Depending on how you receive your Medicare coverage, where you will get health insurance, how much you'll pay, and how to file a Medicare claim differ. Original Medicare Parts A and Part B have different regulations than Medicare Part C (Medicare Advantage) and Part D (prescription drug coverage), which are covered by Medicare-approved private insurance companies. Here are several pointers on when to file an Original Medicare claim form and how to do so.
If you have Original Medicare, the price you pay at the time of service will be determined by whether or not the doctor is a Medicare-participating provider who accepts the assignment. Medicare-participating facilities have agreed to accept assignment for all Medicare-covered programs and equipment as part of a deal with Medicare. Accepting assignment means that a company decides to accept the Medicare-approved sum as full payment for a covered service or supply.
The Medicare "fee schedule" is a list of authorized provider payment rates for each facility set by the Medicare program; a doctor or hospital that accepts assignment may not charge you more than the Medicare fee schedule, although you may still be responsible for cost-sharing. In this case, the provider or supplier is allowed to submit Medicare claims for any services you rendered, and Medicare will reimburse the provider directly. You cannot be charged to file a claim by the provider.
You are also liable for paying the cost-sharing requirements, which can include a copayment (a fixed dollar amount), coinsurance (a percentage of the overall cost), and/or a deductible, as previously stated (the amount you pay first before Medicare or your Medicare plan begins to pay). You may be required to cover all cost-sharing costs at the time of service, or your health-care provider may charge you for the balance later.
The provider can file the claim if you have Original Medicare and rendered treatment from a Medicare-participating provider. Self-filing a Medicare claim can be done only after all other options for getting the doctor to file the claim have been exhausted. Remember even if you paid the whole bill upfront, Medicare will not reimburse you until the claim is filed.
You will be required to pay the full cost of the services at the time of your appointment if you visited a non-participating doctor, and you may be charged more than the Medicare-approved amount. Non-participating providers are not required to accept assignments for all services; instead, they can do so on a case-by-case basis. Providers who aren't participating in the Medicare program will be unable to make the claim, which means you'll have to submit it yourself. If you obtain services from a non-participating provider, find out who is in charge of filing the Medicare petition with the office.
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An application for Original Medicare must be made within one calendar year (12 months) of receiving the health service. For example, if you went to the doctor on December 1, 2020, the Medicare claim deadline is December 1, 2021. Medicare would not pay its part if the claim is not submitted in a timely manner. Please keep in mind that if the service was given by a Medicare-approved company, you would not be billed or held liable if the provider fails to file the claim properly.
And if your doctor is in charge of filing the claim, you may need to follow up and ensure that it is submitted on time. And if you go to a participating provider, Medicare can't guarantee that any deductible amounts were properly applied to you before the claim is submitted.
You can look up the status of any claims that have been made or are still pending by going to:
MyMedicare.gov — Within 24 hours after Medicare processes a petition, the information in your personal web portal is updated.
The Medicare Summary Notice (MSN) — every three months, Medicare sends you this packet, which contains information about all Medicare-covered services you got during that time span and what Medicare-covered.
When you go to the hospital, make sure the doctor accepts Medicare. You won't be held liable if the doctor is a Medicare-participating provider and the claim isn't made on time. If your insurer refuses to accept Medicare and tells that it will not charge Medicare, you must file a claim.
To file a claim on your own, follow these steps:
Download and print the Patient Request for Medical Payment form (CMS 1490S) from Medicare.gov. This form is also available on the CMS.gov website.
Complete the form completely, including your Medicare ID number and a description of the services you got, as well as all itemized receipts from your provider for each facility. For billing purposes, you'll also need to provide your insurance provider's name and address. For your records, make a copy of your claim form and all supporting documents.
To process the claim, mail the form to your state's Medicare contractor. For a list of contractors by territory, go to CMS.gov. You will find the Medicare contractor details here if you're making a claim for durable medical equipment (DME). If you're not sure where to send the form, call Medicare at 1-877-878-1315
Medicare applications are normally processed within 60 days. To check the status of a submitted claim, go to Medicare.gov, as previously stated.
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You shouldn't have to make claims to Medicare if you have Medicare coverage via a Medicare plan, such as a Medicare Advantage plan or a Medicare Prescription Drug Plan. Since Medicare reimburses these plans directly with a fixed monthly amount, this is the case. In certain cases, you will need to file charges for your Medicare Advantage or Part D Prescription Drug Plan, such as if your Medicare plan has a provider network and you see a doctor who is not in the network.
You will need to file a Medicare claim for your Medicare plan in this case (not the Medicare program). Find out how to make claims for covered programs and when you may need to do so by contacting your Medicare plan.
Hopefully, you have a greater understanding of how Medicare claims works. If you're looking for Medicare plans that could save you money, call us at (844)731-6614 to talk with a licensed insurance provider about your Medicare concerns.
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