Posts Tagged ‘How to File a Claim for Medicare’

The U.S. Department of Justice (DOJ) has reached an agreement with the city of Humboldt, KS that will improve access to all aspects of civic life for individuals with disabilities. Several important steps will be taken to improve access for individuals with disabilities. Improvements include making physical changes so that parking, routes into the buildings, entrances, service areas and counters, restrooms and other areas are accessible. The agreement was reached under Project Civic Access (PCA), the department’s initiative to make sure that cities, towns and counties comply with the Americans with Disabilities Act.

Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions. There are five levels in the Medicare Part A and Part B appeals process. The levels are:

First Level of Appeal:    Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC).

Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)

Third Level of Appeal:   Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals

Fourth Level of Appeal: Review by the Medicare Appeals Council

Fifth Level of Appeal:    Judicial Review in Federal District Court


Expedited Determination Appeals Process (Some Part A claims only)

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices with beneficiaries enrolled in the original Medicare (fee-for-service) plan are required to notify beneficiaries of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end.

For more detailed information and timeframes about the Expedited Determination Appeals Process, go to the Expedited Determination Appeals Process page on the left.

For more detailed information about each level of appeal, go to the left side of this page or scroll down to the “Related Links Inside CMS” section. To see a diagram of the original Medicare (fee-for-service) standard and expedited appeals process, go to the “Downloads” section below. 

Appeals Process Diagram [PDF, 16 KB] 
Related Links Inside CMS
Changes to the Medicare Claims Appeal Procedures [PDF, 513 KB]  

Changes to the Medicare Claims Appeal Procedures; Continuation of Effectiveness and Extension of Timeline for Publication [PDF, 51 KB]  

MLN The Medicare Appeals Process Brochure [PDF, 1.23 MB]  



Most Medicare beneficiaries will not see a Part B monthly premium increase as a result of a “hold harmless” provision in the current law.  This allows for 73 percent of beneficiaries to be protected from an increase raising the 2010 Part B monthly premiums from $96.40 to $110.50.  The Administration continues to urge Congressional action that would protect all beneficiaries from higher Part B premiums and eliminate the inequity of a high premium for the remaining 27 percent of beneficiaries.

By law, the Centers for Medicare & Medicaid Services (CMS) is required to announce the Part A deductibles and Part B premium amount – a notice that is published annually in the Federal Register.

Under the Medicare law, the standard premium is set to cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over.   The remaining Part B costs are financed by Federal general revenues. This monthly premium paid by beneficiaries enrolled in Medicare Part B covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items.

In calculating the monthly Part B premium each year, the CMS Office of the Actuary includes a contingency margin to provide for possible variation between actual and projected costs.  The size of the contingency margin estimated to be needed for 2010 is affected by two main factors.

First, the current law formula for physician fees, which will result in a reduction in physician fees of approximately 21 percent in 2010 and is projected to cause additional reductions in subsequent years, is one factor affecting the 2010 contingency margin.  For each year from 2003 through 2009, Congress has acted to prevent physician fee reductions from occurring.

In recognition of the strong possibility of increases in Part B expenditures that would result from similar legislation to override the decreases in physician fees in 2010 or later years, it is appropriate to maintain a significantly larger Part B contingency reserve than would otherwise be necessary.  The asset level projected for the end of 2009 is not adequate to accommodate this contingency.

Second, the Social Security Administration announced there would be no increase in Social Security benefits for 2010.   As a result of the hold-harmless provision, the increase in the Part B premium for 2010 will be paid by only a small percentage of Part B enrollees. Most Part B enrollees will pay the same monthly premium that they paid in 2009 ($96.40 was the 2009 standard monthly premium).

Approximately 27 percent of beneficiaries are not subject to the hold-harmless provision because they are new enrollees during the year (3 percent), they are subject to the income-related additional premium amount (5 percent), they do not have their Part B premiums withheld from social security benefit payments (19 percent), including those who qualify for both Medicare and Medicaid and have their Part B premiums paid on their behalf by Medicaid (17 percent).

As required in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), beginning in 2007 the Part B premium a beneficiary pays each month is based on his or her annual income.  Specifically, if a beneficiary’s “modified adjusted gross income” is greater than the legislated threshold amounts ($85,000 in 2010 for a beneficiary filing an individual income tax return or married and filing a separate return, and $170,000 for a beneficiary filing a joint tax return) the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage.  In addition to the standard 25 percent premium, such beneficiaries now pay an income-related monthly adjustment amount.  These income-related Part B premiums were phased-in over three years, beginning in 2007.  About 5 percent of current Part B enrollees are expected to be subject to the higher premium amounts

The 2010 Part B monthly premium rates to be paid by beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or who file a joint tax return are:

