Plain version: in Original Medicare the provider bills Medicare, and the beneficiary gets a notice, not a bill. Knowing who files, what assignment means and how to appeal answers most client questions.
Who files: the CDI outline says claims are submitted by health care providers and approved medical equipment suppliers to CMS. The law requires the doctor, provider or supplier to file the claim for covered services and supplies, no later than 12 months after the date of service unless an exception applies. A beneficiary should need to file only in rare cases; if a provider fails to file, the beneficiary can submit Form CMS-1490S.
Assignment vs. non-assignment:
A provider who accepts assignment takes the Medicare-approved amount as payment in full, may charge only the Medicare deductible and coinsurance, and must submit the claim directly to Medicare at no charge.
A nonparticipating provider who does not accept assignment can charge more, but in many cases no more than 15% above the approved amount (the limiting charge). The patient may have to pay the full amount at the time of service.
A provider who has opted out of Medicare uses a private contract, and Medicare pays nothing.
Medicare Summary Notice (MSN): it is a notice, not a bill. It lists the services or supplies billed to Medicare during the period, what Medicare paid, and the maximum the person may owe the provider. If an item is denied and the person disagrees, the last page gives step-by-step directions for filing an appeal.
Common exclusions in Parts A and B (Medicare.gov's list): hearing aids and exams for fitting them, eye exams for prescription eyeglasses, non-medical long-term care, cosmetic surgery, massage therapy, routine physical exams, concierge care and most dental care. A Medicare Advantage plan may offer some of these as extra benefits.
Appeals: Original Medicare has five appeal levels.
1. Redetermination by the Medicare Administrative Contractor: requested in writing within 120 days of receiving the notice (presumed received five calendar days after its date), with no minimum amount.
2. Reconsideration by a Qualified Independent Contractor.
3. The Office of Medicare Hearings and Appeals.
4. The Medicare Appeals Council.
5. Federal district court.