A submission, as defined above, is considered to be a filed claim for purposes of determining timely filing on the date that the submission is received by the appropriate Medicare claims processing contractor. At this point, the submission receives a permanent receipt date that remains part of the claim record. Once a submission (or claim) passes edits for completeness and validity described in §70.2 above, it is accepted into the Medicare claims processing system.
The receipt date has two functions. It is used for determining whether the claim was timely filed . The same date is also used as the receipt date for purposes of determining claims processing timeliness on the part of the intermediary.
Determination of Untimely Filing and Resulting Actions
Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished (i.e., generally, the “From” date, with the exception of the “Through” date for institutional claims that have span dates of services, as specified in §70.1). 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.
Where the beneficiary request for payment was filed timely (or would have been filed the request timely had the provider taken action to obtain a request from the patient whom the provider knew or had reason to believe might be a beneficiary) but the provider is responsible for not filing a timely claim, the provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. In appropriate cases, such claims should be processed because of the spell-of-illness implications and/or in order to record the days, visits, cash and blood deductibles. The beneficiary is charged utilization days, if applicable for the type of services received.