CMS Pub. 100-04, ch. 1, § 70.4

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

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.