To be eligible for Medicare reimbursement, providers must file claims for services furnished on or after January 1, 2010, within one calendar year of the date of service.
Patient Responsibility on Claims Denied for Late Filing
The provider may collect 20% of what would have been the Medicare fee schedule allowed amount, when the claim denies for late filing. The patient is not responsible for the entire billed amount.
Claims Denied Based on the Timely Filing Limit Do Not Have Appeal Rights
CMS requires Medicare contractors to deny claims submitted after the timely filing limit. In addition, the CMS Internet-Only Manual (IOM), Publication 100-04, Chapter 1 , Section 70.4 states, "When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal."
Denied Claim Not Filed Within the Time Limits due to Third Party Error
Providers often ask Medicare contractors to reopen claims denied for timely filing when another insurer recouping their previous payment caused the delay. CMS does not accept errors caused by incorrect third-party payment as justification for not submitting timely claims to Medicare. The CMS IOM Publication 100-04, Chapter 34 , Section 10.11, states the following:
"Third party payer error in making a primary payment determination does not constitute good cause for the purposes of reopening an initial determination or redetermination when Medicare processed the claim in accordance with the information in its system of records or on the claim form. Contractors may only reopen for third party payer error under the “within one year for any reason” standard. This is true for both contractor initiated reopenings as well as reopenings requested by a party. All providers and suppliers have a legal obligation to determine the correct primary payer when billing Medicare. Failure to do so, regardless of third party payer error, does not constitute “good cause” that will permit reopening beyond one year. Information regarding such error does not constitute “new and material evidence.”"
Potential Reasons Medicare May Extend the Late Filing Limit
In rare cases, CMS permits Medicare contractors to extend the time limit for filing a claim beyond the usual deadline if the provider can show good cause for the delay in filing the claim. CMS indicates that Medicare contractors could determine good cause exists when an administrative error on the part of an official Medicare employee acting on behalf of the Medicare contractor within the scope of his/her authority caused the delay. Circumstances such as backdated Medicare entitlement may also qualify for an extension of the timely filing deadline. In such situations, providers must file the claim promptly after the error is corrected.
How to File a Waiver to Extend the Timely Filing Limit
Providers who believe they meet the qualifications for "good cause" must submit a hardcopy adjustment along with the following items to request a waiver of timely filing.
- An original UB-04 claim form, submitted as a hardcopy adjustment claim (xx7), plus any documentation needed to process the claim;
- A letter explaining why you filed the claim late;
- Documentation proving you met "good cause" for late filing (e.g., a copy of the beneficiary's retroactive Medicare entitlement letter from the Social Security Administration or Medicaid recoupment letter).
It is important that the request for a waiver of timely filing and documentation supporting the request accompany their claim. The Claims staff will review the request to determine whether good cause exists, as defined by CMS. We will notify providers of the outcome of their request via their remittance notice when we process the adjustment. Providers should mail their adjustment, waiver request, and supporting documentation to the attention of the Claims Manager at the appropriate state specific address below.
Since claims denied for timely filing do not have appeal rights, the WPS Government Health Administrators Appeals area cannot grant any waiver to the timely filing deadline after we process the claim. Therefore, do not send your request to WPS Government Health Administrators using the Redetermination Request Form.
Iowa
WPS GHA
Claims Department
P.O. Box 7665
Madison, WI 53707-7665
Kansas
WPS GHA
Claims Department
P.O. Box 7576
Madison, WI 53707-7576
Missouri
WPS GHA
Claims Department
P.O. Box 8890
Madison, WI 53708-8890
Nebraska
WPS GHA
Claims Department
P.O. Box 8799
Madison, WI 53708-8779
J5 National
WPS GHA
Claims Department
P.O. Box 7861
Madison, WI 53707-7861
For more information about the requirements for extending the time limitation for filing a Medicare claim, please see the CMS IOM Publication 100-04, Chapter 1 , Sections 70.7, 70.7.1 and 70.7.2.
How to File a Waiver to Extend the Timely Filing Limit
Providers who believe they meet the qualifications for "good cause" must submit a hardcopy adjustment along with the following items to request a waiver of timely filing.
- An original UB-04 claim form, submitted as a hardcopy adjustment claim (xx7), plus any documentation needed to process the claim;
- A letter explaining why you filed the claim late;
- Documentation proving you met "good cause" for late filing (e.g., a copy of the beneficiary's retroactive Medicare entitlement letter from the Social Security Administration or Medicaid recoupment letter).
