Retroactive Billing

The practice of billing a payer for services provided before the provider's official enrollment effective date, allowed by some payers under specific conditions.

Retroactive billing is the ability to submit claims for services you provided before your enrollment effective date with a payer. Whether you can do this, and how far back, depends entirely on the specific payer's policy. Medicare is the most well-known payer that allows retroactive billing. Under Medicare rules, providers can bill retroactively up to 30 days before their enrollment effective date. There are also provisions for billing up to 90 days retroactively in certain situations involving disasters or other extraordinary circumstances. Most commercial payers do not allow retroactive billing by default. Your effective date is your effective date, and services before that date are not covered. However, some payers will make exceptions on a case-by-case basis, especially if the enrollment delay was on their end and not yours. Medicaid policies on retroactive billing vary by state. Some state Medicaid programs allow 90 days of retroactive billing for newly enrolled providers. Others do not allow any retroactive billing. Check your specific state's Medicaid provider manual. The key to maximizing retroactive billing is documentation. Keep records of when you submitted every enrollment application, including confirmation numbers, email timestamps, and fax confirmation sheets. If a payer took six months to process your application and you want to argue for a retroactive effective date, you need to prove when you submitted and that the delay was not your fault. Some practices plan around retroactive billing limits by starting to see patients from a specific payer only after receiving confirmation that credentialing is in process, and carefully tracking dates so they can submit retroactive claims as soon as the enrollment is approved. This requires coordination between your credentialing team and your front desk.