About Medicare Claims: There is no denying that Medicare is a lifesaver for millions of Americans. The federal health insurance program makes quality healthcare more accessible by helping the retired and the disabled pay for their medical bills. For this reason, Medicare enrollments are continuously increasing. Having said that, becoming eligible for Medicare or getting enrolled in it is one thing; knowing its ins and outs is another. Out of the millions enrolled in Medicare, many lack a proper understanding of the federal health insurance program. It may not seem necessary to learn about Medicare when everything is going smoothly, but this lack of knowledge can put you in real trouble when things go a little haywire, and you find yourself at the mercy of a not-so-great Medicare agent.
You surely wouldn’t want that. Therefore, it’s best to have all the essential information about the health insurance program. This is even if it doesn’t seem to be of your concern. We are talking about Medicare claims.
Medicare claims are something most beneficiaries do not need to worry about under normal circumstances; your healthcare providers file them for you. But, as they say, there is an exception to every rule; you might need to file a Medicare claim yourself at some point. Since there’s a possibility of that happening, no matter how little, it’s only wise that you know how Medicare claims work. Also know how to file a Medicare claim yourself, if there is a need be. But, before we discuss all of that, let’s briefly talk about the meaning of Medicare claims. This is for those who may be new to Medicare and aren’t aware of the term.
What is a Medicare Claim?
The term Medicare claim may sound like it involves some legal work or has to do something with court. It is not that. A Medicare claim is simply the bill of your availed covered medical services sent to your insurer, which is Medicare.
For Original Medicare beneficiaries, this is done by the doctors or hospitals where they received medical services. There are no claims for Medicare Part C, or Medicare Advantage. The claims for Medicare Part D, or prescription drug plans, are handled by the insurance company you’re working with.
Why are There No Claims for Medicare Advantage Plans?
Medicare Advantage plans do not require filing claims to receive payment for utilized services. This is because Medicare pays a set amount to the private insurance companies. They sell these plans for every enrollee each month.
When Would You Need to File a Medicare Claim Yourself?
As mentioned initially, you should ideally never have to file Medicare claims yourself. However, things do not always go as they should. There may be some instances when you have to complete the claim filing procedure yourself.
Your health care provider may be unable to submit a Medicare claim or deny doing that in the following situations:
§ When Your Health Care Provider Believes the Claim Will Be Denied
While it isn’t a usual occurrence, Medicare may deny claims sometimes for the following reasons:
- The claim is made for services or items no longer covered.
- The services or items were not medically necessary.
- If there were too many or too frequent medical treatments or services.
- There was some payer/contractor issue. These issues could arise when the beneficiary has another primary health insurance. Also, if the beneficiary was in a Skilled Nursing Facility on the date of treatment or service. As well as, if the patient is a Medicare Advantage enrollee.
- The service or item was availed before the Medicare coverage started for that patient
It’s important to note that claim denials are different than rejections. These are made for claims that can’t be processed due to missing, incomplete, or invalid information.
§ When You Receive Services from a Non-Participating Provider
In the Medicare dictionary, non-participating healthcare providers are those who accept Medicare beneficiaries but do not agree to provide services or supplies at Medicare-approved prices. These providers are legally allowed to charge up to 15% more than Medicare prices.
For services that non-participating providers do not accept assignment, they may require patients to pay all their charges upfront. However, the patients can have 80% of the Medicare-approved amount reimbursed by filing a claim.
§ You See a Provider Who Has Opted Out of Medicare in an Emergency Situation
These are health care providers who choose not to be a part of the Medicare network. Since they are not a part of the Medicare program, they can charge whatever amount they want for their time and services. And for the same reason that they are allowed to charge as much as they want, Medicare doesn’t reimburse the payment made to them except in emergency situations.
If you have seen a health care provider who has opted out of Medicare due to an emergency, you may submit a claim yourself.
§ If Your Supplier Doesn’t Submit a Claim for Covered Durable Medical Equipment
Medicare provides coverage for certain medically necessary durable medical equipment prescribed by a beneficiary’s doctor for use at home. These include prosthetics, hospital beds for home care, oxygen pumps, glucometers, nebulizers, crutches, etc.
If you have been prescribed any covered durable medical equipment, but your supplier refuses to submit claims for them (for any reason), you will have to (and should) do that on your own.
§ When Your Health Care Provider Delays Claim Submission
You have 12 months or one calendar year to submit claims for the covered medical services or supplies you receive. The time starts from the day when you get the services or items. While 12 months is enough time for anyone to submit a claim, some healthcare providers may delay it unnecessarily. This is more likely to happen with non-participating providers who have charged you the full amount upfront or when you see a doctor who has opted out of Medicare. Since these providers get their full payment from patients and have nothing to get from Medicare, they may delay submitting your reimbursement claims.
§ For Certain Vaccinations
Medicare Part B covers most necessary vaccinations, and the few it doesn’t are covered by Medicare Part D (prescription drug plan). However, depending on the Part D plan, the enrollees may have to pay for vaccines upfront and then file claims for reimbursement. While your insurance company usually deals with Medicare Part D claims, you might have to step in and do it yourself if they don’t do it or delay filing the claims.
