Assignment and Claims

It is rare that a patient has to file a Medicare claim for a few reasons. First, those who receive their care through Medicare Advantage Plans (formerly Medicare+Choice) need not file claims at all. Those companies are paid a monthly fee by Medicare and do not have to file claims. Second, medical providers and suppliers are required to file claims so that patients need not do so. The circumstances in which patients must file claims, therefore, are very narrow. They depend upon whether the provider is enrolled in Medicare and whether the provider accepts Medicare assignment. These are questions that providers themselves can answer for patients.

Assignment means that a provider has agreed that it will accept the Medicare-defined reasonable and customary fee for its services.

My Provider Is Not Enrolled In Medicare.

If the provider is not Medicare enrolled, the patient must pay the entire bill for any drugs or supplies purchased. For this reason, it is very important to find out whether pharmacies or suppliers are enrolled in Medicare.

My Provider Is Enrolled and Accepts Assignment.

If a provider is enrolled in Medicare and accepts Medicare assignment, the patient is only responsible for his or her share of the claim. In other words, the patient need only pay his or her copayment and any remaining part of his or her deductible. Medicare will pay the remaining amount directly to the service provider.

My Provider Is Enrolled But Does Not Accept Assignment.

Only if a provider is enrolled in Medicare but does not accept assignment could the filing of a claim be potentially necessary.

Initially, it is important to know that not all medical providers can refuse to accept assignment. For instance, hospitals and skilled nursing facilities must accept Medicare assignment; that is, they must agree to accept the reasonable and customary fee for their services. Only physicians and suppliers can refuse assignment, and even they must file a claim on the patient’s behalf after rendering services. However, they may require the patient to pay the full bill, up to 115% of the Medicare-defined reasonable and customary fee, at the time services are rendered.

Before a patient considers filing a claim, he or she should first contact the health care provider and ask it to file the claim. If the provider fails to do so, the patient should then contact his or her local Medicare carrier, which will contact the provider to request the submission of a claim. If neither of these approaches works, the patient should file a claim when the time period for filing is nearing expiration. Local Medicare carriers can tell patients when the time period for filing will expire and can supply the proper form for patients to file the claim. Generally, the time periods range between 15 months and 27 months, depending on when the service, prescription drug, or supply was received.

The name and contact information for a patient’s local Medicare carrier can be found at www.medicare.gov .

Assignment and Claims

AWARDS