Filing a Medicare Claim

WebMD Medical Reference

You should not have to file any claims for hospital and other services covered under Medicare Part A. Providers must be certified by Medicare and must file claims for you. If a Part A provider is not Medicare certified, Medicare will not pay for the service. Part A providers include:

• Inpatient hospitals
• Skilled nursing facilities
• Home health agencies
• Hospices

You should not to have to file any claims for doctor and other services covered under Medicare Part B. Providers must file the claims for you. Part B providers include:

• Doctors
• Laboratories
• Radiology (x-rays)
• Medical equipment and supply companies
• Home health agencies

If your healthcare provider does bill you for services that Medicare should cover, call his or her office. Ask your healthcare provider to send a claim to Medicare directly. If he or she keeps trying to bill you, call Medicare at (800) 633-4227.

You will get Medicare Summary Notices (MSNs) in the mail after you use any Medicare Part A or B covered services. These aren't bills. They are records of what services your healthcare provider charged to Medicare during the last thirty days.

Filing a Medicare Claim

Before you see a doctor or healthcare provider, you should see if they "accept assignment." Medicare determines what it will pay for any particular medical service. This is called the Medicare-approved amount. If your doctor is willing to accept what Medicare pays and won't charge you any more, he or she is said to "accept assignment."

Not all healthcare providers accept assignment. If the provider doesn't accept assignment, you may have to pay the bill up front and wait for Medicare to reimburse you for its share.

Doctors and providers who don't accept assignment may charge up to 15% more than Medicare-approved amount. You pay that extra amount, as well as your 20% co-payment. Since you pay whatever Medicare won't, you will have higher out-of-pocket costs. Medical supply and equipment companies can charge as much as they want. Here's how it works:

• Doctors and medical supply companies still must file the claim for you.
• You would pay the provider in full.
• Medicare will then send you a check for its share of the cost.

If you get Medicare-covered prescription drugs or supplies from a pharmacy or supplier that is not enrolled in Medicare, Medicare won't pay.

The provider must file your claim within one year or Medicare will not pay. If you do not receive reimbursement from Medicare within several months, the provider may not have submitted the bill. Here are steps you can take.

Step 1. Call the provider and ask them to file your claim. If you have contacted the provider about your claim and it still hasn't been filed with Medicare, proceed to Step 2.

Step 2. Call your local Medicare Carrier. You can find this number by visiting the Medicare Helpful Contacts page. The Medicare Carrier will contact the provider and ask them to file the claim.

There is a time limit for filing a claim -- from 15 to 27 months depending on the service. If the claim hasn't been filed and you are nearing the end of the time limit, you may go to Step 3.

Step 3. Call the Medicare Carrier and ask for a claim form to file yourself.

Appeals

Traditional Medicare Plan

You get a Medicare Summary Notice (MSN) when Medicare pays (or does not pay) for a product or service. If Medicare did not pay, the notice will tell you why.

If Medicare has declined to pay for something that you think it should or if you think it hasn't paid enough:

• Make a copy of the notice.
• Talk to your healthcare provider to get any information that might help your case
• Follow the appeal instructions listed on the MSN
  • Circle the item(s) on the notice that you disagree with and explain why.
  • Write down your telephone number and sign.
  • Send the notice, or a copy, to the address in the "Customer Service Information" box on the first page of the MSN.

The time limit for filing an initial appeal is 120 Days -- about four months -- from the date on the MSN.

Medicare Advantage Plans (formerly Medicare + Choice)

• You have the right to appeal your Medicare managed-care plan's decisions. If your plan says it won't cover something and you disagree, look at your plan's membership materials or call your plan to find out about the appeal process. Also, talk to your healthcare provider to get any information that might help your case. Don't delay, since your plan will probably have a time limit on filing appeals.

If you think that waiting through the normal appeals process will seriously harm your health, you may request a fast-track appeal.

• The managed-care plan must process a fast-track appeal within 72 hours.

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Reviewed by Cynthia Haines, MD, August 2005.

SOURCES: Centers for Medicare and Medicaid Services. Medicare.gov web site. National Council on the Aging web site.

© 2005 WebMD Inc. All rights reserved.

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For additional Medicare information, please read the following articles:

• New Benefits At-a-Glance
• Enrolling in Medicare
• Medicare Coverage
• Drug Discount Cards
• Drug Benefits in 2006
• Medigap
• Retiree Benefits
• Long-Term Benefits
• Medicare for People with Disabilities
• Decisions: What's The Right Coverage for You?
• Getting More Information