§ When You Seek Treatment in a Foreign Hospital
Original Medicare doesn’t cover medical services you receive outside the US states and territories unless:
- They experience a medical emergency between Alaska and another state while traveling through Canada via the most direct route, and the Canadian hospital is closer than a US hospital.
- If you encounter a medical emergency within the US, but a foreign hospital is closer than the US hospital.
Since foreign hospitals do not process Medicare claims, the patient would have to file them on their own.
§ If You Receive a Service on a Ship
If you receive a medical service or treatment onboard a ship sailing in US territorial waters, you may be able to claim reimbursement for them. However, certain conditions need to be met for Medicare to reimburse your money. These include:
- The person receiving the medical service/treatment must be enrolled in Medicare Part B.
- The person giving the medical service/treatment is legally allowed to practice medicine in the US.
- The ship is on a US port, has left port less than six hours ago, or will be at a US port within the next six hours.
How to Know Your Health Care Provider Has Not Filed a Claim?
It’s common for Medicare beneficiaries to presume that their health care providers will file timely claims for all the services or supplies they receive. While it happens in most cases, there are some instances when a health care provider is unable or unwilling to file reimbursement claims. But, how would you know about them?
Ideally, your health care provider should tell you about any pending claim that they cannot file and the reason for it. But, if they don’t do so, you can always check the details of the claims in your Medicare summary notice.
Medicare Summary Notice (MSN) is a notice Medicare sends to Original Medicare beneficiaries every three months. It includes details about all the claims made during this period, payments made by Medicare, and any amount you may owe to a health care provider.
Check your Medicare Summary Notice carefully to determine if your health care providers have filed claims for the services or supplies. Follow up with them if they haven’t, or do it yourself.
You can also check the details of your claims by logging into your account on MyMedicare.gov.
How to File a Medicare Claim Yourself?
It’s easy for Medicare beneficiaries to get overwhelmed in the rare instance where they may need to file a claim themselves. But, fret not because we have got you covered. Here’s a step-by-step guide to filing a Medicare claim yourself to make sure you do it right.
Step 1 – Fill Out the Form
Like any other formal procedure, the first step to filing a Medicare claim is to fill out the application form. It’s called the Patient’s Request for Medical Payment or CMS-1490S form and can be filled out in English or Spanish.
The form will require you to provide all the necessary information Medicare needs to process a claim request. These include details for:
- The reason you went to the health care provider
- The treatment you received
- If the illness or injury you got treatment for was work-related
- Your health insurance plan
In addition to this basic information, you may also be required to provide more details for certain claims, such as those related to durable medical equipment, services that are covered under Medicare Part B, and services received at a healthcare facility outside the US.
Step 2 – Get Your Itemized Bill
An itemized bill provides a detailed breakdown of the total medical bill you’re filing the claim for. It lists the charges for every service and/or item you received during your medical treatment. You need an itemized bill to support and verify your Medicare claims. Your health care provider should provide you with an itemized bill for every service you receive as a Medicare beneficiary. If they haven’t, make sure to ask for it before filing your claim. Also, make sure it has all the necessary details.
For those who may not know, an itemized medical bill should have the following details:
- Your diagnosis
- The date you received medical treatment on
- The name and address of the doctor’s office or hospital you went to
- The name of the doctor who provided you the treatment
- A list of every treatment, service, or item received
- Individual charges for every treatment, service, or item you received
Step 3 – Collect Supporting Documents, If Required
If needed, add supporting documents to strengthen your claim. These may include your medical reports, documents related to your medical history, or doctors’ referrals.
Step 4 – Write an Explanatory Letter
Medicare recommends sending a detailed letter explaining why you are submitting the claim yourself along with your reimbursement request.
Step 5 – Fill Out the Authorization Form, If Needed
If you want Medicare to share details about your health and claim with someone else or want another person to get in touch with Medicare on your behalf pertaining to your claim, you should also fill out another form, titled Authorization to Disclose Personal Health Information, also called CMS 10106 form.
The form provides Medicare details of the person(s) you have authorized to have access to your personal health information.
Step 6 – Send Everything to Your Medicare Contractor
Send all your documents, including the Patient’s Request for Medical Payment form, the itemized bill(s), supporting documents (if any), and the Authorization to Disclose Personal Health Information form (if needed) to your Medicare contractor.
You can find the address of your Medicare contractor on the Medicare Administrative Contractor Address table or your Medicare Summary Notice. If you’re unable to find the address of your Medicare contractor, call the Medicare helpline at 1-800-633-4227.
How Long Does Medicare Take to Process Claims?
Medicare usually takes about 30 days to process the claims.
Who is Medicare Claims Paid to?
For services covered under Medicare Part A, claims are paid directly to the health care providers. However, for Medicare Part B services, the payments are made either to the doctor or the beneficiary depending on if the health care provider accepts Medicare assignment or not.
How to Keep Track of Your Medicare Claims?
You can check the status of your claims online by logging into your Medicare account.
Need Help With Filing Your Claim? Contact Our Medicare Experts
While submitting a claim yourself isn’t difficult, don’t hesitate to contact us if you’re experiencing any trouble filling out the forms, are afraid of doing it wrong, or simply do not have time for all the paperwork. We have an experienced and reliable team of Medicare experts who can help you submit a claim and even do it for you. Get in touch with us for all your queries regarding Medicare claims and/or have us do it on your behalf. We would be happy to help.