
HOW TO SUBMIT MEDICARE MEDICAL INSURANCE CLAIMS
This section will tell you about:
     
*    A New Rule. 
     
*    Submitting Your Claim. 
     
*    When Other Insurance Pays First. 
     
*    Submitting Claims For A Person Who Dies. 
     
*    Time Limits. 
*    Where To Send Your Claims. 

A NEW RULE
     For services received on or after September 1, 1990, you do
not have to submit your medical insurance claims to Medicare. 
Your doctor, supplier, or other Medicare medical insurance
provider of services must submit claims to Medicare for you.  For
services you receive before September 1, 1990, the following
information will be useful.
SUBMITTING YOUR CLAIM
     A Patient's Request for Medicare Payment form, also called
Form 1490S (see page xx for a sample form 1490S), must be
submitted to the Medicare carrier for medical insurance to pay
for covered services of doctors and suppliers.  Medicare
carriers, and most doctors' offices, have copies of the form. 
Instructions on how to fill it out are on the back of the form.
     If the doctor or supplier is Medicare-participating, uses
the assignment method of payment, or chooses to submit an
unassigned claim for you, he or she submits the claim, and you do
not have to use the 1490S form.
     If the doctor or supplier does not accept assignment and
does not submit the claim for you, you submit the claim, using
the 1490S form.  Complete and sign the form and attach itemized
bills for the services you received.
     An itemized bill must show:
     o    the date you received the services
     o    the place where you received the services
     o    a description of the services
     o    the charge for each service
     o    the doctor or supplier who provided the services
     o    your name and your health insurance claim number
          (including the letter at the end of the number).  
     If the bill doesn't include all of this information, your
payment will be delayed.  It is also helpful if the nature of
your illness (diagnosis) is shown on the bill.  If you are
submitting a claim for the rental or purchase of durable medical
equipment, you must include the bill from the supplier and the
doctor's prescription.  The prescription must show the equipment
you need, the medical reason for the need, and an estimate of how
long the equipment will be medically necessary.     
     You may submit several itemized bills with a 1490S form.  It
doesn't matter whether all the bills are from one doctor or
supplier or from different people who gave you services.  You can
send in the bills either before or after you pay them.
     Before any Medicare payment can be made, your record must
show that you have met the deductible.  So, as soon as your bills
total $75 in 1990, send them to your Medicare carrier with a
1490S form.  Page XX tells you where to send your claim.  Once
you have met the $75 deductible, we suggest that you send in your
future bills for covered services as soon as you get them so that
Medicare payment can be made promptly.
     If all your medical bills for the year amount to less than
$75, Medicare medical insurance cannot pay any part of your bills
for the year.
     It's a good idea to keep a record of your medical insurance
claim in case you ever want to inquire about it.  Before you send
in a claim, write down the date you mail it, the services you
received, the date and charge for each service, and the name of
the person who provided each service.
There are special rules for submitting your Medicare medical
insurance claim if you are a member of an HMO or CMP.  If you are
a member of an HMO or CMP and you receive a bill for medical
services, equipment or supplies, you should send the bill to your
HMO or CMP for processing.  You can find out who should process
the claim by consulting your HMO/CMP membership handbook, or
contacting your HMO/CMP.
     Note The New Rule Above:  Effective for services received on
or after September 1, 1990, you do not have to submit your claims
to Medicare.  Your doctor, supplier, or other Medicare medical
insurance provider of services must submit claims to Medicare for
you.
WHEN OTHER INSURANCE PAYS FIRST
     If any of the following insurance situations applies to you,
please notify your doctor, hospital, or other provider of
services and, except in the case of liability claims, file your
claim with the other insurer first.  Liability claims must be
filed with Medicare first.
When You or Your Spouse Continue To Work
     Medicare has special rules that apply to beneficiaries who
have employer group health plan coverage through their employment
or the employment of a spouse.
     Employers with 20 or more employees are required to offer
workers and their spouses age 65 and over the same health
insurance benefits offered to younger workers and spouses.  In
such situations you and your spouse have the option to accept or
reject your employer's health plan.  If you accept it, Medicare
will become the secondary payer.  If you reject your employer's
health plan, Medicare will remain the primary health insurance
payer.  If you elect Medicare to be the primary payer, your
employer cannot offer you coverage that supplements Medicare.
     For more information, contact your employer or ask Social
Security for a copy of Medicare and Employer Health Plans.  The
publication is also available from the Consumer Information
Center (see inside back cover).
If You Are Disabled and Under Age 65
     Medicare is the secondary payer for certain disabled people
who have premium-free Medicare hospital insurance and are covered
under an employer's health plan or the employer health plan of an
employed family member.  This secondary payer provision applies
to group health plans of businesses that employ 100 or more
people.  Employees of smaller firms and their dependents may also
be covered under certain conditions.
     For more information, contact your employer or ask Social
Security for a copy of Medicare and Employer Health Plans.  The
publication is also available from the Consumer Information
Center (see inside back cover).
Other Situations Where Medicare is the Secondary Payer
     If you have a work related illness or injury, services
provided as treatment of that illness or injury should be covered
by workers' compensation or Federal black lung benefits.  It is
important that your Medicare claim form note that the treatment
is related to a work related illness or injury, even if the
injury or illness occurred in the past.
     Medicare is a secondary payer for up to one year for
beneficiaries who have Medicare solely on the basis of End Stage
Renal Disease (ESRD), if they have employer group health plan
coverage.
     Medicare also serves as the secondary payer in cases where
no fault insurance or liability insurance is available as the
primary payer.
     Although Medicare benefits are secondary to benefits paid by
liability insurers, you must file claims with Medicare first, and
Medicare will make a conditional payment.  When a liability
settlement is reached, Medicare will recover its conditional
payments from the settlement amount.
If You Have or Can Get Both Medicare and Veterans Benefits
     If you have or can get both Medicare and veterans benefits,
you may choose to get treatment under either program.  But,
Medicare:
     o    cannot pay for services you receive from VA hospitals
          or other VA facilities, except for certain emergency
          hospital services; and
     o    generally cannot pay if the VA pays for VA-authorized
          services that you get in a non-VA hospital or from a
          non-VA physician.
Medicare can pay for covered services you receive from non-VA
hospitals and physicians if the VA has not authorized payment for
the services.  Since July 1986, the VA has been charging
copayments to some veterans with non-service connected conditions
for treatment in a VA hospital or medical facility, or for VA
authorized treatment by non-VA sources.  The VA charges
copayments when the veteran's income exceeds a particular level. 
If the VA charges you a copayment for VA authorized care by a
non-VA physician or hospital, Medicare may be able to reimburse
you, in whole or in part, for your VA copayment obligation.
Note:  Medicare cannot reimburse you for VA copayments for
services furnished by VA hospitals and facilities, unless the
services are emergency inpatient or outpatient hospital services. 
Then, the Medicare payment is subject to Medicare deductible and
coinsurance amounts.
     If you have questions about whether the VA or Medicare
should pay for your doctor and other Medicare medical services,
contact your Medicare carrier.  If you have questions about
whether the VA or Medicare should pay for hospital or other
Medicare hospital insurance services, ask the provider of
services to check with the Medicare intermediary.

