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Medicare Health Insurance Claims in Texas

Generally, it is only in exceptional circumstances that you need to file a claim. Here is how Medicare claims for Original Medicare, Medicare Advantage (Part C) plans, Prescription Coverage (Part D), and Medigap work in Texas:

For Original Medicare, doctors and suppliers file Medicare claims for 80% of the cost of the services and supplies you receive. Medicare claims must be submitted within 12 months (or one calendar year) of the date the services were rendered. Medicare will not pay its part if the claim is not filed within this timeframe. Ensure you go through your “Medicare Summary Notice” (MSN) you receive by mail every three months or log into your Medicare account to see that claims are filed promptly. Contact your doctor or supplier requesting that they file a claim on your behalf if they are not processing your claims promptly. If nothing happens, you can call Medicare at 800 (633)-4227 or (800) 486-2048 for TTY to inform them that your doctor or supplier has refused to file a claim.

You may have to file a claim yourself if the provider or supplier:

  • failed to file a claim,
  • cannot file a claim,
  • is not enrolled with Medicare.

Claims are processed within 30 days.

If you have a Medigap plan, it will pay the remaining 20% of your Original Medicare out-of-pocket costs. So when you visit a doctor that accepts Medicare assignment, once Medicare has handled its part, Medigap will cover the remainder.

Medicare Advantage plans do not have to file claims because Medicare pays the insurance providers every month. However, when you receive medical care outside your plan’s network you may have to file a claim with your insurance provider, not Medicare. Contact your insurance provider if you have questions about claims, including the time limit for submitting claims. The time limit for submitting Medicare Advantage claims is usually shorter than Original Medicare.

Private insurance plans provide Medicare Part D or prescription drug coverage. Each plan’s rules for which drugs are covered are different. A formulary is a set of rules or lists, and the amount you pay is determined by a tier system (generic, brand, specialty medications, etc.). Your claims for covered medications will be filed by the pharmacy (retail or mail order), where you fill your prescriptions. The copayment and any coinsurance must be paid. You cannot file a claim with Medicare if you pay for medication yourself; ensure you file your claims with your insurance provider.

If you have questions about your claims or other personal Medicare information, log into (or create) your secure Medicare account or call (800) 633-4227. TTY users can call (877) 486-2048.

How Do I File a Claim for Medicare Insurance in Texas?

Complete the Patient Request for Medical Payment form (CMS-1490S) (Spanish version available). Follow the instructions on the form and provide the information required to process your claim. They could be:

  • The reasons you went to the healthcare provider
  • The treatment or services you got
  • Information about your insurance plan

You may have to submit the following documents to report your claim:

  • The filled out claim form
  • The itemized bill from your healthcare provider
  • A letter outlining your reasons for submitting the claim, such as your provider or supplier being unable to file the claim, refusing to file the claim, and/or not being enrolled in Medicare.
  • Any documents that you need to back up your claim

You may want to complete the Authorization to Disclose Personal Health Information form if:

  • You want someone to contact Medicare on your behalf regarding your claim.
  • You want Medicare to give someone else personal information about you and your claim.

Send your request to the appropriate address for your claim. All the addresses can be found on the second page of the instructions. You can also find the appropriate address on your “Medicare Summary Notice” (MSN).

In addition, you can report a claim to your insurance provider for your Medicare Advantage plan, Prescription Coverage plan, or Medigap. Notify your insurer about the services you got and all the necessary information about them. They will give you a claim form to complete and submit. The form will require your personal information and information about the service you received. Submit this form to your insurance provider.

Is a Claim a Bill for Medicare Insurance in Texas?

Yes, a Medicare claim in Texas is a bill sent to your Medicare or your private insurance provider for the healthcare services you received from a medical professional. The hospital usually submits the claim you received treatment from on your behalf. However, in certain circumstances, you have to make the claim yourself. The claim includes the list of services you received and how much you are charged for them. Medicare or your insurance provider uses the information in the claim to decide if you should get reimbursed.

You will receive a Medicare Summary Notice (MSN) from Medicare every three months. It is a document that provides details of the services you received. For Medicare Part A claims, it will include:

  • The date of service,
  • The number of benefit days,
  • Any non-covered charges, deductibles or coinsurance, and
  • How much you are to pay.

For Medicare Part B claims, it will include:

  • The date of service
  • The services provided
  • The amount charged by the provider
  • Whether the claims were assigned
  • The Medicare-approved cost
  • How much you owe

If you have a Medicare Advantage, Prescription Coverage, or Medigap plan, you will get a similar report called an Explanation of Benefits (EOB) statement. These documents are not bills. They basically let you know what was covered, what you have to pay for, and any other related information. Check the reports to ensure all your claims are filed and processed promptly.

How Long Do I Have to File a Medicare Insurance Claim in Texas?

Medicare claims must be submitted within 12 months (or one calendar year) after the date the services were rendered. If a claim is not filed within this time, Medicare will not be able to pay its portion.

What Happens After I File a Claim With My Medicare Insurance?

Medicare or your insurance provider will review your claim based on the information you provided. They may approve or deny your claim. You will get reimbursed if your claim is approved. If your claim is denied, you will be notified, and they will provide the reason for the denial. You may appeal the decision if you feel the decision is not right.

