DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for ...

CMS-1503-FC 917
year after the date that the service was furnished. An incomplete or rejected claim cannot
act as a placeholder for a claim that has yet to be filed because that would clearly be a
way for providers and suppliers to avoid the 1 calendar year requirement stated in
section 6404 of the ACA. Moreover, it would create a multitude of problems for CMS to
deal with operationally or administratively because CMS would need to have the ability
to track all rejected claims or all claims that failed to receive an initial determination and
be able to match those rejected or incomplete claims up with all of the complete or valid
claims that would eventually be filed months or years later so that an initial determination
could be made.
Comment: One commenter stated that it is unnecessary to impose an additional
restriction to the exception for claims filed for services provided to dual-eligible
individuals. The third condition for the exception at §424.44(b)(3) that a State Medicaid
Agency recovers the Medicaid payment for the furnished service from a provider or
supplier 11 months or more after the date of service is too restrictive and CMS should
have used a different time period.
Response: We agreed with the commenter that the 11 months or more after the
date of service requirement in §424.44(b)(3)(iii) was too restrictive and therefore we
modified the final rule based on these comments by changing the time period from
11 months to 6 months or more after the service was furnished.
Comment: One commenter suggests that CMS amend the third condition of
§424.44(b)(3) to read as follows-- "A State Medicaid agency or Provider recovered the
Medicaid payment for the furnished service from the provider or supplier 11 months or
more after the date of service." The commenter stated that occasionally providers