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MMA 2003

How to File a Claim

If you are in the Original Medicare Plan, providers (e.g., hospitals, skilled nursing facilities, home health agencies, and physicians) and suppliers are required by law to file Medicare claims for covered services and supplies that you receive. You should not need to file any Medicare claims. Medicare claims must be filed within one full calendar year following the year in which the services were provided. For example, if you see your physician on March 22, 2001, the Medicare claim for that visit must be filed by December 31, 2002.

Is your pharmacy or supplier enrolled in Medicare?
If the answer is no, you will be responsible for the entire bill for any drugs or supplies purchased. Important information you need to know before you make your purchase.

Note: This information on filing a Medicare claim only applies if you are in the Original Medicare Plan. If you get your Medicare health care through a Managed Care Plan or a Private Fee-for-Service Plan, Medicare claims are not filed. Medicare pays these private insurance companies a set amount every month. Therefore, they do not need to file Medicare claims.

My Provider or Supplier Accepts Medicare Assignment

You pay your share of the bill (coinsurance and deductibles) to the provider or supplier. The provider or supplier files a Medicare claim. Medicare pays its share of the bill directly to the provider or supplier.

My Physician or Supplier Does Not Accept Medicare Assignment

Note: Only physicians and suppliers can decide not to accept assignment.

If your physician or supplier does not accept assignment for covered services, your physician or supplier may require that you pay most or all of the bill at the time you receive services or supplies. However, the physician or supplier is still required to file a Medicare claim on your behalf. Medicare then pays its share of the bill directly to you.

Medicare cannot pay you its share of the bill until a Medicare claim is filed. You should take the following steps if your doctor or supplier does not file the Medicare claim in a timely manner.

Step 1 - Contact Your Physician or Supplier: Call your physician or supplier directly and ask the physician or supplier to file a Medicare claim.

Step 2 - Contact Your Local Medicare Carrier: If your physician or supplier still does not file a Medicare claim after you have called and asked, you should call your local Medicare Carrier. The Medicare Carrier phone number can be found in our Helpful Contacts section of this web site. Your local Medicare Carrier will contact the physician or supplier on your behalf to make the physician or supplier aware of the responsibility for filing a Medicare claim. Also ask the Medicare Carrier for the exact time limit for filing a Medicare claim for the service or supply that you received.

IMPORTANT: There is a time limit for filing a Medicare claim. If a claim is not filed within this time limit, Medicare cannot pay you its share. The time limit may be as short as 15 months or as long as 27 months depending on when you received the service or supply. It is important that you ask the Medicare Carrier what the time limit is for filing your claim.

Step 3 - When You Should File a Claim: You should only need to file a Medicare claim in very rare situations. You should contact your local Medicare Carrier and ask for the forms to file a Medicare claim yourself when:

  • you have completed steps 1 and 2 above; AND
  • the physician or supplier still has not filed the Medicare claim; AND
  • it is close to the time limit for filing your Medicare claim. (For example, if your time limit is 15 months, you should consider filing a Medicare claim if the physician or supplier has not filed the Medicare claim 12 months after you received the service or supply).

To file a Medicare claim yourself, call your local Medicare Carrier and ask for the proper form for a Medicare beneficiary to file a claim. Your Medicare Carrier can also answer your questions about how to complete the claim form.

For more information about assignment, read the brochure: Does Your Doctor or Supplier Accept Assignment? For a list of physicians in your area who always accept assignment, use the Participating Physician Directory on this web site.

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