Retrospective billing may be available, but it depends on the provider or supplier type, the approved enrollment, and the applicable effective date. For physicians and certain other suppliers, Medicare rules can allow billing for eligible services before that effective date when the requirements are met. Keep the application, proof of submission, and approval notice, and confirm the permitted billing date with your Medicare Administrative Contractor before submitting claims.
Are special modifiers required?
Retrospective billing does not remove the usual coding and documentation requirements. Use the codes and modifiers appropriate to the service, date and billing arrangement, and follow your contractor’s instructions.
Do timely filing limits still apply?
Yes. Medicare generally requires claims to reach the correct Medicare Administrative Contractor within one calendar year after the date of service. A pending provider enrollment does not automatically waive that deadline. Limited exceptions apply under CMS rules. Confirm any exception with your contractor and retain the documentation supporting it.
The following physician example illustrates the distinction between enrollment approval and the permitted billing date. Confirm the dates and requirements in your own approval notice.
Which date controls billing?
For the physician in this example, the effective date of billing privileges is the later of these two dates:
- The filing date of an enrollment application that was subsequently approved, or
- The date the provider first began furnishing services at a new practice location.
The provider may bill retrospectively for services when:
- The supplier has met all program requirements, including state licensure requirements, and
- The services were provided at the enrolled practice location for up to
- 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or
- 90 days before the effective date if a presidentially declared disaster under the Stafford Act prevented enrollment in advance of providing services to Medicare beneficiaries.
Example: how the dates fit together
- March 1Physician starts providing services at the new office.
- April 1Earliest retrospective billing date in this example, if all requirements are met.
- May 1Application filing date and effective date of billing privileges.
- June 1Contractor approves the enrollment application.
The May 1 filing date is later than the March 1 start date. If the physician meets the retrospective billing requirements, the permitted billing date is April 1, 30 days before May 1. The June 1 approval date is a separate milestone. Confirm the dates in the contractor’s approval notice.
References: CMS timely filing requirements; exceptions for late filing; CMS enrollment manual, section 10.6.2.