How To File A Medicare Claim: A Comprehensive Guide 

You won’t typically have to worry about submitting your own Medicare claims. Most providers allow assignment, so they offer the claim on your behalf.  But if you ever need to submit your claim, you’ll be glad you know how to do it. The supplier you visited might not accept the assignment if you need to submit a claim. 

Contacting your doctor or supplier and asking them to submit a claim will make filing a Medicare claim simple. or by dialling 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048. Request the precise deadline for submitting a Medicare claim for the service or item you received.

In this article, we will cover all the necessary steps to follow for filing a medicare claim, eligibility for filing the claim, and resources available to file a Medicare claim. Let’s get started and file your medicare claim. 

What Are The Steps Involved In Filing A Medicare Claim?

You can file a medicare claim only when you are eligible for a medicare plan, for that you have to be eligible for Medicare. There are certain criteria you need to fulfill to be eligible for Medicare, You must be a citizen of the United States or have been a permanent legal resident for at least five years straight to qualify for Medicare Parts A and B. In some instances, if you meet the requirements for a disability, you may be eligible for Medicare before you turn 65. Now, as you have passed all the eligibility criteria you can easily file a medicare claim.

Finding a provider who accepts Medicare is the next stage in the Medicare claim process. This indicates that the provider has consented to accept the benefits assignment made by Medicare. As a result, the provider may not charge you more than what Medicare has authorized. Medicare will pay the provider immediately.

Using the Medicare provider directory, you can locate a provider who accepts Medicare. You can search by specialty, area, and type of provider.

Once you have located a Medicare-accepting provider, you must collect the required paperwork to submit your claim. Included in these documents could be: Your Medicare Member ID number, the time you first received medical attention, the name and location of your supplier or doctor, your medical history (e.g., prescription medication, hospital stay, doctor’s visit) the price of your medical care, if it is known, and a detailed invoice from your physician, vendor, or other healthcare provider.



Who Can File A Medicare Claim And What Documentation Is Needed?

Anyone who is enrolled in a Medicare plan can file a medicare claim, also every beneficiary has a choice to allow someone who can file the claim on their behalf. Whenever you are allowing someone to file a claim it is necessary to provide written consent mentioning the details of the person and a request from your side mentioned in the consent. You can also allow your doctor and healthcare provider to file the claim. 

The following things must generally be submitted:

  • The CMS-1490S (Patient Request for Medical Payment form) (PDF, 52KB) claim form, is filled out.
  • Your physician’s, vendor’s, or other healthcare provider’s itemized bill
  • A letter outlining your specific reasons for filing the claim, such as the fact that your physician or supplier isn’t able to file the claim, isn’t willing to file the claim or isn’t registered in Medicare
  • Anything that supports your assertion in writing

Where Do I File A Medicare Claim And What Is The Deadline? 

It is very easy to file a medicare claim if you have all the valid documents, there are two ways in which you can file your medicare claim:

  1. Send your claim to your Medicare Administrative Contractor (MAC). Medicare claims processing in your area is handled by local MAC. Using the Medicare website, the provider directory, or by contacting 1-800-MEDICARE (1-800-633-4227), you can identify your MAC.
  1. Request that your physician or supplier submit the claim on your behalf. This is the simplest and most typical approach to submitting a Medicare claim. Your physician or supplier will handle the entire process on your behalf and will have all the information required to submit your claim.

Medicare claims need to be submitted within a year after the service date. The deadline for timely filing is known as this. If you submit your claim after the deadline for timely submission, Medicare may reject it.

How To Read And Understand Your Medicare Summary Notice (Msn)? 

Original Medicare recipients receive a letter in the mail every three months outlining the services that are covered by Parts A and B of Medicare.

On the MSN program:

  1. All of your services or goods that suppliers and providers invoiced to Medicare during three months.
  2. Payment from Medicare
  3. The maximum amount you might owe the service

The costs and payments related to Medicare should be determined by looking at the “Amount Billed” and “Amount Paid” columns. The “Amount Billed” column shows the Medicare billing amount for the provider. The actual payment made by Medicare for the therapy is specified in the “Amount Paid” column.

What Happens If My Medicare Claim Is Denied And How Do I Appeal The Decision? 

All claims submitted to Medicare are consistently entered, processed, and paid on time by the Medicare fee schedule.  However, errors can occur at any stage of the billing process and do. Understanding the cause of your claim denial is crucial. The following list of potential causes is provided:

  1. The assertion does not back up medical necessity.
  2. There are Payer/Contractor concerns with the claim, such as the fact that the patient is a member of a Medicare Advantage Plan, that the patient was a resident of a skilled nursing facility (SNF) on the day of service, or that the patient has another insurance that is primary to Medicare.
  3. The costs were incurred whether the beneficiary was receiving Medicare benefits or not.
  4. A wrong NPI, employer identification number, or facility address, for example, are problem with the provider number for the claim.

In the Medicare appeals procedure, there are four tiers of appeal:

  1. The first stage of appeal is a redetermination. Within 120 days of getting the decision you’re appealing, you must submit a request for a redetermination.
  1. This level of appeal is called reconsideration, 60 days after getting the redetermination choice, you have to submit a reconsideration request.
  1. Third-level appeal hearing, after getting the verdict on the reconsideration, you have 60 days to ask for a hearing.
  1. The Medicare Appeals Council is the fourth and last stage of the appeals process. Within 60 days of obtaining the result from the hearing, you must ask the Medicare Appeals Council to examine the case.

How Can I Protect Myself From Medicare Fraud And Scams? 

To protect yourself from medicare fraud, you have to be alert in many terms, there are some common tricks followed by fraudsters, just be aware of the following things:

  1. You are informed by a healthcare professional that a service or item of medical equipment is cost-free, but they require your Medicare number for their records.
  2. Medicare “wants you” to receive a specific service, a provider claims. Or they claim to know how to get Medicare to cover a service.
  3. People with Medicare are offered “free” consultations, according to a healthcare provider. Then, though, they need your Medicare number.
  4. You mistakenly diagnose a patient on a claim so that Medicare will pay. Alternatively, you discover that a physician or other service provider charged Medicare for products or services you never received.

You can report anything if you think it might be Medicare fraud or if it seems off. As follows:

  • Phone 1-800-MEDICARE at (800) 633-4227. Call 1-877-486-2048 if you use a TTY.
  • Call 1-800-HHS-TIPS (1-800-447-8477) to report fraud to the Department of Health and Human Services Office of the Inspector General. Call 1-800-377-4950 if you need a TTY.


What Resources Are Available For Assistance With Medicare Claims And Grievances?

There are many resources available for medicare beneficiaries, and the most used assistance for claims and grievances is SHIP, In every state and territory, there is a free and private Medicare counseling program called SHIP. If you have any questions about Medicare, including how to submit a claim, appeal a claim denial, or settle a complaint, SHIP counselors can assist you. Visit the SHIP website or dial 1-800-633-4227 to identify your neighborhood SHIP.

Apart from SHIP, there are some more resources to help you with claim and grievances-related issues, which are as follows:

  • Medicare Administrative Contractor (MAC), Charged with processing Medicare claims and compensating physicians and suppliers.
  • Customer service for Medicare is available to respond to general inquiries concerning benefits and coverage.
  • Medicare Beneficiary Ombudsman (MBO) is an impartial, unbiased resource that can assist in resolving Medicare complaints.
  • AARP, Legal Aid, and the National Council of Senior Citizens are further organizations.

Contact one of these resources if you require help with a Medicare claim or complaint. They can offer you the support and assistance you require to find a solution to your problem.