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How to File a Claim

If you are in a Medicare advantage program, you do not need to file a claim. These programs are designed to circumvent the claims process. However, if you are on the Medicare Original program, there may be a time when you will need to file a claim or Medicare appeal.

When a Claim is Necessary

Medicare claims must be filed by the end of the year following the date of service. For example, if you received service on April 1, 2010 your claim must be filed no later than December 31, 2011. Your health care provider (i.e. doctor, pharmacy, clinic, etc.) usually will file the claim on your behalf. Sometimes however, for various reasons this does not happen. If your provider fails to file your claim, you will want to file it yourself in order to avoid losing your coverage for that service.

Filed Claims

Medicare sends its members a quarterly statement of their benefit account. This statement is called an MSN. MSN Stands for "Medicare Summary Notice" and it details for each recipient all claims which have been filed in the previous quarter.

Remember though, the claim has to be filed by no later than December 31st of the year after the date of service. This means that your MSN will not necessarily have all of the services that you received in the prior three months, nor will it have only the services you received in that time frame. It is necessary for you to check each and every Medicare Summary Notice you receive to ensure that all of your claims have been filed.

A good way to manage this is to utilize your calendar. Most of us keep track of doctor's appointments on our calendars. It would be beneficial if you work out some sort of system wherein you go back through your calendar when you receive your MSN and check off (or highlight, or cross out, etc.) each occurrence of service when it shows up on your Summary. This will help you to know when a claim has not been filed.

If you find that the deadline for filing your claim is approaching and your claim has not yet been filed, you should first contact your health care provider. It is possible that they are having difficulty filing the claim. It is also possible that your claim got lost in the shuffle. You do not want to let this go, however because once your time frame for filing has expired the financial responsibility for paying the bill falls to you. The simple fact that the health care provider has not filed the claim does not mean that they will not eventually desire payment for their services, and you will want to make sure that your covered services are being paid.

When you call your provider, be prepared to tell them the date of the service and the service type (checkup, blood test, etc.). If they have neglected to file the claim, please ask them to do so. Once you have done this, you will want to follow up with them periodically to make sure it is done.

If your health care provider does not file the claim (for whatever reason) it may become necessary for you to file the claim yourself. The process for this is relatively simple. There is a form on the Medicare website called the "Patient's Request for Medical Payment". There are instructions right there with it that will tell you all you need to know about how to file a claim.


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