Tuesday, July 11, 2017

Must I File Claims for the Medical Services I Receive

In most cases, claims for medical services and supplies covered by Medicare will be filed by the provider. However, there are some instances where you may be responsible for filing the claim yourself. These are rare cases, and they may be different depending on the provider and your type of Medicare coverage. 
For example, the process and guidelines for filing a claim with Medicare Part A and B may be different than with Medicare Part C and Medicare Part D. Medicare Supplement plans may also be slightly different.

Do I Need to File Claims with Original Medicare for Medical Services

Your health care provider is legally required to file Medicare claims for you if you have Medicare Part A and/or Medicare Part B, and the doctor or hospital is a Medicare-participating provider.
You should always check to see if your provider participates in Medicare and accepts assignment, as this will determine the amount you are charged and whether or not the health care provider will bill Medicare for the services.
Medicare-participating health care providers are under a contract with Medicare to accept a predetermined amount for specific medical services or supplies. This means that the doctor or hospital is essentially a contractor and has accepted assignment of Medicare-approved rates as determined by the Medicare "fee schedule.".
In these instances, the Medicare-participating health care provider will be responsible for filing the claim and billing Medicare directly. They may charge you the cost-sharing amount (copay or deductible) or bill you for it later, but responsibility for filing the Medicare claim lies solely with the provider. Once the doctor or hospital files the claim, Medicare will pay it directly to that provider.

Filing a claim with Medicare

If you see a Medicare-participating health care provider, that provider is legally required to file the claims for any medical services. It is only in very rare instances that a Medicare beneficiary would be responsible for personally filing the claim
However, if your provider does not accept Medicare assignment, the process and prices can be different. These providers are not required to file a Medicare claim and may require full payment for the service upfront. They are also not governed by the Medicare fee schedule and may charge you up to 15 percent more than the amount approved by Medicare. 
In these cases, you may be responsible for paying the cost of the service and filing a claim with Medicare for reimbursement. If you are uncertain about whether your provider accepts Medicare, you can call our team of expert advisors for help.

How to File a Claim

The process of how to file a claim for Medicare Supplement insurance is very similar to that of Medicare Parts A and B. If the doctor or hospital is a Medicare-participating provider, the provider will send the same claim forms to Medicare. Medicare will then forward the claim information to the Medicare Supplement (Medigap) carrier to process.
The Medigap carrier then processes the claim according to Medicare guidelines based on deductible, copay and cost-sharing amounts for the specific plan. In these cases, you will not be responsible for the out-of-pocket expenses that are required upfront for individuals not enrolled in Medicare Supplement.
If the provider does not accept Medicare assignment, you may be required to pay the total amount for the services upfront. If this is the case, the process can be more complex, and you will need to know how to file a claim for Medigap. If you are still unclear about the differences between these types of Medicare, you can call our team of advisors for further instructions.
If your provider does not accept Medicare assignment and you are required to pay upfront, you can file for reimbursement according to Medicare guidelines. To begin the process:
  • Download, print and fill out the "Patient Request for Medical Payment." This can be found at Medicare.gov or CMS.gov.
  • Obtain an itemized bill from your health care provider that includes the name and address of the provider, the date of the service and the amount charged.
  • Write a detailed letter explaining why you are filing the claim yourself.
  • Mail the form, the bill, the letter and any other supporting documents to your state's Medicare contractor. You can find the address for the contractor at CMS.gov or on your Medicare Summary Notice (MSN).
  • If you need more detailed instructions or help finding your state's Medicare contractor, you can call our team of expert advisors for help.

Do I Need to File Claims for Medicare Advantage and Medicare Part D

In most cases, you would not be required to file claims for Medicare Advantage or Medicare Prescription Drug (Part D) services. Since Medicare pays these private insurers a set amount each month, individuals do not need to file claims for medical services.
If your provider is outside of the network, you may be required to pay the costs upfront and file a claim with your specific Medicare plan for reimbursement. For specific information on this process, contact the carrier of your plan directly. You can also contact our advisors for more detailed help on filing claims with Medicare Advantage plans.

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