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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
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  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


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Medicare Timely Filing Guidelines

Background

The Patient Protection and Affordable Care Act (PPACA) signed into law on March 23, 2010, by President Obama included a provision which amended the time period for filing Medicare Fee-For-Service (FFS) claims. This provision was aimed at curbing fraud, waste, and abuse in the Medicare program. Under the law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year (12 months) after the "through" date of service on the claim.

Note: Adjustment claims (Type of Bill ending in XX7) submitted by the provider are also subject to the one calendar year timely filing limitation. In addition, claims that have Returned to Provider (RTP'd) for corrections and resubmitted, are also subject to timely filing standards.

Exceptions

On January 21, 2011, the Centers for Medicare & Medicaid Services (CMS) announced four exceptions to the 12 month Medicare claim filing period.

  • Administrative Error
    • Error or misrepresentation of an employee, the Medicare Contractor or agent of the Department of Health and Human Services (DHHS) that was performing Medicare functions and acting within the scope of its authority
    • Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider or supplier received notice that an error or misrepresentation was corrected
  • Retroactive Medicare Entitlement
    • Beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished
    • Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider or supplier received notification of Medicare entitlement retroactive to or before the date of the furnished service
  • Retroactive Medicare Entitlement Involving State Medicaid Agencies
    • A state Medicaid agency recoups payment from a provider or supplier six months or more after the date the service was furnished to a dually eligible beneficiary
    • Medicare will extend the timely filing limit through the last day of the sixth month following the month in which a state Medicaid agency recovered Medicaid payment from a provider or supplier
  • Retroactive Disenrollment from a Medicare Advantage (MA) Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization
    • A beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups its payment from a provider or supplier six months or more after the date the service was furnished
    • In these cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the MA plan or PACE provider organization recovered its payment from a provider or supplier

Phone or Written Requests for Exceptions

  • Providers may contact the J15 Part A Provider Contact Center (PCC) by phone at 866.590.6703for questions and assistance.
  • Please note Customer Service Representatives are unable to manually process a claim through the Fiscal Intermediary Standard System (FISS) in order to ensure a claim complies with timely filing standards. If it is determined that documentation is required to overturn timely filing (based on the four exceptions listed above), the telephone representative will inform the caller that a written request for exception must be submitted to:

    J15 Part A Provider Contact Center
    P.O. Box 20200
    Nashville, TN 37202

The written request for exception for claim(s) sent to CGS must contain the following elements:

  1. Be in writing
  2. Be on company letterhead
  3. The address on the company letterhead must match the 'Master Address' in the provider's Medicare enrollment record
  4. The provider's six-digit Provider Transaction Access Number (PTAN)
  5. The provider's National Provider Identifier (NPI)
  6. The last five digits of the provider's Federal Tax Identification (ID) number
  7. Beneficiary's name
  8. Beneficiary's Medicare number
  9. Beneficiary's date of birth
  10. Dates of service for the claim(s) in question
  11. Include supporting evidence (see below for examples)

Note:A written request for exception may take up to 45 business days for research and a response.

Supporting Evidence/Documentation

Administrative Error

  • A written report by the agency (Medicare, Social Security Administration (SSA), or Medicare Administrative Contractor (MAC)) based on agency records, describing how its error caused failure to file within the usual time limit
  • Copies of an agency (Medicare, SSA, or MAC) letter reflecting an error
  • A written statement of an agency (Medicare, SSA, or MAC) employee having personal knowledge of the error
  • CGS Claims Processing Issues Log (CPIL) showing the system error

    Note: The provider must demonstrate that they submitted the claim within six months after the month in which they were notified that the system error was corrected. In addition, there must be a clear and direct relationship between the system error and the late filing of the claim(s).

Retroactive Medicare Entitlement

  • Copies of a SSA letter reflecting retroactive Medicare entitlement
  • Dated screen prints of the Common Working File (CWF) showing no Medicare eligibility at the time the claim was originally submitted and dated screen prints of CWF showing the retroactive Medicare eligibility

Retroactive Medicare Entitlement Involving State Medicaid Agencies

  • Copy of a state Medicaid agency letter reflecting recoupment
  • Proof of Medicaid recoupment of a claim

Retroactive Disenrollment from a MA Plan or PACE Provider Organization

  • Copies of an MA plan or PACE provider organization letter reflecting retroactive disenrollment
  • Dated screen prints of the CWF showing MA plan or PACE provider organization eligibility at the time the claim was originally submitted
  • Proof of MA plan or PACE provider organization recoupment of a claim

Note: Each provider request for exception will be evaluated individually based on the evidence submitted with the request.

References:

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