What is a Medicare part of a claim? Unpacking the Key Components

According to the Centers for Medicare & Medicaid Services (CMS), most healthcare providers electronically file Medicare claims on behalf of beneficiaries. A better understanding of what is a Medicare part of a claim can help you review your statements for accuracy and ensure proper coverage.

Quick Summary

A Medicare claim is a request for payment submitted to Medicare for healthcare services or supplies received. Key components include beneficiary and provider information, dates of service, and details about the specific services or items provided, as summarized on a Medicare Summary Notice.

Key Points

• Claim vs. Notice: A Medicare claim is the provider's request for payment, while an MSN or EOB is the summary statement you receive detailing how the claim was handled.

• Provider's Responsibility: In most cases, your healthcare provider is responsible for submitting the claim to Medicare on your behalf.

• Essential Information: A claim includes crucial details such as beneficiary and provider identification, dates and descriptions of service, and diagnosis codes.

• Claim Filing Deadline: For Original Medicare, claims must be filed within 12 months of the date of service.

• Different for Advantage Plans: For Medicare Advantage plans, your provider bills your private insurer, and you receive an Explanation of Benefits (EOB) instead of an MSN.

• Self-Filing Requirements: In rare instances of self-filing, you must use form CMS-1490S and include an itemized bill and a letter of explanation.

• Monitoring Your Claims: You can monitor the status of your claims and review your notices online at Medicare.gov to protect against errors and fraud.

A Medicare claim is a formal request for payment that a healthcare provider submits to Medicare after you receive services or supplies. While the provider typically handles the billing process, the claim contains specific parts that are crucial for determining coverage and payment. Understanding these elements is essential for beneficiaries to review their Medicare Summary Notices (MSNs) and ensure that everything is billed correctly.

What a Medicare Claim Comprises

A Medicare claim includes several standard pieces of information that identify the beneficiary, the provider, and the services rendered. A doctor's office, hospital, or durable medical equipment supplier sends this information to a Medicare Administrative Contractor (MAC) for processing.

• Beneficiary Information: This section identifies the person who received the care. It includes the beneficiary's name, address, and Medicare Beneficiary Identifier (MBI), which replaced the Social Security Number (SSN)-based Health Insurance Claim Number (HICN) to protect against identity theft.
• Provider Information: This section identifies the healthcare professional or facility that provided the services. It includes the provider's name, address, and National Provider Identifier (NPI).
• Date and Place of Service: A claim specifies the exact date(s) when services were provided and where they were received. This could be a doctor's office, a hospital outpatient department, or another location.
• Service Details: A detailed, line-by-line description of the specific medical procedures, tests, or supplies furnished. Each service is represented by a standardized billing code (HCPCS).
• Diagnosis Codes: The claim includes the primary and secondary diagnoses associated with the services rendered. This is used by Medicare to determine the medical necessity of the services provided.
• Charges: For each service, the claim lists the total charge submitted by the provider and the amount approved by Medicare.

The Role of a Medicare Summary Notice (MSN)

After a claim is processed, beneficiaries with Original Medicare receive a Medicare Summary Notice (MSN). The MSN is not a bill, but a statement that details the claims submitted on your behalf during a three-month period. For beneficiaries enrolled in a Medicare Advantage (Part C) plan, the private insurer sends an Explanation of Benefits (EOB) with similar information.

Your MSN provides a comprehensive breakdown of each processed claim, including:

• The service or supply provided, including a description of the item or service.
• The amount billed by the healthcare provider.
• The amount Medicare approved for payment.
• The amount Medicare paid to the provider.
• The amount you may owe the provider, which may include deductibles, copayments, or coinsurance.

Comparing Claim Information: Original Medicare vs. Medicare Advantage

Aspect	Original Medicare (Part A & B)	Medicare Advantage (Part C)
Payer	The federal government.	The private insurance company managing the plan.
Primary Document	Medicare Summary Notice (MSN).	Explanation of Benefits (EOB).
Document Frequency	Sent every three months for processed claims.	Typically sent monthly when services are used.
ID Card Used	Present your red, white, and blue Medicare card to providers.	Present your private insurer's ID card; store your Medicare card securely.
Claim Submission	Provider bills Medicare directly.	Provider bills the private insurer directly.

The Standard Medicare Claim Process

For most beneficiaries, the claim process is straightforward and requires minimal action. When you receive a covered service from a Medicare-participating provider, the provider is responsible for filing the claim.