SUBMITTING CLAIMS FOR A PERSON WHO DIES
     When a Medicare beneficiary dies, any hospital insurance
payments due will be paid directly to the hospital, skilled
nursing facility, home health agency or hospice that provided
covered services.
     For services covered under Medicare medical insurance, some
special rules apply, depending on whether the doctor's or
supplier's bill has been paid.
     If the bill was paid by the patient or with funds from the
patient's estate, payment will be made either to the estate
representative or to a surviving member of the patient's
immediate family.  If someone other than the patient paid the
bill, payment may be made to that person.
     If the bill has not been paid and the doctor or supplier
does not accept assignment, the Medicare payment can be made to
the person who has legal obligation to pay the bill for the
deceased patient.  The person can claim the medical insurance
payment either before or after paying the bill.
     Your Medicare carrier can provide additional information
about how to claim a medical insurance payment after a patient
dies.
TIME LIMITS
     Under the law, there are some time limits for submitting
medical insurance claims.  For medical insurance to make payments
on your claims, you must send in your claims within these time
limits.  You always have at least 15 months to submit claims. 
The table below tells you exactly what the time limits are.
                         START-OF-TABLE

[In the following table, the column headings are: For service you
received Between;  Your claim must be submitted by.]        
                                                                
Oct 1, 1988, & Sept. 30, 1989 Dec. 31, 1990
                                                                
Oct 1, 1989, & Sept. 30, 1990 Dec. 31, 1991
                                                                
Oct 1, 1990, & Sept. 30, 1991 Dec. 31, 1992
                          END-OF-TABLE
                                                                
WHERE TO SEND YOUR CLAIMS
     The list on pages XX to XX  gives the names, addresses, and
telephone numbers, by State, of the Medicare carriers selected to
handle claims.  To find out where to send your Medicare medical
insurance claim, look in the list for the State where you
received the services. 
     Under the name of the State, you will find the name of the
carrier that will handle your claim.  If there is more than one
carrier in the State, look for the county where you received
services to find the carrier that will handle your claim.  (See
page XX to find out how to submit claims.)
     If you are not sure where to send your first claim and
happen to send it to the wrong office, your claim will be sent to
the right place.
     Whenever you send in a claim, be sure to include the word
"Medicare" in the carrier's address on the envelope.  Also, be
sure to put your return address and a stamp on the envelope.
     After you make a claim, the carrier will usually send you
another 1490S form for your next claim.  The form will usually
show the carrier's name and address in the top right hand corner. 
If you ever need to file a claim and don't have a claim form, you
can use the one on page XX or you can get one by calling your
Medicare carrier.
NOTE:  If you get Medicare under the Railroad Retirement system,
send your medical insurance claims to The Travelers Insurance
Company office which serves your region.  Regional offices of The
Travelers are listed in Your Medicare Handbook for Railroad
Retirement Beneficiaries, which is available at any railroad
retirement office.
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