Ophthalmology and Optometry 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 gives you only 12 months to file a claim, and exceeding this limit will cause instant denials.

The time period for filing Medicare fee-for-service claims was amended as part of the Patient Protection and Affordable Care Act (PPACA). 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 or non-participating, to submit the claim to Medicare on behalf of the beneficiary. This includes submitting those claims on a timely basis.

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

There are four limited exceptions to the one-year filing rule. According to CMS guidance, these include:

• Administrative Error;
• Retroactive Medicare Entitlement;
• Retroactive Medicare Entitlement Involving State Medicaid Agencies and;
• Retroactive Disenrollment from a Medicare Advantage (MA) Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization.

Resource: Read more about the Medicare claims time exceptions at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7270.pdf.