Medicare Claims and Appeals

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Usually, the medical provider submits a Medicare claim, but there are sometimes when you can or must submit a claim. You can file a Medicare claim form whenever a decision has been made by Medicare, your Medicare health plan or the prescription drug plan that you disagree with, such as a decision on covered services, payment obligations and a change to your existing Medicare. The process of completing a Medicare claim form and submitting an appeal is different depending on the part of Medicare you are subscribed to, so it is crucial that you understand the claim and appeal process that will affect your Medicare health insurance. For more information on Medicare claims and appeals, review the sections that have been provided below.

What does it mean to submit a claim and file an appeal with Medicare?

Physicians and health care clinics submit Medicare claims after a service is rendered to be reimbursed financially. A Medicare claim must be filed in a timely manner for the provider to receive payment. If the provider does not submit a claim by the Medicare deadline, then Medicare will not pay for the service. It is rare that you will need to file a Medicare claim, as you can typically contact your provider to submit the form. However, you may need to submit a Medicare claim form after a decision has been made about your Medicare that you disagree with.

Generally, a Medicare claim appeal process will go through five levels before a final decision is made. You will receive a letter after each step on how to move forward with the Medicare claim appeal process. It is important to understand that completing a Medicare claim form does not guarantee that a decision will be made in your favor. In fact, if you do request an appeal, then it is crucial that you speak with your health care provider and ask for any information that can help you win your Medicare appeal case. This information would then need to be provided to Medicare.

How to File a Medicare Claim Form for Medicare Part A and Part B

If you are filing Medicare claim for Medicare Part A or Part B, then there are a few steps that you should be aware of. You cannot submit a Medicare claim online, and you must wait to receive your Medicare Summary Notice (MSN) before a claim can be submitted. You will receive an MSN in the mail every three months and you will have a set number of days to file an appeal from the delivery date of your MSN. The following are the three different options for submitting your Medicare claim form:

  1. Complete a Redetermination Request form and mail it to the Medicare contractor that is listed on the MSN
  2. Circle the items or services that you disagree with on your MSN and write a letter explaining why you disagree with the decision on a separate sheet of paper
  3. Send a written request to the company that handles claims for Medicare

Once you have submitted your Medicare claim, you will need to wait for a decision letter from Medicare. If you still do not agree with the Medicare claim decision, then follow the instructions that the letter will provide in order to reach the next level of the appeal process. For more details on the information needed with you submit a Medicare claim for, download our comprehensive guide.

Completing a Medicare Claim for Medicare Part C

The first step in filing a Medicare claim for Medicare Part C is by requesting an organization determination. During this step of the Medicare claim appeal, you or your doctor can make this request. It can take time for a decision to be reached once the claim has been submitted unless you believe waiting will seriously harm your health. In cases such as these, you have the right to request that the plan provides you with a fast decision.

You may file a Medicare claim form using the appeal process and instructions that will be listed in your decision letter if you agree with the organizational decision. Similar to Medicare claims that are filed for original Medicare plans, there are five levels of the appeal process and you must wait for a decision between each level.

Completing a Medicare Claim for Medicare Part D

The process of submitting a Medicare claim for Medicare Part D is a bit different than the other parts of Medicare. The first thing that you should do if Medicare Part D will not cover a prescription drug is ask your doctor whether your plan has coverage rules or if there is an over-the-counter or brand-name drug that does have coverage and may work as well as the prescription that you were given. If you would still like to file a Medicare claim form, then you will first need to obtain a written explanation (coverage determination) from your Medicare drug plan. This can be obtained by contacting your Medicare plan or having your doctor do so on your behalf.

Once your Medicare Part D plan has received your Medicare claim request, it has 72 hours to notify you of the decision. The Medicare claim process can be expedited if you or your doctor call and both of the following apply:

  • You have not received your prescription
  • Your plan or your physician has determined that waiting the 72-hour period could seriously jeopardize your life, health or functionality

You will then receive a written Medicare claim decision in the mail. If you disagree with this decision, then start the Medicare claim appeal process by completing the instructions located on the written decision. Download our free guide for details on appealing a Medicare decision successfully.

How to Check a Medicare Claim Status

After your Medicare claim has been submitted, it is important to know how to check the status of your claim. Medicare claim status for Part A and Part B claims can be checked online while you will need to check the status of claims for Medicare Part C and Part D by contacting your health plan provider.



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