Defining the effective date for Medicare claims

Q: A new physician joined our practice in March. Because we had difficulty obtaining some of the documents and/or information required for credentialing, we did not complete and file an application to Medicare until June 1. When we completed the application, we indicated the new doctor's effective date would be April 1; however, he began seeing patients almost as soon as he joined us in March.

This should have been fine, because we had 30 days before the effective date to submit retroactive claims. We understood that the retroactive period changed in 2009 from 27 months to 30 days, but we also understood that period changed earlier this year. We have filed claims for all the patient visits he did since he joined us but are receiving numerous rejections based on the retroactive time period. Can you clarify the rule for us?

For the definition of the effective date, it's necessary to go back to the Code of Federal Regulations, Title 42: Public Health, Chapter IV, Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Subchapter G, Standards and Certification; Part 489-Provider Agreements and Supplier Approval; Subpart A–General Provisions; Section 489.13 (b)–Effective date of agreement or approval, which states that the effective date is the date the state agency, CMS, or the CMS contractor survey determines the provider or supplier meets all applicable federal requirements.

This date has been interpreted generally by CMS contractors as the date the application is received, provided no reason exists to deny or reject the application for missing or incomplete information.

This is the definition that is used, regardless of the effective date indicated on the application, unless the effective date indicated on the application occurs after the application is received. That's what happens when applying 60 days in advance of a physician starting to see Medicare patients, and in that case, the definition would be either the effective date or the date the physician began seeing Medicare patients, whichever is earlier.

The notification you received indicating that your new physician has Medicare billing privileges also should contain an effective date. This is the date that the MAC will use to begin paying claims.

The effective date is either 30 days before the MAC received the application or the date you indicated in the application that the physician will start to see Medicare patients. In your situation, any claims before the effective date will be rejected.

The author is president of Healthcare Consulting Associates of NW Ohio Inc., Waterville, and a Medical Economics editorial consultant. She has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant.