What are Medicare Claims?

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  • Written By: Brenda Scott
  • Edited By: Bronwyn Harris
  • Last Modified Date: 24 June 2019
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In the United States, Medicare is a federally subsidized health insurance plan for people who are disabled, or who are at least 65 years of age. Medicare A covers hospital and inpatient services, and is usually available at no additional charge to those who have paid Medicare taxes. Two optional plans include Medicare B, a supplemental policy that covers outpatient services, and Medicare D, a supplemental prescription drug plan, both available for an additional premium. Medicare claims are requests for payment of benefits for medical services provided to Medicare patients.

Like all insurance providers, Medicare has a schedule of allowable charges for medical procedures. In the US, providers are required to file all Medicare claims for the patient, and they must do so within one year from the date service is rendered. If a provider accepts Medicare assignment, then the patient is only required to pay the co-payment up front. If the patient chooses to use a doctor that does not accept direct payments from Medicare, then he or she will generally be required to pay the bill in full. In this case, Medicare claims are still filed by the provider, but the reimbursement is sent directly to the patient.


There are times, however, when a patient may need to file Medicare claims personally. This may happen if the provider has failed to file and the deadline for Medicare payment is about to expire. Another exception is for the purchase of durable medical equipment. Some medical equipment is covered under Medicare, but must be purchased by the patient from a company which does not provide Medicare billing. In these cases, patients may submit Medicare claims using official submittal forms.

Medicare is also the name used for the national health care program in Australia. This program is not insurance, and is available to all citizens regardless of age or income. In Australia, treatment at public hospitals is covered in full, with no initial payment from the patient. For outpatient services, the patient pays the bill first and then files for a rebate. Medicare claims can be filed electronically, via phone, in person or through the mail.

The universal, nationally funded health care plan in Canada, known unofficially as Medicare, also provides coverage for all legal residents. Canadian Medicare benefits include 100% of the cost of all treatments deemed necessary, regardless of whether they are provided by a doctor or a hospital. Dental and most vision benefits, however, are not included. Unlike the universal system used in the UK, most doctors and hospitals are privately employed. Medicare claims are billed directly by the provider on a fee-for-service basis.

Canadian Medicare only provides drug coverage if the drugs are administered at a hospital. Some provinces have drug plans, while others do not. In cases where there is no coverage, or limited coverage, the patient can pay or carry a private insurance policy to assist with these costs.

In all countries, assistance is available from the Medicare agencies to both patients and practitioners in properly filing Medicare claims. Official manuals are available from the applicable agencies both in written form and via the internet. All agencies also require proper documentation and coding on claims in order to ensure the appropriate reimbursement.



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