This video will provide you an overview of how to file a Medicare claim. It includes basic
information about the Medicare Fee-for-Service, Original Medicare, billing process.
For more information, visit the Medicare Learning Network (or MLN) at http://go.cms.gov/mln.
What is a Medicare Claim?
A Medicare claim is a payment request for
benefits or services a health care provider gives to the beneficiary.
Know these four steps before filing a Medicare claim.
First, complete your Medicare applications. Second, know when to not file a claim.
Third, determine the Medicare Secondary Payer status,
and fourth, collect the beneficiary’s unmet deductibles, coinsurance, and copayments.
Step One, to obtain payment from Medicare, you must apply for both
One: A National Provider Identifier (NPI), and two: The Medicare Program Enrollment.
Step Two, don’t file a Medicare Claim for
Services furnished outside the United States (U.S.)
Non-covered services, unless the beneficiary requests submission of a claim to Medicare
You opted-out of the Medicare Program and entered into a private contract with the beneficiary
or if Medicare has excluded or debarred you from the program
Step Three, be sure to determine Medicare’s secondary payer status.
If another plan, insurer, or program is the primary payer, file with the
primary payer first and then identify such payers on the claim you submit to Medicare.
Step Four, collect the beneficiary’s unmet deductibles, coinsurance, and copayments.
Now, you’re ready to submit a claim.
File your Medicare claims with CMS claims contractors,
also known as Medicare Administrative Contractors or MACs.
MACs process Medicare Part A, Part B, and Durable Medical Equipment Prosthetic
Orthotics and Supplies (DMEPOS) claims. Medicare claims have timely filing requirements
File your claims with the MAC no later than one calendar year from the claim’s date of service.
How do you submit the claims to your MAC?
CMS requires the submission of Electronic Claims via Electronic Data Interchange
(EDI) except in limited situations.
In limited situations, you may submit paper claims to Medicare.
Use the Health Insurance Claim Form (CMS-1500) or Institutional paper claim form (CMS-1450)
Contact your MAC for more information about electronic or paper claims.
To find your MAC go to http://go.cms.gov/MAC-website-list
on the CMS website. Select your place of business or MAC’s name from the list provided.
Providers who submit claims that aren’t based on their place of business can use the MAC name list.
You’ve filed your claim with the MAC, what’s next?
The MAC will check your claim for required information
and verify the claim data. If your claim passes,
the MAC will process it according to Medicare payment policies and guidelines
After the MAC has processed your claim, the MAC will send you an electronic payment
along with a notice of payment and adjustment also known as a Remittance Advice (RA)
This concludes our introduction to Medicare part A and B claims. We hope you found this helpful.
This educational product was prepared as a service to the public
and is not intended to grant rights or impose obligations. This educational product may
contain references or links to statutes, regulations, or other policy materials.
The information provided is only intended to be a general summary. It is not intended to take the
place of either the written law or regulations. We encourage readers to review the specific statutes,
regulations, and other interpretive materials for a full and accurate statement of their contents.
The Medicare Learning Network®, MLN Connects®,
and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).
Paid for by the Department of Health & Human Services.