CMS Pub. 100-04, ch. 1, § 70.7.3

Agencies

(Rev. 2477, Issued: 05-25-12, Effective: 08-27-12 Implementation: 08-27-12)

The time for filing a claim will be extended if CMS or one of its contractors determines

that failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was not entitled to Medicare.

(b) The beneficiary subsequently received notification of Medicare entitlement

effective retroactively to or before the date of the furnished service.

(c) A State Medicaid Agency recovered the Medicaid payment for the furnished

service from a provider or supplier 6 months or more after the date of the

furnished service.

In these situations, at the time services were furnished the beneficiary was entitled to

Medicaid but not to Medicare. After the date of the furnished services, the beneficiary is

then notified that he or she is entitled to Medicare. Finally, sometime after the date of the

furnished service, the State Medicaid Agency recoups the money it paid the provider or

supplier. If the State Medicaid Agency recoups the money it paid the provider or supplier

6 months or more after the date the service was furnished, the provider or supplier may

be given an extension to have those claims filed to Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the

claims processing contractor with the following information:

• documentation verifying the date that the State Medicaid Agency recouped money

from the provider/supplier;

• documentation verifying that the beneficiary was retroactively entitled to

Medicare to or before the date of the furnished service (e.g., an official SSA letter

to the beneficiary, or if an official SSA letter is not available, the contractor shall

check the CWF database and may interpret the CWF date of accretion and the

CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s

retroactive entitlement; see the example in section 70.7.2 above concerning the

CWF for additional details regarding this contractor verification process); and,

• documentation verifying the service/s furnished to the beneficiary and the date of

the furnished service/s.

If the contractor determines that all of the conditions described above for meeting this

exception are met, the contractor will notify the provider or supplier in writing that a

filing extension will be allowed from the end of the 6th calendar month from the month in

which the State Medicaid Agency recovered its money.