Medicare learning network Updates Medicare Claim Submission Guidelines

Center of Medicare and Medicaid services has released fact sheet on Medicare claim submission guidelines. The fact sheet offers billers, coders and physicians up-to-date guidance on how to file Medicare Claims. Following are some important points mentioned in the fact sheet:

Timely filling of claim is one of the important guidelines mentioned in the fact sheet. Payment for any claim can only be received if the claims are received on time i.e. Claims with date of service on or after January 1, 2011 must be received no later than one calendar year from the claim’s DOS. Claims that are filed after the specified timeframe will be denied with no appeal rights. For claims that include span dates of service, claims filing timeliness is determined as follows:

  • The “Through” date is used to determine the date of service for institutional claims; and
  • The “From” date is used to determine the date of service for professional claims.

However there are some exceptions in the filling of claims. Billers and coders are not required to file claims when
a) The claim is for services for which:

  • Medicare is the secondary payer;
  • The primary insurer’s payment is made directly to the beneficiary; and
  • The beneficiary has not furnished the primary payment information needed to submit the Medicare secondary claim;

b) Physician has opted-out of the Medicare Program and entered into a private contract with the beneficiary; or physician have been excluded or debarred from the Medicare Program.
c) The claim is for items or services furnished outside the U.S., except in limited cases
d) The claim is for services initially paid by third-party insurers who then file Medicare claims to recoup what Medicare pays as the primary insurer (e.g., indirect payment provisions)
e) The claim is for other unusual services, which are evaluated by Medicare Contractors on a case-by-case basis
f) The claim is for excluded services, unless the beneficiary requests submission of a claim to Medicare (some supplemental insurers who pay for these services may require a Medicare claim denial notice prior to making payment)
Apart from these guidelines the factsheet also contains information on

  • How to apply for a national provider identifier (NPI) and enroll in the Medicare program
  • How to Opt out of Medicare and arrange private contracts with Medicare beneficiaries

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