What You Need To Know When You Are Filing For Medicare Claim

Medicare claims request reimbursement for services used by Medicare beneficiaries.

Original Medicare (Part A and Part B) covers inpatient and outpatient hospital stays. Doctors or other Medicare-participating providers fill out and submit reimbursement requests.

Medicare rejects Part B medication and diabetes test strip claims.

However, a Medicare request for medical reimbursement may be needed in some cases. Below are some common reasons this may be essential.

The method for making Medicare claims is an important part of the health care system. It makes sure that healthcare providers get paid for the services they do for Medicare recipients and that Medicare recipients get the care they need without having to go into debt.

What Is Medicare Claim

A Medicare claim is a request for payment for services or goods given to a Medicare beneficiary that is sent to Medicare by a healthcare provider. Providers of health care, like doctors, hospitals, and other health care sites, can send in Medicare claims.

Claims sent to Medicare must include certain details, like the name and Medicare number of the beneficiary, the date of service, the services or supplies given, and the name and National Provider Identifier (NPI) number of the provider. After the claim is sent in, it is looked over to make sure it meets Medicare's rules for coverage and payment. Claims processing is the name for this process.

How Do Medicare Claims Work?

Medicare claims are typically submitted electronically by healthcare providers. The electronic claims submission process is faster and more efficient than paper claims submission. After a claim is submitted, it goes through a review process to determine if it meets Medicare's coverage and payment rules. This review process includes automated edits and reviews by Medicare contractors.

If the claim is approved, Medicare will pay the healthcare provider directly for the services or supplies provided to the beneficiary. The payment amount is based on the Medicare fee schedule, which is a list of prices for each covered service or supply. If the claim is denied, the healthcare provider or beneficiary will receive an explanation of benefits (EOB) that explains why the claim was denied. The healthcare provider may appeal the decision if they disagree with the EOB.

Who File Medicare Claims

Medicare Part A and B are submitted directly to Medicare by your insurer. It takes approximately 30 days to process each claim. Medicare Part A claims directly to the facility or agency that provides you the care.

You’re the one responsible for the deductibles, copayments, and non-covered services. While Medicare Part B claims are submitted either to your provider or by yourself. But the claims will be determined by the assignments:

• If the providers agree to accept the assignment, meaning he accepts the Medicare’s approved amount as full reimbursement. Medicare will the Part B claims directly to him or her for 80% approved amount. And the remaining 20% will be shoulder by you, this will be your co-insurance.
• If the provider does not accept the assignment, he/she is required to send in your claims to Medicare, which then pays the Part B claim directly to you. And you will shoulder the pay 

Beneficiaries can submit their own claims for certain services when the insurer won’t file a claim. However, you cannot file a claim with the Original Medicare for diabetic test strips, Part B drugs, or medical equipment paid under DMEPOS Competitive Bidding Program. Your pharmacy or medical supplier must bill Medicare for these items.

Where Do I File Claim

Original Medicare has participating and non-participating providers. Participating providers accept Medicare reimbursement plus your coinsurance as full payment. And they agreed to always bill Medicare once you need to receive care. On the other hand, non-participating providers can charge you up to 115% of Medicare’s rate and don’t need to file claims with Medicare. This means that you have to submit your own healthcare claim if you choose to see a non-participating provider.

What Do You Need When Filing For A Medicare Claims

Filing for Medicare claims can be a complex process, and it's important to understand what you need to file a claim accurately and effectively. In this section, we'll discuss what you need when filing for Medicare claims, including the required information and documents.

1. Medicare Card: You will need your Medicare card when filing for Medicare claims. Your Medicare card includes your Medicare number, which is required when submitting a claim.
2. Doctor's or Supplier's Name and Information: You will need to provide the name and information of the healthcare provider or supplier who provided the service or supplies to you. This includes their name, address, and National Provider Identifier (NPI) number.
3. Date of Service: You will need to provide the date of service for the service or supplies received.
4. Description of Service or Supply: You will need to provide a detailed description of the service or supply provided. This includes the procedure or item name, the quantity, and the cost.
5. Diagnosis and Treatment Codes: You will need to provide the diagnosis and treatment codes for the service or supply provided. These codes are used to describe the medical condition and treatment provided.
6. Itemized Bill or Statement: You will need an itemized bill or statement that shows the services or supplies provided and the cost for each service or supply.

Assignment of Benefits Form: If you want the healthcare provider or supplier to receive payment directly from Medicare, you will need to sign an Assignment of Benefits form.

How Long Does The Claim Need To File

Original Medicare claims must submit within 12 months of when you received care. Medicare Advantage plan has different time limits, the time limits for advantage plan is shorter than Original Medicare. The best way to find out the time limits for your Medicare Advantage is to ask your insurance provider.

If you have any questions about your Medicare status, claims, and eligibility you can reach Chris Antrim Insurance as he knows when it comes to Insurance and Medicare. When it comes to insurance and Medicare it is always better to ask your agent if you don’t understand anything. Remember that you are the one using the benefits not them.

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