Beneficiaries who file an individual tax return with income: Beneficiaries who file a joint tax return with income:

Income-related monthly adjustment amount

Total monthly premium amount

Less than  or equal to $85,000 Less than or equal to $170,000



Greater than $85,000 and less than or equal to $107,000 Greater than $170,000 and less than or equal to $214,000



Greater than $107,000 and less than or equal to $160,000 Greater than $214,000 and less than or equal to $320,000



Greater than $160,000 and less than or equal to $214,000 Greater than $320,000 and less than or equal to $428,000



Greater than $214,000 Greater than $428,000



In addition, the monthly premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at any time during the taxable year are:

Beneficiaries who are married but file a separate tax return from their spouse:

Income-related monthly adjustment amount

Total monthly premium amount

Less than or equal to $85,000



Greater than $85,000 and less than or equal to $129,000



Greater than $129,000



Part B Deductible

The Part B deductible was increased to $110 in 2005 and, as a result of the Medicare Modernization Act, is currently indexed to the annual percentage increase in the Part B actuarial rate for aged beneficiaries.  In 2010, the Part B deductible will be $155.

Part A Premium and Deductible

Today, CMS is also announcing the Part A deductible and premium for 2010.  Medicare Part A pays for inpatient hospital, skilled nursing facility, hospice, and certain home health care services. The $1,100 deductible for 2010, paid by the beneficiary when admitted as a hospital inpatient, is an increase of $32 from $1,068 in 2009.  Beneficiaries must pay an additional $275 per day for days 61 through 90 in 2010, and $550 for lifetime reserve days.  The corresponding amounts in 2009 are $267 and $534, respectively. Daily coinsurance for the 21st through 100th day in a skilled nursing facility will be $137.50 in 2010, up from $133.50 in 2009.

Approximately 99 percent of Medicare beneficiaries do not have to pay a premium for Part A services because they have at least 40 quarters of Medicare-covered employment (or are the spouse or widow(er) of such a person).  However, other seniors and certain people under age 65 with disabilities who have fewer than 30 quarters of coverage may obtain Part A coverage by paying a monthly premium set according to a statutory formula.  This premium will be $461 per month for 2010, an increase of $18 from 2009.  A reduced premium applies in the case of individuals with 30 to 39 quarters of coverage, who will pay a premium of $254 in 2010, compared to $244 in 2009.

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CMS uses five different provider and supplier enrollment applications. In general, Part A providers are required to use the CMS-855A to enroll or update their enrollment information; Part B suppliers (except suppliers of Durable Medical Equipment, and Prosthetics, Orthotics, and Supplies (DMEPOS)) are required to use the CMS-855B to enroll or update their enrollment information; physicians and non-physician practitioners are required to use the CMS-855I to enroll or change their enrollment information; and DMEPOS suppliers are required to use the CMS-855S to enroll or update their enrollment information.  In addition to these four enrollment applications, individual practitioners who would like to reassign their benefits to an eligible provider or supplier or terminate an existing reassignment agreement would use the CMS-855R.

To ensure timely processing of your application, make certain to completely fill out the application and provide all required supporting documentation at the time of filing. Section 17 of the Medicare enrollment application lists the supporting documentation that you will need to submit with your enrollment application. Once you have completed the application, you should mail it to the Medicare contractor servicing your state.  A contractor can generally process your application within 60 days if you submit a complete application with all required supporting documentation.  It will take longer to be enrolled if you are a provider or supplier that requires a State survey or accreditation.  If you have any questions about the enrollment process, please contact your Medicare contractor.


How to File a Claim for Medicare

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 30, 2009, the Medicare claim for that visit must be filed by December 31, 2010.

Is My 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 1-800-Medicare: If your physician or supplier still does not file a Medicare claim after you have called and asked, you should call 1-800-Medicare (1-800-633-4227). Also ask 1-800-Medicare 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 1-800-Medicare 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 only 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, you will need to print out and complete the form called Patient’s Request for Medical Payment, Form CMS 1490S. The form is available for download on in the CMS Forms section.

Once there, you will need to do three things: (1) print out the 1490S form; (2) select and print out the applicable instructions; and (3) review all of the information on this page about how to file a claim form.

To file a Medicare claim yourself, call 1-800-Medicare and ask for the proper form for a Medicare beneficiary to file a claim. 1-800-Medicare can also answer your questions about how to complete the claim form.If you want Medicare to give your personal health information to someone other than you, you need to let Medicare know in writing.

You can fill out the “1-800 Medicare Authorization to Disclose Personal Health Information” form. Call 1-800-MEDICARE (1-800-633-4227) to get a copy of the form, or you can download the form in the Medicare Online Forms section of this web site.

For a list of physicians in your area who always accept assignment, use the Physician and Other Healthcare Professional Directory on this web site.

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