Beneficiary submitted claims

Change request 5683 updates the procedures for processing claims submitted by Medicare beneficiaries to carriers and serves as a reminder to providers and suppliers that they are required by law to submit claims to Medicare for services they render to Medicare beneficiaries.

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, and

• Submit a complete CMS-1490S with all supporting documentation.

Upon receipt of both the beneficiary’s complaint that the provider/supplier refused to submit the claim, and the CMS-1490S (and all supporting documentation), the contractor will process and pay the beneficiary’s claim if it is for a service that would be payable by Medicare were it not for the provider’s or supplier’s refusal to submit the claim and/or enroll in Medicare.

Contractors will maintain:

• Documentation of beneficiary complaints involving violations of the mandatory claims submission policy, and

• A list of the top 50 violators of the mandatory claim submission policy.

Additional information is available on the CMS Web site. Here is the link to the MLN Matters article MM5683

Source: CMS MLN Matters Article MM5683