Mandatory Claim Submission
Note: If you enter into a private contract, this article does not apply to you.
Section 1848 (g) (4) of the Social Security Act requires physicians, and suppliers to submit claims for covered services. The Centers for Medicare and Medicaid Services (CMS) policy for filing Medicare Part B claims is stated below:
All claims for covered services rendered to Medicare beneficiaries must be submitted to the Medicare Carrier.
The claims filing requirement applies to all physicians and suppliers who provide services to Medicare beneficiaries.
Physicians and suppliers are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare participating physician and supplier program, or the Medicare beneficiary is a recipient of a state medical assistance program, or the service is otherwise subject to mandatory assignment.
Physicians and suppliers may not charge the beneficiary for preparing and filing the Medicare claim. Physicians and suppliers are responsible for mailing the claim form. They may not ask Medicare beneficiaries to assume the responsibility to file Medicare claims.
Medicare assigned claims must be filed within one year from the service date or payment will be reduced by 10%.
Patients should be informed that a claim will be completed and filed on their behalf. If the patient is given a copy of the claim, the following statement (or one similar) should be documented in the claim: "Do not use this bill for claiming Medicare benefits. A claim will be submitted to Medicare on your behalf by this office."
Providers are not required to submit claims for the following services:
- Used DME purchased from a private source
- Third party biller claims
- Foreign claims
- Medicare Secondary Payer (MSP) claims, when a provider does not possess information necessary for filing an MSP claim.
If the provider does possess the essential information needed to file a claim, mandatory claims submission requirements apply.
As a reminder, providers are responsible for obtaining and updating the address and insurance information for their patients.
Exception:
As a rule, providers are not required to submit claims for non-covered services. However, if the beneficiary or his/her representative believes a service may be covered or desires a formal Medicare determination for consideration by a supplemental insurance, the provider must submit a claim. The claim should indicate the service is non-covered but is being submitted at the beneficiary's insistence.
Timely Filing of Claims
Generally, claims must be filed within the qualifying time limits to be eligible for Medicare consideration. Claims must be submitted by the end of the calendar year following the year in which the services were rendered. Services provided during the last three months of a calendar year are, for purposes of this rule, considered provided in the calendar year. Below are examples of the time limits.
Service Dates:
October 1, 2007 - September 30, 2008
Claims must be filed by: December 31, 2009
Service Dates:
October 1, 2008 - September 30, 2009
Claims must be filed by: December 31, 2010
As a reminder on assigned claims, there is a 10% reduction in the Medicare payment for untimely claim submissions. Providers are prohibited from billing beneficiaries for the penalty payment reductions that is applied to assigned claims filed more than twelve (12) months after the date of service. Providers may only charge the beneficiary for the remaining annual deductible, co-insurance, and/or for non-covered services. Since the late claim filing penalty does not fall within one of these categories, Medicare providers cannot bill the beneficiary for the 10% payment reduction.
Monitoring of Violators
The Mandatory Claims Submission Monitoring Unit monitors physicians and suppliers to ensure compliance with the Medicare mandatory claim filing requirements. Physicians and suppliers who do not submit claims for beneficiaries, who charge for preparing and filing claims, and/or who charge the beneficiary the 10% reduction in the Medicare payment for untimely claim submission may be subject to civil monetary penalties of up to $10,000 per violation.
Page Last Updated: Thursday, 18-Mar-2010 05:56:21 CDT
