Forum - Questions & Answers

Dec 6th, 2016 - rphelps 615  1 

New Physiscian working not credentialed

Would you hold claims or bill under current physician until credentialed by Medicare?

Nov 8th, 2017 - ChrisW   256  1 

re: New Physiscian working not credentialed

Determining when to submit your claims to Medicare depends on the provider’s effective date and retrospective billing date. In addition, you have 365 days to file a claim once the service has been rendered. Claims submitted prior to the application or retrospective date will not be paid.

The effective date is typically the effective date of the provider’s contract. A provider can, however, chose a retrospective billing date that is 30 days prior to the enrollment date on the CMS-855I application. This date is 30 days prior to the date the application was submitted, assuming that the requirements of 42 CFR § 424.521(a) are met. The only exception to this is if there is a Presidentially-declared disaster, in this situation a provider may treat 90 days prior to the effective dates.

Here is an example from First Coast:

Suppose that a non-Medicare enrolled physician began furnishing services to beneficiaries at her office March 1. She submitted the CMS-855I initial enrollment application May 1, and the application was approved June 1. The physician’s effective date of enrollment would be May 1, which is the later of: (1) the date of filing, and (2) the date she began furnishing services. The retrospective billing date is April 1 (or 30 days prior to the effective date of enrollment

Source: The Centers for Medicare & Medicare Services (CMS) internet-only manual (IOM) publication 100-08, chapter 15, section 15.17

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