• Receive Treatment: When you see a doctor or get hospital care, the provider collects your Medicare information.
• Provider Files Claim: The provider submits the claim electronically to the appropriate Medicare Administrative Contractor (MAC), which processes claims for a specific geographic region.
• Medicare Processes Claim: Medicare reviews the claim to ensure the service is medically necessary and covered by your plan. This process can take around 30 days.
• Payment is Sent: For Part A, Medicare pays the facility directly. For Part B, Medicare pays the provider directly if they accept assignment. If not, the payment goes to the beneficiary, who then must pay the provider.
• Review Your Notice: You receive an MSN (for Original Medicare) or EOB (for Medicare Advantage) detailing how the claim was processed. This is your opportunity to review for accuracy.

When You Might Need to File a Claim Yourself

While rare, there are instances where a beneficiary might need to file a claim personally using a Patient Request for Medical Payment form (CMS-1490S). This typically occurs in a few specific scenarios:

• Your provider refuses or fails to file a claim on your behalf.
• You receive services or durable medical equipment from a supplier who does not bill Medicare.
• In certain specific cases of travel, such as a medical emergency in Canada when closer than a U.S. hospital.
• You receive a bill from your provider because they haven't submitted the claim.

When filing a claim yourself, you must also submit an itemized bill from the provider and a letter explaining the reason for the claim. Claims must be filed within one calendar year of the date of service.

Conclusion

Understanding what is a Medicare part of a claim is crucial for managing your healthcare costs effectively. By familiarizing yourself with the standard claim process and how to read your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB), you can verify that the care you received is accurately represented and covered. In the rare event that you need to file a claim yourself, having this knowledge ensures you can navigate the process correctly and receive the reimbursement you are entitled to. Regularly reviewing your notices is a simple but important step in protecting yourself from billing errors and potential fraud.

To learn more about your Medicare rights and claims process, visit the official Medicare.gov website.

Common Medicare Claim Terms

• Assignment: An agreement by a doctor, provider, or supplier to accept the Medicare-approved amount as full payment for covered services.
• Coinsurance: The percentage of the cost of a covered service you pay after you've paid your deductible.
• Copayment: A fixed amount you pay for a covered service after you've paid your deductible.
• Deductible: The amount you must pay for covered healthcare services before Medicare starts to pay.
• Excess Charges: The difference between a provider's charge and the Medicare-approved amount. A non-participating provider can charge up to 15% more than the Medicare-approved amount.
• Provider: A doctor, hospital, or medical supplier that provides healthcare services to a patient.

Checking on a Claim's Status

• Online Account: You can check the status of your claims by logging into your secure account on Medicare.gov.
• MyMedicare.gov: This online portal allows beneficiaries to view their claim history for the past 36 months.
• Customer Service: For specific questions, you can call 1-800-MEDICARE or contact your Medicare Advantage plan directly.

What to Do If You Disagree with a Claim

• Contact Provider: If you spot an error, contact your healthcare provider's billing office first to see if they can correct the information submitted to Medicare.
• File an Appeal: If you still disagree, you have the right to file an appeal. The steps and timeframe for appeals are outlined on your MSN or EOB.
• Seek Assistance: You can get free, local assistance with the appeals process from your State Health Insurance Assistance Program (SHIP).

Frequently Asked Questions

What is the difference between a Medicare claim and a Medicare Summary Notice?

A Medicare claim is the bill submitted by your healthcare provider to Medicare for payment. A Medicare Summary Notice (MSN) is the statement you receive afterward, detailing the claims that were processed for you, showing what was billed and what Medicare paid.

Who is responsible for filing a Medicare claim?

In almost all cases, your healthcare provider—including your doctor, hospital, or medical supplier—is responsible for filing the claim with Medicare.

What information should I look for on my Medicare Summary Notice (MSN)?

You should check that the MSN accurately lists the services you received, the dates of service, the amount billed, the amount approved by Medicare, and the portion that you are responsible for paying.

When would I need to file a Medicare claim myself?

You might need to file a claim yourself if your provider refuses or is unable to do so, if you receive services from a supplier who doesn't bill Medicare, or in specific cases of receiving emergency medical care abroad.

What happens if a provider does not accept Medicare assignment?

If a provider does not accept assignment, they can charge you more than the Medicare-approved amount, up to 15% in excess. The provider must still submit a claim to Medicare, but the payment is sent to you, and you are responsible for paying the provider.

How long does Medicare take to process a claim?

After a provider files a claim, Medicare typically takes around 30 days to process it. You will be able to see the processed claim on your online Medicare account within about 24 hours of completion.

What is an Explanation of Benefits (EOB), and is it different from an MSN?

An Explanation of Benefits (EOB) is a document from a private insurance company, such as a Medicare Advantage plan, that details how a claim was paid. It is similar to an MSN but comes from a private insurer, not directly from Medicare.