Last Modified: 8/4/2018 Location: FL, PR, USVI Business: Part A, Part B
Medicare claims: Beneficiary resources
It’s all about you
As a Medicare beneficiary, you are the most important person in the Medicare program. Although you will rarely need to file a claim, it is important for you to understand the Medicare claims process and the resources available to you as a Medicare beneficiary.
The Centers for Medicare & Medicaid Services (CMS) is responsible for managing the Medicare program; however, CMS does not do it alone. Medicare administrative contractors (MAC) across the country are responsible for processing claims and furnishing information to health care providers who furnish services to Medicare beneficiaries within their assigned jurisdictions.
First Coast Service Options Inc. (First Coast) is the MAC for Florida, Puerto Rico, and the U.S. Virgin Islands. It is First Coast’s responsibility to process Part A and Part B “Original Medicare” claims (i.e., not Medicare Advantage or other replacement plan claims) within its assigned jurisdiction. In addition, First Coast keeps members of its provider community informed about changes to the Medicare program and offers an array of resources to facilitate their participation in the Medicare program as a health care provider.
Medicare websites created exclusively for you
Medicare beneficiaries have two dedicated websites that not only furnish information about the Medicare program but also offer exclusive access to online resources created just for them:
• Medicare.gov -- the official U.S. Government site for Medicare -- offers an array of resources to guide beneficiaries not only through the enrollment process but also several interactive resources to help them take advantage of all of the Medicare benefits to which they are entitled. For Medicare beneficiary information in Spanish, please visit: https://www.medicare.gov/find-a-plan/questions/home.aspx?language=Spanish or call 1-800-MEDICARE (1-800-633-4227).
• MyMedicare.gov -- Medicare's free, secure online service for beneficiaries for accessing personalized information about their Medicare benefits and services.
Beneficiary tip: You can also access your Medicare Part A and B claim information, order duplicate Medicare Summary Notices (MSN), and access quality information about your providers.
• Blue Button -- this new service offered on the MyMedicare.gov website allows beneficiaries to download their health information to their computers or to their mobile devices.
Beneficiary tip: Look for the Blue Button as you search claims and view your On the Go Report.
Your provider is responsible for filing your Medicare claim -- it’s the law
Doctors and suppliers are required by law to file Medicare claims for covered services and supplies furnished to beneficiaries who have Medicare Part A and Part B plan coverage (i.e., original Medicare). Medicare beneficiaries should only need to file a claim in very rare cases.
If you have a Medicare Advantage Plan or other Medicare replacement plan, you will not have to file a claim with Medicare because Medicare pays these private insurance companies a set amount each month.
What you need to know …
• Medicare claims must be filed no later than 12 months (or one full calendar year) after the date in which services were provided. If a claim has not been filed within this time limit, Medicare cannot pay its share.
• Check your Medicare Summary Notice (MSN) , which shows all of your services and supplies for which providers and suppliers billed Medicare during the three-month period, the amount that Medicare paid, and the maximum amount that you may owe the provider.
• Medicare will mail a new MSN to you every three months
• If you don’t want to wait for your MSN, you can access your Part A and Part B Medicare claims information online at MyMedicare.gov .
What to do if your provider has not filed your Medicare claim
• If your Medicare claim has not been filed by your doctor or supplier, follow these steps:
1. Call 1-800-MEDICARE and ask the representative to tell you the exact deadline for filing your claim for the service or supplies you received
2. Contact the doctor or supplier and ask them to file the claim before the deadline
• If it's close to the filing deadline and your doctor or supplier still hasn't filed your Medicare claim, you may file the claim yourself by following these steps:
1. Complete, sign, and date the Patient Request for Medicare Payment form (CMS-1490S)
2. Attach any itemized bills from your doctor(s) or supplier(s) associated with the claim to the back of the CMS-1490S form
3. If services were provided for you in Florida, Puerto Rico, or the U.S. Virgin Islands, mail the completed form and required attachments to:
First Coast Service Options Inc.
P.O. Box 2525
Jacksonville, FL 32231-0019
P.O. Box 2525
Jacksonville, FL 32231-0019
How to check your claim’s status: MyMedicare.gov
• If you would like to check the status of your Medicare claim, you may check your MSN or access your claims information online at MyMedicare.gov . You’ll usually be able to see a claim within 24 hours after Medicare processes it.
• For specific billing questions and questions about your claims, medical records, or expenses, you may call 1-800-MEDICARE or visit MyMedicare.gov .
How to file an appeal
If you disagree with a coverage or payment decision made by Medicare, you have the right to file an appeal. You may also file an appeal if Medicare stops providing or paying for all or part of a health care service, supply, item, or prescription drug you feel that you still need.
If your Medicare claim has been denied and you would like to file an appeal, ask your doctor, health care provider, or supplier to file the appeal for you. If the provider is unwilling to file an appeal, ask them for information that may help your case. If you choose to file an appeal yourself, the best place to start is by reviewing your MSN. It will show if Medicare has fully or partially denied your medical claim.
1. Complete a Redetermination Request Form and send it to the Medicare contractor at the address listed on the MSN.
2. Follow the instructions on the back of the MSN. You must send your request for redetermination to the company that handles bills for Medicare (their address is listed in the Appeals Information section of the MSN.)
• Circle the item(s) and/or services with which you disagree on the MSN.
• Describe the reasons why you disagree with the decision on the MSN, or you may write it on a separate piece of paper and attach it to the MSN.
• Include your name, address, phone number, and Medicare number on the MSN and sign it.
• Include any other information you have about your appeal with the MSN. Ask your doctor, health care provider, or supplier for any information that may help your case.
3. Send a letter to the company that handles bills for Medicare (their address is listed in the Appeals Information section of the MSN.) Your letter must include:
• Your name and Medicare number.
• The specific item(s) and/or service(s) for which you're requesting a redetermination and the specific date(s) of service.
• An explanation of why you don't agree with the initial determination.
• Your signature, or the name and signature of your representative.
The appeals process has five levels . If you disagree with the decision made at any level of the process, you may generally proceed to the next appeal level. At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal. For more helpful tips about the appeals process, please review: 5 things to know if you want to appeal a payment decision .
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.