Understanding Medicare Claims

When you are covered by Medicare benefits under Original Medicare, your doctor or medical supply provider will usually be responsible for filing Medicare claims on your behalf. Medicare "claims" are formal documents that allow the Medicare system to evaluate the products and services you have received and ensure everything is included in coverage. Although you are rarely responsible for filing Medicare claims personally, understanding Medicare claims is vital, because it is possible a claim will be contested.

From the perspective of a patient, the most important function of a Medicare claim is to ensure you receive the benefits you are entitled to. A Medicare claim is the document that allows you to receive your benefits. If a claim is never filed for a covered procedure or service, you cannot receive your benefits. Notice that the Medicare claim is important only for patients covered by Original Medicare.

Patients covered by a Medicare Advantage program do not need to file claims. That's because Medicare pays out a given amount to these organizations on a regular basis. If you receive a covered medical service and your doctor or other provider talks about filing a Medicare claim, you should ensure that they understand you are on an Advantage program. Clerical mistakes can lead to problems receiving your correct benefits.

Just like any private insurance organization, Medicare operates on a strict basis that allows it to review all claimed services and rescind coverage of anything that it deems is not covered under its umbrella. Medicare claims facilitate this process, which is why they are among the most contentious parts of the Medicare process. However, Medicare claims are also helpful and informative to the patient, because they allow you to see at a glance the kinds of services that you received, the cost, and the level of coverage.

Filing a Medicare Claim

In the vast majority of cases, your Medicare claim will be filed by the doctor's office or by the medical supplier who furnished any covered services. You will not bear any responsibility for the filing process, though you should always work with the doctor to ensure the claim is sent.

Medical organizations across the country use very sophisticated data entry programs that allow them to gather all the needed information and file a claim. If they fail to use these programs, they are not legally allowed to file the claims -- and will frequently go out of business as a result!

One of the most important things to know about Medicare claims is that they must be filed, either by you or by the medical organization, within twelve months of the date you received treatment. If they are not filed within this deadline, Medicare will not pay benefits. As long as a claim is filed, you can usually contact the medical provider and ensure that you will not have to pay any installments for covered procedures, even if it takes a long time for the provider to receive their fee. You should never pay for covered procedures, as this can make it difficult to receive future benefits in some cases.

Infrequently, you may have to file a Medicare claim yourself. Covered individuals generally only file claims when they determine that their medical provider is not filing them on time. Every three months, you will receive a Medicare Summary Notice (MSN) that outlines everything charged to Medicare in the last three months. If you have received covered services that aren't listed, your first move should be to contact your provider. If the services still aren't listed within six months, file the claim personally.

You will need a Patient's Request for Medical Payment form, which you can download through Medicare's government website. This is a brief, one-page form that will allow you to submit a claim on your own behalf. The reason why you should always submit a claim after waiting no more than six months -- two Medicare Summary Notices -- is so you can review the third MSN, issued after nine months. This way, if you still do not see a claim mentioned within nine months, you have a full three months to take further action.

Understanding Medicare Claims: Dispute Resolution

Whenever filing a Medicare claim, there is some danger of a dispute. During a dispute, Medicare will assert that a certain amount of your claimed procedure is not covered by their umbrella. You are empowered to file an appeal by following the established appeal process. You can also appeal if Medicare ceases payment (or partial payment) for any service you feel you still need to maintain your health.

The appeals process varies based on what kind of Medicare coverage you have: Original Medicare, Medicare Advantage plans, and Medicare Prescription Drug Plans all differ. If you have a Medicare Advantage plan or Medicare Prescription Drug Plan, you should contact your plan administrator to get details on appeal.

If you are covered by Original Medicare, you can file an appeal using the information included with your Medicare Summary Notice. You should file the appeal as soon as possible, since you only have a maximum of four months (120 days) to do so.