Practice Management Alert

You don't have to sacrifice your claim if a third party prevents filing on time

What reasons for late claim filing will a carrier consider acceptable? Many billers have racked their brains with this question at one time or another.
 
Billers are allowed to file a claim late, without incurring any penalty, under four scenarios, CMS clarifies in an Aug. 20 Program Transmittal.
 
Filing deadline: To file timely, providers must submit Medicare claims on or before Dec. 31 of the calendar year following the year in which the provider rendered the service. However, CMS considers services furnished in the last quarter of the year as furnished in the following year (meaning the time limit is the second year after the year in which the provider rendered the service).
 
For example, if a provider renders a service in January 2005, the timely filing date is Dec. 31, 2006 (the service year plus one year - a 23-month filing period). If a provider renders a service in November 2004 (during the last quarter of the year), the timely filing deadline is also Dec. 31, 2006, because CMS considers the service year 2005.

Learn Your 4 Late-Filing Options

 CMS lists these four conditions that establish good cause for late filing:

 1. Administrative error. This would mean Medicare sources (carrier, intermediary, CMS) provided incorrect or incomplete information to the provider. For example, a typo on the carrier's information may have instructed a provider to send claims to the wrong mailing address, thereby causing late filing, says Kent J. Moore, manager of healthcare financing and delivery systems issues for the American Academy of Family Physicians based in Leawood, Kan.

 2. Unavoidable delay in securing required supporting claim documentation or evidence from one or more third parties. This situation may occur if you're submitting a claim to Medicare as a secondary payer and you're waiting for information from the patient's primary insurance, Moore says. To fall into this category, you must show that you made reasonable efforts to secure the documentation.

 3. Unusual, unavoidable or other circumstances beyond the provider's control that demonstrate the provider could not have reasonably been aware of the need to file timely. This category is very broad and could include any number of unforeseen disruptions or obstacles in the billing office.

 4. Destruction or other damage of the provider's records (unless, of course, the provider's willful act or negligence caused the damage). For example, if a fire or hurricane destroys a provider's office, it may cause unfiled claims to sit undiscovered until well past the timely-filing deadline, Moore says.
 
Expert recommendation: "If you file a late claim and you know it's late, you should be sure to include an explanation (if a valid reason exists) and have evidence to support your statement," Moore says. If a fire damaged your practice, for example, a form from the fire department or a local press clipping should be sufficient evidence that destruction of your records caused late claim filing.
 
Editor's note: To read the full transmittal online, visit www.cms.hhs.gov/Manuals/pm_trans/R282CP.pdf.