How Do Medicare Insurance Companies Pay Out Claims in Texas?

If your claim is approved, Medicare will send a Medicare Summary Notice (MSN) that will include a check, reimbursing you for your claims. Your private insurer may also send a check if your claim is approved. Health providers are paid mainly through Electronic Funds Transfer (EFT) or by mailing a paper check.

Can a Medicare Insurance Company Refuse to Pay a Claim?

Yes. Your Medicare claim can be refused, either in part or entirely. You will be informed of the reason for the denial of your claim. When this happens, you have a timeframe, depending on your Medicare coverage, within which you can appeal the decision. An Original Medicare appeal should be submitted within 120 days, while a Medicare Advantage appeal should be submitted within 60 days. You can appeal the following:

  • A request for a service, supply, item, or drug for which you think you have coverage.
  • A request for payment you already got.
  • A request to change how much you will pay for a service, supply, item, or drug.
  • Medicare or your plan’s failure to provide or pay for healthcare that you still need
  • An at-risk decision given by a drug management program limiting access to coverage for drugs that are usually abused.

Original Medicare Appeal

You start your Original Medicare Appeal by first going through your Medicare Summary Notice (MSN). It identifies if your Medicare claim was fully or partially denied. Then, if you disagree with the decision regarding coverage or payment, you can appeal through any of the following ways:

  1. Complete the Redetermination Request Form and send it to any of the addresses provided on your MSN.
  2. You can appeal by following the instructions on how you can send an appeal on your MSN. Send the request for redetermination to the company that handles claims for Medicare (their address is listed in the “Appeals Information” section of the MSN).
    • Select the service or item you disagree with on the MSN.
    • Provide the reason why you disagree with the decision. Alternatively, write it on another paper with your Medicare number and attach it to the MSN.
    • Fill in your name, phone number, and Medicare Number on the MSN.
    • Fill in any additional information you have about your appeal with the MSN. Then, you can contact your doctor, other health care provider, or supplier to provide you with any helpful information.
  3. Send a written request to the company in charge of Medicare claims. You can find their address in the “Appeals Information” section of the MSN. The written request should include the following:
    • Your name and Medicare Number.
    • The item and/or service you are requesting a redetermination and the date of service.
    • Explain why you do not agree with the initial determination.
    • If you have chosen a representative, provide the name of your representative.

You will get a Redetermination Notice within 60 days after submitting your appeal.

Medicare Advantage Appeal

To appeal the decision of your Medicare Advantage plan, begin your appeal process through your plan provider. If you have a Medicare health plan, start the appeal process through your plan. Follow the instructions in the initial denial notice and plan papers.

Within 60 days following the coverage determination, you, your representative, or your doctor must file an appeal with your plan. If you miss the deadline, you must explain why you filed late.

In your written request, include the following information:

  • Your name, address, and Medicare number from your Medicare card
  • The services or items you are requesting reconsideration of a coverage decision, the dates, and the reason(s) for your appeal.
  • If you have appointed a representative, provide the name of your representative and proof of representation.
  • Anything else you can think of that would aid your case.

If you believe that waiting the customary 14 days for a decision may impair your health, ask your plan for an expedited decision. If the plan or your doctor determines that waiting for a normal decision may risk your life, health, or capacity to restore maximum function, the plan must decide within 72 hours.

The length of time it takes your plan to react to your request is determined by the type of request:

  • Expedited request - 72 hours
  • Standard service request - 30 days
  • Payment request - 60 days.

Medicare Prescription Drug Plan Appeal

Start the appeal procedure through your separate Medicare drug plan. If you want to be reimbursed for medications you have already purchased, you or your prescriber must submit a standard request in writing. Send a letter or a filled-out Model Coverage Determination Request form to your plan. Under “Downloads,” you'll find the form and instructions at the bottom of the page.

If you have not received prescription drug benefits yet, you or your prescriber can request a coverage determination or an exception from your plan. You can do one of the following to request a coverage determination or an exception:

  • Send a filled-out “Model Coverage Determination Request” form.
  • Make a letter out to your plan.
  • Make a call to your plan.
  • If you are requesting an exception, your prescriber must offer a statement outlining the medical basis for the exception.

You or your prescriber can request an expedited request if you have not received your prescription yet. If your plan determines, or your prescriber informs your plan, that waiting for a standard decision will risk your life, health, or capacity to restore maximum function; your request will be expedited.

The length of time it takes your plan to react to your request is determined by the type of request:

  • Expedited request - 24 hours
  • Standard service request - 72 hours
  • Payment request - 14 days

Take note of the following when appealing a decision:

  • All documentation you provide with your appeal request should include your Medicare number.

  • As part of your appeal, keep a copy of everything you send to Medicare.

  • You can provide more information or evidence after filing the redetermination request, but the Medicare Administrative Contractor (MAC) that processes Medicare claims may take longer than 60 days to make a judgment. If you provide more information or evidence after filing, the MAC will have an additional 14 calendar days to reach a judgment.

