Frequently Asked Questions

No. Section 1902(a)(25)(I)(iv) of the Social Security Act requires states to pass laws that would require health insurers to accept claims submitted by the state within the 3-year period beginning with the date on which the item or service was furnished. States are not precluded from having laws or regulations that would require insurers to accept claims for a period of time longer than three years.

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FAQ ID:94291

No. States typically do not meet the definition of a covered health care provider, and therefore, are not eligible to receive a National Provider Identifier (NPI) number to enable them to bill Medicare. The NPI is the standard unique identifier for health care providers that CMS adopted in 2007. At that time, Medicare revoked existing billing numbers previously issued to Medicaid agencies and notified Medicare carriers to stop enrolling Medicaid programs as Medicare providers. Only recognized providers and suppliers of services that have an NPI can enroll in Medicare. Medicare will not enroll state Medicaid programs, as they are not direct providers or suppliers of services.

Medicaid may submit claims to health plans on behalf of Medicaid beneficiaries who have assigned their rights to payment from third parties (other than Medicare) to the Medicaid program, under the authority of sections 1912, 1902(a)(25)(H), and 1992(a)(25)(I)(ii) of the Social Security Act. However, Medicaid doesn't have the same authority to submit claims to Medicare on behalf of a "dually" eligible beneficiary. The rights to Medicare benefits are not assignable; only the Medicare provider and the beneficiary may submit claims to Medicare.

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FAQ ID:94301

No. The DRA limit applies to health insurers, defined in section 1902(a)(25)(A) of the Social Security Act, that are regulated by the states. Medicare Parts A and B are not subject to state regulation, as they do not need to be licensed to do business in the states. State law requiring health insurers to honor claims submitted within the timely filing period established by the state (minimum of three years) would apply to Medicare Part C and D plans.

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FAQ ID:94306

Sections 1814(a)(1), 1835(a)(1), and 1842(b)(3)(B) of the Social Security Act, as well as the Medicare regulations at 42 CFR section 424.44, specify the time limits for filing Medicare Fee-For-Service (FFS)--Part A and Part B--claims.

The Affordable Care Act reduced the maximum period for submission of all Medicare FFS claims to no more than 12 months (one calendar year) after the date services were furnished. This time limit policy for claims submission became effective for services furnished on or after January 1, 2010. In addition, claims for services furnished prior to January 1, 2010, had to be submitted no later than December 31, 2010. Section 6404 of the Affordable Care Act also mandated that CMS may specify exceptions to the one calendar year time limit for filing Medicare claims.

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FAQ ID:94311

Medicare regulations at 42 CFR section 424.44(b) allow for the following exceptions to the 1 calendar year time limit for filing fee for service claims:

1. Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority.
2. Retroactive Medicare entitlement, where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service.
3. Retroactive Medicare entitlement involving state Medicaid agencies, where a state Medicaid agency recoups payment from a provider or supplier 6 months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished, the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service. The state Medicaid agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the timely filing limit has expired.
4. Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, where 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 6 months or more after the date the service was furnished.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 252.32 KB) 

FAQ ID:94316

No. Based upon federal authority set forth at 10 U.S.C. section 1103, Congress explicitly provided for preemption of state and local laws pertaining to health care financing methods for a contract entered into for medical and/or dental care, under Chapter 55 of the Armed Forces Title of the U.S. Code, by the Secretary of Defense or administering Department of Defense secretaries. The preemption applies to contracts entered into for the purpose of administering TRICARE. Thus, it is the position of the Department of Defense that TRICARE's 1-year timely filing limit is not superseded by the 3-year limit established in the DRA for health insurers who are regulated by the states, and that TRICARE is exempt, not only from the DRA timely filing requirements, but from the DRA requirements altogether.

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FAQ ID:94326

Each physician must self-attest to being a qualified provider. It is not appropriate for a state to rely on a modifier to a claim for the initial self-attestation. Under the final rule, states are not required to independently verify the eligibility of each and every physician who might qualify for higher payment. Therefore, it is important that documentation exist that the physicians themselves supplied a proper attestation. That attestation has two parts. Physicians must attest to an appropriate specialty designation and also must further attest to whether that status is based on either being Board certified or to having the proper claims history. Once the signed self-attestation is in the hands of the Medicaid agency, claims may be identified for higher payment through the use of a modifier.

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FAQ ID:94276

As with all Medicaid services, the state in which the beneficiary is determined eligible (state A) sets the payment rate for services. Therefore, state A would be responsible for paying using the methodology it had chosen with respect to determining the appropriate Medicare rate and would not be required to pay the rate the physician would receive from state B.

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FAQ ID:94361

The correction was published in the Federal Register on December 14, 2012. In it CMS clarified that states must reimburse providers the lower or the provider’s charge or the applicable Medicare rate.

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FAQ ID:94376

States may accept the certificate and need not verify. The Centers for Medicare & Medicaid Services (CMS) expects states to make physicians aware that they are responsible for providing accurate information.

FAQ ID:92686