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 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

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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.
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 website.
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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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Timely Filing Requirements

The Medicare regulations at 42 C.F.R. §424.44 and the CMS Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 1, §70 specify the time limits for filing Part A and Part B fee-for- service claims.

Important Notes for Providers

The "Through" date on a claim is used to determine the timely filing date. For example, if the "From" date of service is 7.1.2021 and the "Through" date of service is 7.31.2021, the claim must be received by 7.31.2022.
Claims that Return to Provider (RTP) for correction that are resubmitted and adjustment claims (Type of Bill XX7) are also subject to the one calendar year timely filing limitation.
If a beneficiary indicates another insurer is primary over Medicare, bill the primary insurer prior to submitting a claim to Medicare. Once payment is received from the primary insurer, submit a Medicare Secondary Payer (MSP) claim to Medicare, even if no payment is expected. This will allow you to adjust the MSP claim if the primary insurer later recoups their money.

Filing a claim after you find out Medicare is primary is not a valid reason to waive the timely filing deadline. MSP and tertiary payer situations do not change or extend Medicare's timely filing requirements.

When a claim denies because it was received after the timely filing period, such denial does not constitute an "initial determination" and, therefore, is not subject to appeal.

Exceptions Allowing Extension of the Time Limit

The Centers for Medicare & Medicaid Services have established the following exceptions to the one calendar year time limit:

Error or misrepresentation by an employee, Medicare contractor, or agent of the Department of Health and Human Services (HHS) that was performing Medicare functions and acting within the scope of its authority.
Retroactive Medicare entitlement to or before the date of the furnished service.
Retroactive Medicare entitlement where a State Medicaid Agency recoups money from a provider or supplier 6 months or more after the service was furnished.
A Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recoups money from a provider or supplier 6 months or more after the service was furnished to a beneficiary who was retroactively disenrolled to or before the date of the furnished service.

Required Documentation for Timely Filing Exception Request

Administrative Error

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

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.

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
Proof of MA plan or PACE provider organization recoupment of a claim
Dated screen prints of the CWF showing MA plan or PACE provider organization eligibility at the time the claim was originally submitted

When a Claim Rejects for Untimely Filing (Reason Code 39011)

If one of the above exceptions apply, you may request that CGS review the reason the claim was rejected. Providers can submit a hardcopy UB-04 adjustment or a reopening request if one of the exceptions apply.

Reviewed: 12.01.22