Oncology & Hematology Coding Alert

Question: We had a problem with a claim and didn't get it filed with Medicare until over a year after the procedure date. Will this get paid?

Codify Subscriber

Answer: No. Medicare allows only 12 months from the date of the service to file the claim. Exceeding this limit will cause a denial.

The time period for filing Medicare fee-for-service claims was amended as part of the Patient Protection and Affordable Care Act. Under this law, the claims for services furnished on or after Jan. 1, 2010 must be filed within one calendar year after the date of service.

Medicare requires all providers, both participating (accepting Medicare payment terms as payment in full) and non-participating (accepting Medicare, but not accepting assignment in all cases and may charge up to 15% more than the allowable- depending on the state), to submit the claim to Medicare on behalf of the beneficiary. This includes submitting those claims on a timely basis.

Lost pay:  Medicare considers claims not submitted on time as "provider liable," meaning you cannot charge the beneficiary for those services.

There are some limited exceptions to the one-year filing rule, which include administrative error and retroactive Medicare entitlement.

Important note: "Opt-out providers" do not accept Medicare at all and have voluntarily signed an agreement to be excluded from the Medicare Program. Services from opt-out providers are not covered by Medicare, except in emergencies and they do not bill Medicare for their services.