How Do I File Claims for Medicare Reimbursement?

How Do I File Claims for Medicare Reimbursement?

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Medicare reimbursement is the process by which a doctor or health facility receives funds for providing medical services to a Medicare beneficiary. However, Medicare enrollees may also need to file claims for reimbursement if they receive care from a provider that does not accept assignment. In this case, some documents would be required to receive full reimbursement for a health procedure.

What is Medicare reimbursement?

Medicare reimbursements are payments that hospitals and physicians receive in return for services they have provided to Medicare policyholders. Generally, you do not need to submit Medicare costs or claims for any services rendered since these will be taken care of by the provider or your doctor if they accept assignment.

When a provider accepts assignment it means that the provider of the medical services has signed an agreement with Medicare to accept Medicare reimbursement for their work.

For example, you go to your doctor for an x-ray during which the normal cost is $100. If the doctor you visited accepted assignment then you would only be charged $20 since this is Medicare's allowable charge for that service. However, you would still need to pay the Part B coinsurance of 20% (20% x $20 = $2) if you did not have a Medigap policy which covered it.

Medicare reimbursement rates and allowable charges

Medicare reimbursement rates or allowable charges are the amount of money that Medicare pays to doctors after they have filed a claim for services. Also known as the Medicare Physician Fee Schedule, the payments vary depending on which service is provided.

Medicare reimbursement rates will be based upon Current Procedural Terminology codes (CPT). These codes are numeric values assigned by the The Centers for Medicare and Medicaid Services (CMS) for services and health equipment doctors and facilities use.

An example scenario would be when a doctor performs a diabetes test. After the treatment they may look up the CPT code for the procedure then file the necessary claim to Medicare. In return, Medicare would look up the allowable charge for that procedure and then reimburse the doctor the amount of money. Generally, doctors are reimbursed at a lower rate for Medicare services — 80% of the total rate — when compared to private health insurance.

When do I need to file a claim for Medicare reimbursement?

If you visited a doctor or provider that does not accept assignment, then you would need to file a claim for Medicare reimbursement yourself. In this scenario, the provider would still provide you the health service but is allowed to charge more. Furthermore, in most cases, you would be billed up front for the service. Once you are billed, then you could seek reimbursement from Medicare.

Note that a provider cannot bill you more than 15% of the Medicare allowable rate set by the CMS. In Medicare, this is known as the excess charge or Part B excess charges.

For example, if you got a service that normally costs $500 and Medicare pays $250 then the doctor cannot bill you more than $287.50 (15% more than $250).

What forms are needed for Medicare reimbursement?

To file for a Medicare reimbursement, you must complete the following steps.

  • Complete Medicare Form 1490
  • Itemize the bill from the provider
  • Send both documents to the Medicare contractor near you

The first and most important step in filing for Medicare reimbursement is to complete the Medicare Form 1490. Also known as the Patient's Request for Medical Payment form, this is where you would fill out the reasoning for the claim, any services you received and the health insurance you have.

Along with the completed 1490 form, you would include the itemized bill from the provider. On this bill you should check to make sure that service information was provided correctly from your doctor. This includes the date and facility where you received treatment, the type of treatment and cost and name and address of the provider.

Once these documents are compiled, you should send or deliver them to a Medicare contractor. Medicare administrative contractors are often local insurers that process medical claims and can be found on the CMS website.

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