Definition and Filing

Medicare regulations define a claim for payment as a request for payment from a provider, supplier, or beneficiary, and the provider, supplier, or beneficiary requesting payment must furnish the appropriate Medicare contractor with sufficient information to determine the amount of payment. Medicare also defines the basic requirements for claims for payment, which specifically states, "A claim must be filed with the appropriate AB MAC or DME MAC on a form prescribed by CMS in accordance with CMS instructions."

There are two types of claims that can be filed to Medicare:

  1. Paper on the CMS-1500 claim form
  2. Electronic using the Health Insurance Portability and Accountability Act (HIPAA) approved transaction through the Common Electronic Data Interchange (CEDI) contractor

Claims Filing Based on Beneficiary Address

The beneficiary's state of residence on file with the Social Security Administration determines the DME MAC jurisdiction that should be billed. A claim should be sent to the DME MAC for the state in which the beneficiary permanently resides.



Last Updated Nov 17 , 2022