Reimbursement Information Page

How to File a Medicare Claim

If you are in the ORIGINAL MEDICARE PLAN, providers (e.g., hospitals, skilled nursing facilities, home health agencies, and physicians) and suppliers (e.g., durable medical equipment suppliers, pharmacies) are required by law to file Medicare claims for covered services and supplies that you receive. You should not need to file any Medicare claims. Medicare claims must be filed within one full calendar year following the year in which the services were provided.

Note: This information on filing a Medicare claim only applies if you are in the original Medicare plan. If you get your Medicare health care through a managed care plan or a private fee-for-service plan, Medicare claims are not filed. Medicare pays these private insurance companies a set amount every month. Therefore, they do not need to file Medicare claims.

If your physician or supplier does not accept assignment for covered services, they may require that you pay most or the entire bill at the time you receive services or supplies. However, the physician or supplier is still required to file a Medicare claim on your behalf. Medicare then pays its share of the bill directly to you.

Medicare cannot pay you its share of the bill until a Medicare claim is filed. You should take the following steps if your doctor or supplier does not file the Medicare claim in a timely manner:

Step 1 - Contact your physician or supplier: Call your physician or supplier directly and ask the physician or supplier to file a Medicare claim.

Step 2 - Contact your local Medicare carrier: If your physician or supplier still does not file a Medicare claim after you have called and asked, you should call your local Medicare carrier. Your local Medicare carrier will contact the physician or supplier on your behalf to make the physician or supplier aware of their responsibility for filing a Medicare claim. Also ask the Medicare carrier for the exact time limit for filing a Medicare claim for the service or supply that you received.

IMPORTANT:
There is a time limit for filing a Medicare claim. If a claim is not filed within this time limit, Medicare cannot pay you its share. The time limit may be as short as 15 months or as long as 27 months depending on when you received the service or supply. It is important that you ask the Medicare carrier what the time limit is for filing your claim.

Step 3 - When you should file a claim: You should only need to file a Medicare claim in very rare situations. You should contact your local Medicare carrier and ask for the forms to file a Medicare claim yourself when:

* you have completed steps 1 and 2 above; AND
* the physician or supplier still has not filed the Medicare claim; AND
* it is close to the time limit for filing your Medicare claim. (For example, if your time limit is 15 months, you should consider filing a Medicare claim if the physician or supplier has not filed the Medicare claim 12 months after you received the service or supply).

To file a Medicare claim yourself, call your local Medicare Carrier and ask for the proper form for a Medicare beneficiary to file a claim. Your Medicare Carrier can also answer your questions about how to complete the claim form.

How to File a Medicaid Claim

If you are enrolled in a state medical assistance program, providers (e.g., hospitals, skilled nursing facilities, home health agencies, and physicians) and suppliers are contracted to file claims for covered services and supplies that you receive. You should not need to file any Medicaid claims. Medicaid claims must be filed within a filing period (contact supplier or local Medicaid office for your state's filing limitations) in which the services were provided.

Note: For Basic Medicaid, contact your local Medicaid office. If you get your Medicaid health care through a managed care plan claims are filed directly to your managed care plan. Medicaid pays these private insurance companies for contracted services rendered. Members should contact their managed care plan directly for information on how to file a claim.

Members are and will be responsible for services or supplies not covered under Basic Medicaid. If a service or supply is not covered no claim should be submitted.

How to File a Commercial Insurance Claim

Providers (e.g., hospitals, skilled nursing facilities, home health agencies, and physicians) and suppliers are generally contracted to file claims for covered services and supplies that you receive. You should not need to file claims. Providers should be aware of any filing period limitations under your plan in which claims must be filed for the services or supplies provided (e.g., 180 days from date of service or purchase, within one calendar year from date of service, etc). There are times when members must submit a claim directly to their medical plan.

FORMS: Members should contact member services (listed on the insurance ID card) about which form or documentation is required (e.g., HCFA1500 claim form, health benefit claim form, manufacturer or supplier invoice, physician's order, etc)

HCFA1500: Members should complete as much information as they can. Be sure to sign the appropriate boxes (see example). Members will need to know the following:

1. HCPCS or Billing Code (ie. B4086, B9998, etc.)
2. ICD-9 or Diagnosis Code

Health Benefit Claim Form:

Your particular medical plan may have specific forms for their members to file. Contact member services listed on your insurance card for more information.

INVOICE: Some medical plans only require the member to submit a copy of their purchase receipt or the manufacturer or supplier invoice. To ensure your claim is processed accurately and timely, members should be sure to have the following information on the invoice:

1. Complete description of the medical supply
2. HCPCS or Billing Code (ie. B4086, B9998, etc.)
3. ICD-9 or Diagnosis Code (contact your physician)

CLAIM ADDRESS: Your insurance card should supply a claims address. If not, contact member or customer service at the toll-free number listed on the insurance card. Be sure to sign claim forms, if applicable, and attach invoice or other documentation necessary for your insurance to process your claim correctly.

IF THE CLAIM IS DENIED OR NOT REIMBURSED: As a member, you have the right to request a review of the denied claim or file a grievance in which you do not agree with how your claim was processed. To do this, you must contact member services, listed on your insurance card. You will need the following information:

1. Your Policy or Contract ID Number
2. Date of Service or Purchase Date supply was billed under
3. Amount or charge submitted on claim
4. Name of medical supplier

MIC-KEY Reimbursed Products

Contact the Kimberly-Clark Customer Service at 1-800-742-1996 to find out to how purchase MIC-KEY enteral feeding tubes.

For more information on Medicare and Medicaid reimbursement, visit the main Kimberly-Clark Health Care site Reimbursement page.