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New provider roadmap: Claims submission

Once enrolled as a Medicare provider, a billing method with Medicare needs to be established.

Step 1: Choose your billing method

There are two general billing methods: electronic or paper submission.

Medicare does adhere to Administrative Simplification Compliance Act (ASCA) requirements. This requires all initial claims for reimbursement, except for small providers, be submitted electronically, with limited exceptions. Medicare will not accept claims submitted on paper that do not meet the limited exception criteria. To see if you qualify for these exceptions, refer to the self-assessment form  to determine if you are a small provider.

Electronic submission methods:

For additional information on Electronic Data Interchange (EDI)

Paper submission method:

Step 2: Submit the claim

After the claim submission option was selected, claims can be submitted. Claims must be submitted no later than 12 months, or one calendar year, after the date of service(s) were furnished. With few exceptions, claims received without an explanation for the late filing are generally assumed to be filed late and the provider accepts responsibility for late filing. Please refer to the CMS IOM Pub. 100-04 for further instructions.

Step 3: Check claim status

Upon receipt of a claim, a unique tracking number will be assigned to the claim. For Part A claims this is a document control number and Part B claims are an internal control number.

The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail or otherwise finalize the initial determination on a clean claim. A clean claim is one that does not require the MAC to investigate or develop on a prepayment basis. Medicare has 30 days to pay the claim but cannot pay before the payment floor:

  • Electronic claims: 14 days from date of receipt of claim
  • Paper claims: 29 days from date of receipt of claim

There are multiple ways to check claim status:

  • SPOT
  • FISS  (Part A only)
  • IVR:
    • Part B 877-847-4992
    • Part A 877-602-8816

Once a claim has processed through the Medicare system, a Medicare remittance advice will be sent to the provider of the service. Denial messages are utilized within the claims processing system and will determine which claim adjustment reason code / remittance advice remark code will be entered. These codes will provide additional information as to whether the service was rejected, denied, or allowed.

Customer contact center

Interactive voice response (claims and eligibility information):

  • Part B: 877-847-4992, options 1, 2
  • Part A: 877-602-8816, options 2 or 5

Provider inquires:

  • Part B
    • PR: 877-715-1921
    • FL:  866-454-9007
  • Part A
    • PR:  877-908-8433
    • FL: 888-664-4112

Monday to Friday, 8 a.m. - 4 p.m. (ET)

 

Continue to Appeals Part B section

Continue to Appeals Part A section

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