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Understanding the Basics of Medicare Claims

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Understanding the Basics of Medicare Claims

Filing a claim is a rare case for Medicare beneficiaries. Nonetheless, you have to know the process if in case you have to do the filing instead of your care provider. Obviously, you have to be eligible for government-sponsored Medicare insurance before you can ask for payments or reimbursements.

  • Filing a Claim
    You can contact your healthcare provider to file a claim if you are covered with Original Medicare. If your doctor is a participating provider, he or she will be the one to process the claim. However, if your physician is a non-participating provider, you have to do the filing yourself. Fortunately, if you are a Medicare Advantage Plan (Part C) beneficiary, you don’t already have to file a claim.
  • Updating Your Claim
    Before filing your claim, it’s better to ask for assistance from reliable Medicare consultants in Pennsylvania to guide you. Claims for Original Medicare could last for 12 months while reimbursements for Medicare Advantage could be processed in a shorter period depending on your claim. Log in to your Medicare account or register to “Medicare Summary Notice” (MSN) to check the updates of your billing and claims.
  • Filing an Appeal
    After Medicare has made a decision, you can file an appeal if you believe the resolution is not fair. Your health insurance broker in Allentown, Pennsylvania may help you in the process to ensure that you get what you deserve. If you believe you’ve been denied with your Medicare coverage, healthcare plan, prescription plan, or Medicare Medical Savings Account (MSA) Plan, you can file an appeal with your healthcare provider.

For further assistance, please don’t hesitate to get in touch with us here at Medicare Professional Advisors. Talk to us at 800-518-3986 today!

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Medicare Parts


Medicare Part A

Part A of Medicare covers hospitalisation. Inpatient treatment, limited time in a licenced nursing facility, limited home health care services, and hospital care are all covered under Part A.


Medicare Part B

Non-hospital medical costs such as doctor's appointments, blood tests, x-rays, diabetes testing and supplies, and outpatient hospital treatment are covered by Part B benefits. For this component of the original health insurance, you pay a monthly fee.


Medicare Part C

In a health insurance plan, Medicare Advantage or Medicare Part C normally covers all forms of health insurance coverage. Private insurance businesses that have been contracted by the CMS to provide a medicare plan as an alternative to the original health insurance plan provide it.


Medicare Part D

Medicare Part D is a prescription medication coverage option. Part D health insurance is available as a stand-alone plan from private insurance firms, with monthly rates varying from one to the next. Depending on the plan you're registered in, you'll split the cost of your prescription medicines.

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You get the same coverage as Original Medicare plus additional benefits from the Medicare Advantage insurance provider when you enroll in a Medicare Advantage plan.

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  • Initial Enrollment Period – Most persons can enrol in Medicare Part A, Part B, Part C, and/or Part D for the first time within a seven-month period: three months before, three months during, and three months after they reach 65.
  • Special Enrollment Period (SEP) – Certain life circumstances, including as moving or losing current coverage, may qualify you for coverage. You usually have two months to enrol, depending on your circumstances.
  • Medicare Part C & D Annual Enrollment Period (AEP) – Every year, from October 15 to December 7, Existing Medicare beneficiaries can take advantage of this time to review and adjust their Medicare Advantage (Part C) and Medicare prescription medication plans (Part D). You cannot utilise AEP to enrol for the first time in Part A and/or Part B. The following year’s coverage begins on January 1st.
  • Medicare General Enrollment Period – Every year, from January 1 to March 31, While the majority of individuals will receive Part B coverage when they join in Medicare, this period is allocated for those who did not enrol in Part B when they initially became eligible. Coverage begins on July 1st of the following year.
  • Medicare Advantage Open Enrollment Period (OEP) – Every year, from January 1 to March 31, You can change to a different Medicare Advantage plan with or without medication coverage during this period, or move to Original Medicare and join a separate Medicare Prescription Drug plan. You cannot, however, go from Original Medicare to a Medicare Advantage plan, join a prescription drug plan while on Original Medicare, or change from one prescription drug plan to another prescription drug plan while on Original Medicare.