Written by Megan Smith, PT
55 million Americans - roughly 15% of the population - are currently enrolled in Medicare.
And yet with 55 million Medicare beneficiaries, one common question continues to be asked by anyone trying to file a Medicare claim, and that’s “How on earth do I do this?!”
If you feel overwhelmed or intimidated at the thought of filing a claim through Medicare, you are certainly not alone.
Medical forums, insurance companies, and government agencies do their best to make sure policies and procedures are thoroughly explained, but even the most well-meaning attempts at explanation often get lost in the jargon of confusing phrases and terminology.
We have people who can help us file our taxes when we aren’t sure how to do them ourselves, but that same kind of help isn’t typically offered when filing a claim through Medicare.
If you’ve been feeling unsure about filing a claim for payment or have been putting it off due to uncertainty, we’re here to help.
In our Everything You Need to Know About Filing a Medicare Claim, you’ll find a walk-through of how to file a direct medical payment claim, as well as an FAQ, broken down by individual questions and answers.
So take a deep breath, and let’s jump in!
First, some fast facts about Medicare and Medicaid.
Q: How do I know if I have a valid claim to submit to Medicare?
A: All Medicare beneficiaries have the option to submit a claim on behalf of five categories. These categories include:
If you have an unresolved medical situation that falls into one of these five categories, wonder no more - you are eligible to submit a claim!
Q: What is an Advance Beneficiary Notice of Non-Coverage (ABN), and what does it imply?
A: An ABN is a paper or electronic form all Medicare subscribers are required to fill out if their doctor has any reason to think that the services the subscriber is getting have the potential of not being covered by Medicare.
Put simply, the form is a written agreement between the subscriber and the subscriber’s doctor that Medicare isn’t legally expected to pay for the costs/services being obtained, why they aren’t expected to pay, and the monetary estimate for the costs accrued.
Doctors and healthcare professionals are required to furnish you with an ABN if they have reason to believe your service won't receive coverage. The form is meant to help patients understand clearly what kind of financial obligations they could potentially be getting themselves into before pursuing the desired treatment or necessary medical assistance.
There are exceptions to when a doctor may choose to furnish you an ABN; for example, if you were in the back of an ambulance and under great duress, requesting your medical consent to the financial implications of treatment would be inappropriate (not to mention unkind). It is at the discretion of the healthcare provider when you are made aware of your options, and the likelihood of non-coverage.
All users have the option to file an appeal if a request for payment is submitted and denied.
Q: What will Medicare pay for (and not pay for) if I have a medical emergency on a ship, in Canada/Mexico, or while in a foreign country?
A: As might be expected, Medicare, like any form of insurance, has pretty strict parameters as far as what’s covered, and what’s not.
If you are a Medicare beneficiary and receive medical services aboard a cruise ship, Medicare will cover the cost of expenses so long as you are either within six hours of a U.S. port, or in U.S. sanctioned waters. Anything else (services were performed in international waters, the ship was more than six hours from a U.S. port), and you will need to submit a claim.
In general, health care services for Medicare beneficiaries are not covered if rendered outside the U.S.
Exceptions to this rule include the following (as stated on Medicare.gov):
It's worth mentioning that Medicare beneficiaries are strongly encouraged to purchase travel insurance while on extended trips outside of the U.S., as the claims process can be tedious, and approval is not guaranteed.
Q: What is Medicare talking about specifically when it refers to “durable medical equipment” (DME)?
A: Durable medical equipment can be defined by the following points:
Q: What durable medical equipment (DME) does Medicare cover?
A: According to Medicare.gov, the list of DME products that are covered are as follows:
Q: What does it mean to “submit a Medicare claim for direct medical payment for DME”?
A: Medicare beneficiaries will need to submit a Medicare claim for direct payment only in situations when their Medicare network doctor or physician prescribes a product that falls outside Medicare’s network of services, or for which there is no Medicare-approved substitute.
Typically, a doctor or physician would submit a claim on you or your loved one’s behalf. But in instances where DME is purchased independently of a Medicare prescriber, a claim is necessary.
The process of actually submitting a claim for coverage is something you will either undertake for yourself, or on behalf of a loved one - which brings us to our second question.
Q: How can I submit a Medicare claim for direct medical payment for DME?
A: To begin the process of submitting a claim, begin by downloading and filling out this form. This is called a “Patient Request for Medical Payment”.
Then, follow these instructions listed on Medicare.gov to properly fill out your Patient Request for Direct Medical Payment form. The instructions explain exactly what needs to be submitted along with your claim; but in case it’s unclear, our next question will recap.
Q: What all needs to be submitted with my completed “Patient Request for Medical Payment” form?
A: Before you start, it’s important that all Medicare beneficiaries have complete and accurate forms submitted and signed from the physician who prescribed either the medical treatment, and/or the order for the DME being purchased.
In the absence of these correct files, Medicare may reject your claim. (Refer to the first FAQ question regarding an Advance Beneficiary Notice of Non-Coverage, or ABN.) Rejection of a claim would either delay your process of purchasing your needed medical equipment, or cause you to have to pay out of pocket for the service/product.
Clearly, neither of these are desirable options.
Make sure you have the following documents to successfully submit your claim:
Q: I submitted my form! How long will I need to wait before knowing if my claim has been accepted or rejected?
A: The short answer is, it varies!
However, all submitted claims will be visible online within 24 hours of being submitted. Beneficiaries need only log into their account at MyMedicare.gov using their account credentials, and may view the status of their claim at any time.
You can read more about Medicare, Medicaid, and the process of filing a claim at Medicare.gov.
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Megan has been a part of Rehabmart since its inception nearly 20 years ago. For the past several years she has been enjoying her role as HR Director while maintaining her Physical Therapy license. When she isn't working on her next in-service or working to find a new team member, she enjoys her five children, helping those who have PT type ailments, baking, practicing yoga, and working out.