It is important that the request for a waiver of timely filing and documentation supporting the request accompany their claim. The Claims staff will review the request to determine whether good cause exists, as defined by CMS. We will notify providers of the outcome of their request via their remittance notice when we process the adjustment. Providers should mail their adjustment, waiver request, and supporting documentation to the attention of the Claims Manager at the appropriate state specific address below.
Since claims denied for timely filing do not have appeal rights, the WPS Government Health Administrators Appeals area cannot grant any waiver to the timely filing deadline after we process the claim. Therefore, do not send your request to WPS Government Health Administrators using the Redetermination Request Form.
Indiana
WPS GHA
Claims Department
P.O. Box 8602
Madison, WI 53708-8602
Michigan
WPS GHA
Claims Department
P.O. Box 8604
Madison, WI 53708-8604
For more information about the requirements for extending the time limitation for filing a Medicare claim, please see the CMS IOM Publication 100-04, Chapter 1 , Sections 70.7, 70.7.1 and 70.7.2.
How to File a Waiver to Extend the Timely Filing Limit
Providers who believe they meet the qualifications for "good cause" must submit the following items to the WPS Government Health Administrators Claims Manager to request a waiver of timely filing.
- An original, paper (red and white) CMS-1500 claim form, plus any documentation needed to process the claim;
- A letter explaining why you filed the claim late;
- Documentation proving you met "good cause" for late filing (e.g., a copy of the beneficiary's retroactive Medicare entitlement letter from the Social Security Administration).
It is important that the request for a waiver of timely filing and documentation supporting the request accompany their claim. The Claims Manager will review the request to determine whether good cause exists, as defined by CMS. We will notify providers of the outcome of their request via their remittance notice when we process the claim. Providers should mail their claim, waiver request, and supporting documentation to the attention of the Claims Manager at the appropriate state specific address below.
Since claims denied for timely filing do not have appeal rights, the WPS Government Health Administrators Appeals area cannot grant any waiver to the timely filing deadline after we process the claim. Therefore, do not send your request to WPS Government Health Administrators using the Redetermination Request Form.
Iowa
WPS GHA Part B
Claims Department Manager
P.O. Box 8550
Madison, WI 53708-8550
Kansas
WPS GHA Part B
Claims Department Manager
P.O. Box 7238
Madison, WI 53707-7238
Missouri
WPS GHA Part B
Claims Department Manager
P.O. Box 14260
Madison, WI 53708-0260
Nebraska
WPS GHA Part B
Claims Department Manager
P.O. Box 8667
Madison, WI 53708-8667
For more information about the requirements for extending the time limitation for filing a Medicare claim, please see the CMS IOM Publication 100-04, Chapter 1 , Sections 70.7, 70.7.1 and 70.7.2.
How to File a Waiver to Extend the Timely Filing Limit
Providers who believe they meet the qualifications for "good cause" must submit the following items to the WPS Government Health Administrators Claims Manager to request a waiver of timely filing.
- An original, paper (red and white) CMS-1500 claim form, plus any documentation needed to process the claim;
- A letter explaining why you filed the claim late;
- Documentation proving you met "good cause" for late filing (e.g., a copy of the beneficiary's retroactive Medicare entitlement letter from the Social Security Administration).
It is important that the request for a waiver of timely filing and documentation supporting the request accompany their claim. The Claims Manager will review the request to determine whether good cause exists, as defined by CMS. We will notify providers of the outcome of their request via their remittance notice when we process the claim. Providers should mail their claim, waiver request, and supporting documentation to the attention of the Claims Manager at the appropriate state specific address below.
Since claims denied for timely filing do not have appeal rights, the WPS Government Health Administrators Appeals area cannot grant any waiver to the timely filing deadline after we process the claim. Therefore, do not send your request to WPS Government Health Administrators using the Redetermination Request Form.
Indiana
WPS GHA Part B
Indiana Claims Manager
PO Box 8940
Madison, WI 53708-8940
Michigan
WPS GHA Part B
Michigan Claims Manager
PO Box 8987
Madison, WI 53708-8987
For more information about the requirements for extending the time limitation for filing a Medicare claim, please see the CMS IOM Publication 100-04, Chapter 1 , Sections 70.7, 70.7.1 and 70.7.2.