what situation provider don't need to submit the claims to Medicare

MEDICARE CLAIMS


A claim is defined as a request for payment for benefits or services received by a beneficiary. Providers and suppliers who furnish covered services to Medicare beneficiaries are required to submit claims for their services and cannot charge beneficiaries for completing or filing a Medicare claim. Medicare Contactors monitor compliance with these requirements. Offenders may be subject to a Civil Monetary Penalty of up to $10,000 for each violation.

Medicare fee-for-service claims must be filed timely, which means that they must be filed on or before December 31 of the calendar year following the year in which the services were furnished. Services furnished in the last quarter of the year (October through December) are considered furnished in the following year.

Exceptions to Mandatory Filing


Providers and suppliers are not required to file claims on behalf of Medicare beneficiaries when:

The claim is for services for which Medicare is the secondary payer, the primary insurer’s payment is made directly to the beneficiary, and the beneficiary has not furnished the primary payment information needed to submit the Medicare secondary claim;

The claim is for services furnished outside the U.S.;

 The claim is for services initially paid by third-party insurers who then file Medicare claims to recoup what Medicare pays as the primary insurer (e.g., indirect payment provisions);

The claim is for other unusual services, which are evaluated by Medicare Contractors on a case-by-case basis;

 The claim is for excluded services (some supplemental insurers who pay for these services may require a Medicare claim denial notice prior to making payment);

 He or she has opted-out of the Medicare Program by signing a private contract with the beneficiary; or He or she has been excluded or debarred from the Medicare Program.