  • Within 60 days of receiving your request, the MAC will send you a “Medicare Redetermination Notice” (either in the form of a letter or an MSN).

  • You have 180 days after receiving the notice to request a reconsideration by a Qualified Independent Contractor if you disagree with the decision (QIC).

  • If you decide to file an appeal, ask your doctor, healthcare provider, or supplier for any information that might be useful.

  • If you believe that waiting for a decision on a service would jeopardize your health, ask the plan for an expedited response. If the plan or the doctor agrees, the plan has 72 hours to make a decision.

  • The plan must include written instructions on how to appeal. The plan will reconsider its decision once you file an appeal. The appeal is then examined by an independent body that works for Medicare, not the plan, if your plan does not find it in your favor.

  • You have the right to an expedient review by your Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO). If you consider you are being discharged from a hospital too soon. You will be permitted to stay in the hospital for free while your case is being reviewed. However, you cannot be forced to leave until the BFCC-QIO makes a decision.

  • When you disagree with a determination that you no longer need services from a skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation center, you will have the right to a fast-track appeals process.

There are five tiers to the appeals process, each with its own set of reviewers. If you do not agree with a decision, you may advance to the next level. Each level requires a decision letter from Medicare, which gives directions on what to do next. The five levels of review are as follows:

  • Initial review and appeal from your plan
  • Reconsideration by a Qualified Independent Contractor (QIC) or an Independent Review Entity (IRE)
  • A determination by the Office of Medicare Hearings and Appeals (OMHA)
  • Review by the Medicare Appeals Council (Appeals Council)
  • Judicial review by a Federal District Court if the claim is over a minimum amount. In 2022, the minimum claim amount that can be brought before the Federal District Court is $1,760.

Why Do Medicare Insurance Companies Deny Insurance Claims?

Your Medicare claims may be denied for any of the following reasons:

  • The service is not considered medically necessary by Medicare.
  • You stayed in a hospital or care facility for the maximum number of days allowed.
  • Your plan does not cover the service or treatment you received.
  • You did not provide sufficient information about your claim.
  • You have reached the highest permitted benefits for that service.

What are the Top Reasons a Claim Might Be Denied for Payment in Texas?

The popular reasons why Medicare might deny your claim in Texas include:

  • Because the service is not a medical necessity
  • The treatment or service you received is excluded from your plan’s coverage
  • Your doctor has already submitted a claim
  • Lack of necessary information to properly assess your claim
  • There is a substantial error with your claim.
  • You have already gotten the maximum allowable benefits for that service.

How Much Does Medicare Insurance Pay Out?

There is no standard amount that Medicare or your private insurer pays out for claims. There are different factors that determine how much they pay, including your plan’s terms and the cost of the service you received.

What if My Medicare Insurance isn’t Paying Enough for My Claim?

Here are ideas of what you may do when Medicare or your insurance company in Texas is not paying enough for your claim:

  • Read your insurance policy well to confirm your out-of-pockets requirements and how much coverage you normally should receive. If you believe that you should be paid more, exercise your right to request an appeal.
  • Ask an experienced licensed health insurance agent in Texas for assistance.
  • Talk to your insurance provider directly or Medicare at (800) 633-4227 or (800) 486-2048 for TTY.
  • Seek assistance from the Texas Department of Insurance. You can call (800) 252-3439.

How Long Can a Medicare Insurance Company Investigate a Claim in Texas?

Medicare processes and settles each claim in about 30 days. However, the process can take much longer if there are any questions or issues with the claim. The time it takes to process a claim is determined by whether it was a “clean claim.” A clean claim is a claim that includes all the necessary information, is properly formatted, and does not contain errors. Clean claims give Medicare or your insurance provider all the information they need regarding the claim, and they can make their decision on time. In the same vein, if you exclude particular important information, it may take more time because the claim will have to be amended or adjusted. Medicare or your insurance provider may even have to verify directly from the healthcare provider that treated you.

How Can I Check the Status of My Medicare Insurance Claim?

You can check the status of your claim online. You’ll usually be able to see a claim within 24 hours after Medicare processes it. Log into your Medicare account and check your Medicare Summary Notice (MSN). It will show:

  • Your covered services or supplies billed to Medicare within that 3-month period
  • The amount of Medicare paid
  • How much you owe the provider

Use the Blue Button to download and save your claims information.

Do I Need to Tell Medicare if I Received a Service From a Doctor That Does Not Accept Medicare Assignments?

Yes, because you will most likely have to cover the cost of the service at that time. You can reach out to Medicare or your insurance provider to speak about the possibility of getting reimbursed. You can talk to a licensed insurance agent in Texas on the types of things you should inform Medicare or your insurance provider.

When Not to File a Medicare Insurance Claim?

You will rarely have to file a Medicare claim in Texas. However, to know when not to file a Medicare claim, you need to know your policy, including what it covers and how claims work. For example, while you have to make a claim for a service received from a non-Medicare-approved professional, you should not file that claim if Medicare does not cover the service you received.

While your claims history does not affect your premium rates, you should not make claims for services not covered by your policy. Consider speaking to a licensed insurance agent in Texas to know more about Medicare claims.