Mandatory Claim Submission

Centers for Medicare & Medicaid Services Claims Filing Policy

  • For services furnished on or after September 1, 1990, physicians and suppliers must complete and submit both assigned and non-assigned durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) claims for beneficiaries. Beneficiaries should not be asked to file their own claims.
  • The claim filing requirement applies to all suppliers who provide covered services to Medicare beneficiaries.
  • Suppliers are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare Participating Supplier Program or where CMS regulations require mandatory assignment, i.e., Medicare covered drugs.
  • Suppliers may not charge the beneficiary for preparing and filing a Medicare claim.
    • DME MACs monitor compliance with the Medicare claims filing requirement.
    • Suppliers who do not submit Medicare claims for Medicare beneficiaries may be subject to a civil monetary penalty of up to $2,000 for each violation.
  • If the supplier determines that the beneficiary has other insurance which may pay primary to Medicare, they may file a claim with the primary insurer on the beneficiary's behalf. However, suppliers are not required by law to submit claims to other payers. If the supplier receives a determination on the claim directly from the primary payer, they are responsible for submitting a claim to Medicare for secondary payment. If the beneficiary files a claim to the primary insurer, they may forward the primary payer information to the supplier to submit the Medicare Secondary Payer (MSP) claim. The supplier must submit the secondary claim to Medicare for the beneficiary in accordance with the mandatory claims filing requirements.
  • If a beneficiary elects to receive an item for which there is no order, the claim must be filed with an EY modifier.

Mandatory Claim Filing Does Not Affect the Following:

  • Supplier/Beneficiary Payment Arrangements – Suppliers who do not accept assignment may continue to request payment in full at the time the service is provided if the claim for this service is unassigned.
  • Providing Supplier's Information on Non-assigned Claims - By not accepting assignment of Medicare benefits, suppliers are not a party to the Medicare payment transaction between Medicare and the Medicare beneficiary. The transaction is covered by the Privacy Act. MACs can only give limited information on non-assigned claims and cannot disclose payment amounts.
  • Non-Covered Medicare Services - Suppliers are not required to file claims on behalf of Medicare beneficiaries for non-covered benefits or for other health insurance benefits. However, if the beneficiary (or his/her representative) believes that a service may be covered or desires a formal Medicare determination, the supplier must file a claim for that service to effectuate the beneficiary's right to a determination.

Resources

 

Last Updated $dateUtil.getDate( $modifieddate , "MMM dd , yyyy" , $locale , $tzone )