Ophthalmology and Optometry Coding Alert

Question: Our patient gave us her Medicare card but said Medicare was her secondary payer. She took a long time to get us her primary insurance card, and when we finally submitted the claim, the insurer was slow to get back to us. They eventually denied the claim. But when we tried to submit it to Medicare as secondary, the MAC said we exceeded the limit on timely filing requirements and rejected the claim. Can we file an exception report for this?

Oregon Subscriber

Answer: Unfortunately, it doesn’t sound like your situation warrants an exception to the timely filing requirements, which demand that you submit your claims within a year of the date of service. The exceptions are as follows:

• If you missed the deadline due to an error or misrepresentation of an employee, Medicare contractor, or agent of the department that was performing Medicare functions
• When a beneficiary receives notification of Medicare entitlement retroactive to or before the date of service 
• When a state Medicaid agency retroactively recoups money from a provider six months or more after the date of service was furnished to a dually eligible beneficiary
• Retroactive disenrollment from a Medicare Advantage plan or Program of All-Inclusive Care of the Elderly provider organization.

In your case, it sounds more like the patient was too slow to give you her insurance card and then the primary insurer must have taken a while to process the claim. 

Source: You can read about the timely filing exceptions in the Medicare Claims Processing Manual at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf.