Mandatory Claim Submission: Physicians and Other Health Care Practitioners Not Enrolled in Medicare
Providers and suppliers who are not enrolled in the Medicare program must adhere to the mandatory claims submission rules at Section 424.32(a)(1) (Basic requirements for all claims) and section 1848(g)(4) of the Social Security Act. Section 1848(g)(4) of the Act requires that you submit claims for all your Medicare patients. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries.
In addition, if the mandatory claims submission requirements are not met the provider or supplier may have sanctions imposed as outlined in section 1848(g)(4) of the Act for failure to file a claim as required. Violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation and/or Medicare program exclusion.
Compliance of the claims mandatory claim filing requirements is monitored. Contractors return to the beneficiary any claims submitted claims on the CMS-1500 form. When returning a beneficiary submitted claim, the contractor will inform the beneficiary by letter that:
- The provider or supplier is required by law to submit a claim on behalf of the beneficiary for services that would otherwise be payable
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If a beneficiary receives services from a provider or supplier that refuses to submit a claim on the beneficiary’s behalf for services that would otherwise be payable by Medicare, the beneficiary should notify the contractor in writing that the provider or supplier refused to submit a claim to Medicare
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In order to submit the claim, the provider must enroll in the Medicare program
Contractors are required to maintain documentation of beneficiary complaints involving violations of the mandatory claims submission policy. Providers and suppliers may not charge patients for preparing or filing a Medicare claim.
Medicare guidelines do not require you to file claims on behalf of Medicare beneficiaries for the following services:
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Non-covered services
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Used DME purchased from a private source
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Medicare Secondary Payer (MSP) claims when you do not possess all the information necessary to file a claim
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Foreign claims
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Services billed to the third party insurers (indirect payment provisions)
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Opting out of the Medicare Program by signing private contracts with Medicare beneficiaries
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Other unusual services (evaluated by Palmetto GBA on a case-by-case basis)
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However, many Medicare supplemental insurance policies pay for services that Medicare does not allow and they may require a Medicare denial notice
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