Medigap Insurance Claims in Texas

Like Medicare, you may not need to file a claim if you have a Medigap plan in Texas. Because if you have Medigap coverage, it will pay the out-of-pocket costs according to your plan’s terms. If you receive services or supplies from a medical professional that accepts Medicare assignment, they will submit a claim to Medicare on your behalf. Medicare will handle its part, then Medigap will cover the remainder following the terms of your policy. If you receive a bill, review your Medicare Summary Notice first and see if your insurance provider paid what was required. If they did and you still owe anything, you will have to pay the rest of the cost. If they did not, you could submit a claim to your insurance provider.

Remember that Medicare supplement policies only pay for services that Medicare determines as medically necessary. If Medicare rejects a claim, you can appeal the decision. The appeal process and timeline are stated in your Medicare Summary Notice.

Insurance companies are required under Texas law to pay claims promptly. You, your medical doctor, or your hospital can submit a complaint with the Texas Department of Insurance (TDI) if your Medigap provider refuses to pay a Medicare-approved charge or delays payment of your claims.

What is a Medigap Claim?

A Medigap claim is what Medicare sends to your Medigap insurance company when Medicare has covered its part for the medical service or supplies that you received. Usually, Medicare submits the claim on your behalf, but where this does not happen, you may have to submit the claim by yourself.

For What Does Medigap Insurance Pay?

Medigap pays for the out-of-pocket costs that arise from getting healthcare services under Original Medicare. These out-of-pocket costs include deductibles, copayments, and coinsurance. Some Medigap plans also pay for emergency medical fees when you travel outside the United States.

How are Medigap Claims Processed?

If you have to submit a Medigap claim, you will have to follow the process that your insurer prescribes. Most insurers provide their enrollees with claims or reimbursement forms. You will complete the form by providing your name, insurance ID number, address, contact information, sex, and information about the claim. You will submit the completed form to your insurer with the following:

• An itemized bill from your doctor, supplier, or other healthcare providers.

• A letter outlining your reasons for submitting the claim, such as your physician or supplier being unable to file the claim or refusing to file the claim.

• Any documents that you need to back up your claim.

You should not submit a claim for services not covered by Original Medicare, except for a service that your Medigap plan particularly covers, like emergency care while traveling. Speak to your Medigap insurance provider or a licensed insurance agent in Texas to know more about Medigap claims in Texas.

Does Medicare Send Claims to Supplemental Insurance?

Yes. Medicare and Medigap handle claim payments through the Medicare “crossover” system. This system makes the process of the claims payment for Medicare and Medigap coverage easier and more efficient.

The “crossover” system works by Medicare first handling its part of the bill. Then, it sends the rest of the bill or claims information to the secondary payer (the Medigap company). Thus, Medicare mostly coordinates payment for the provider. Providers have relatively little actual communication with secondary insurance, such as Medigap coverage. The Medigap company pays claims electronically through the “crossover,” and providers largely deal with Medicare.

What to Do if a Medicare Supplement Claim is Denied?

You can submit a complaint to the Texas Department of Insurance (TDI) or Medicare.

To file a complaint to the TDI, you can do any of the following:

• Submit a complaint through its online Insurance Complaint Process.

• Call (800) 252-3439 and file your complaint with them.

You will need to provide all the relevant information to help them address your complaint.

For complaints to Medicare, fill the Medicare complaints form or call (800) 633-4227 or (877) 486-2048 for TTY users.