CMS Pub. 100-04, ch. 1, § 80.1

The carrier or FI will consider claims as received for timely processing purposes from the

date of their receipt. Improperly completed claims that it returns are considered received

for timely processing purposes when received again, properly completed.

A. Provider Billing Via Terminal or Equivalent

If the provider bills via remote terminal with on-site (in the provider) editing or if the

carrier or FI otherwise can communicate edit results to it electronically, the carrier or FI

establishes a control record when the bill passes its consistency edits.

B. Manual Hardcopy Claim/Bills and Electronic Claim/Bills

The carrier or FI establishes a control record when it enters the initial claim into its

system. The claim is counted for administering timely billing and payment only if it

passes carrier or FI edits to the extent a pending record can be established. The date

received is the date the carrier or FI received the claim properly completed, passing all

carrier or FI edits, even if entered into its system on a later date.

C. Bills Returned to Provider

If the carrier or FI returns the bill and retains a claim record to minimize data entry cost

when returned, the receipt date is corrected when the bill is properly completed and

passes carrier or FI edits.

D. Bills Requiring Medical Information

When a carrier or FI requests medical documentation, it retains the bill as a pending

record until it either pays, denies, or rejects (in the case of FIs) it. Returning cases for

review by the PRO is not a request for medical documentation. Claims that fail initial

carrier or FI edits because required medical reports or other required attachments are not

included are also not requests for medical documentation.

E. Adjustment and Cancel Bills

An adjustment request bill is a correction to a claim previously processed. The carrier or

FI establishes a control record for it.

The carrier or FI counts adjustments as received and pending only when they pass carrier

or FI edits. The carrier or FI assigns the date received in its mailroom as the receipt date

for hospital and MSP adjustment requests.

The carrier or FI counts adjustment bills as processed when no further action by it is

required. The final action taken on the adjustment request bill depends upon the

situation.