April 30, 2001

Medi-966-01

TO: ALL MEDICARE PROVIDERS

SUBJECT: CLAIMS SUBMITTED WITH A WRITTEN STATEMENT OF INTENT

PRIMARY INTERESTS: BUSINESS OFFICE MANAGERS

EFFECTIVE DATE: OCTOBER 1, 2000

The Health Care Financing Administration has issued the following information.

This provides instructions concerning the processing claims where a statement of intent (SOI) was used to extend the timely filing period for submission of claims. This is effective for the claims filing period ending December 31, 2000.

o The SOI should arrive at the appropriate Medicare contractor or be forwarded to the correct Medicare contractor from the appropriate regional office. It is the submitter’s responsibility to submit the SOI to the appropriate Medicare contractor. If the contractor receives an SOI which should have been submitted to a different contractor, then it will return the SOI to the submitter with instructions that they must forward the SOI to the appropriate contractor.

o The contractor must return a letter of acknowledgment to the submitting entity, (provider, supplier, Medicaid State Agency or entity acting on behalf of the Medicaid State Agency, or beneficiary) upon receipt of a valid or invalid SOI . Before sending out the acknowledgment letter, the contractor will search history to assure that a claim has not previously been submitted for these services.

o The proper claimant then has 6 months after the month in which the acknowledgment letter for a valid SOI is issued to submit a claim to Medicare (42 CFR 424.45(c)). Contractors are not required to develop a claim from the submitted SOI. Contractors are also not to solicit the submission of claims from entities that have submitted SOIs.

o Contractors must keep the SOI for a minimum of 6 months after the month of acknowledgment of the claim, in order to match the SOI with incoming claims.

o Contractors must be able to match the statement of intent with the claim.

Within 6 months after the month of the SOI acknowledgment letter, a valid claim form (either electronic or hardcopy) must be submitted in accordance with Medicare claims standards.

When a claim is submitted beyond the filing deadline, the contractor will verify that the 6 month acknowledgment letter time limit has not expired.

o If more than 6 months have passed after the month of the SOI acknowledgment letter, the claim will be denied.

o If less than 6 months have passed, verify that a valid SOI exists. If a valid SOI does not exist, the claim will be denied.

o If the information on the claim does not match the information on the SOI, the claim will be denied.

o If the SOI was filed correctly and the claim is submitted timely (within 6 months after the month of the acknowledgment letter), the claim will be processed as usual, according to the claims processing sections of the Medicare Intermediary Manual.

-- Effective October 1, 2000, condition code H0 (zero) has been approved by the National Uniform Billing Committee to facilitate this process. When a claim comes in with this condition code, this signals to the system that an SOI exists for this claim before the claim is rejected for timely filing. The claim will suspend and allow for verification that an SOI exists for this claim. If the SOI does not match the information/service on the claim or an SOI cannot be found, the claim will be denied. If the SOI and the claim match, the claim will be processed as usual.

If the submitter of the SOI is not the provider/supplier who will be submitting the claim, they must instruct the provider/supplier to place one of these codes on the claim.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER STAFF. NO COST COPIES ARE ALSO AVAILABLE FROM OUR WEB SITE AT riverbendgba.com

Please refer any questions to our office toll free at 877-296-6189.