OR ADDED CONDITION CODE) BECAUSE…
    • GOOD CAUSE- C-A OC (CHANGED OR ADDED OCCURRENCE CODE) BECAUSE…
    • GOOD CAUSE- C-A OSC (CHANGED OR ADDED OCCURRENCE SPAN CODE) BECAUSE…
    • GOOD CAUSE- C-A VC (CHANGED OR ADDED VALUE CODE) BECAUSE…
    • GOOD CAUSE- C-A DX (CHANGED OR ADDED DIAGNOSIS CODE) BECAUSE…
    • GOOD CAUSE- C-A MOD (CHANGED OR ADDED MODIFIER) BECAUSE…
    • GOOD CAUSE- C-A PX (CHANGED OR ADDED PROCEDURE CODE) BECAUSE…
    • GOOD CAUSE- C-A LIDOS (CHANGED OR ADDED LINE ITEM DATES OF SERVICE) BECAUSE…
    • GOOD CAUSE- C-A PSC (CHANGED OR ADDED PATIENT STATUS CODE) BECAUSE…
    • GOOD CAUSE- C-A HCPCS
    • GOOD CAUSE- C-A HIPPS
    • GOOD CAUSE- C-A OTHER BECAUSE…
    • GOOD CAUSE- NME (NEW AND MATERIAL EVIDENCE) BECAUSE…
    • GOOD CAUSE- F-E (FAULTY EVIDENCE) BECAUSE…
  7. To assist in quickly processing a reopening, any reopening request that contains changes or additions from the original claim should contain a remark/note explaining what has been changed. If the change or addition affects a line item instead of a claim item, please indicate which lines are being changed in the remark/note.

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 CR7080 - Timely Claims Filing: Additional Instructions
  • 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
  • CMS CR8581 - Automation of the Request for Reopening Claims Process

 

Last Updated Wed, 16 Feb 2022 16:36:10 +0000

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