HOW TO FILE A MEDICARE CLAIM AND APPEAL IN TEXAS

While Medicare claims are rare, it is important to know how to file a claim should the need arise. Medicare claimants with Original Medicare plans (Part A or Part B) require doctors and suppliers to file claims for covered services and supplies. Medicare claimants with a Medicare Advantage Plan (Part C) do not have to file claims since Medicare pays the private insurance companies a specified total each month. Medicare claims should be filed within one year of the date of services received. If Medicare claims are not filed within this time frame, Medicare cannot pay for the claim.  If Medicare claims are not filed in a timely manner, petitioners should contact their doctor or supplier and request that the doctor files a claim. Medicare claimants can also contact Medicare directly to ask for details regarding the timeline of the claim.  Below, Medicare applicants can find information on filing a Medicare claim in-person or online:

  • How to file a Medicare claim in Texas
  • How to submit a Medicare claim form in Texas
  • How to check Medicare claim status in Texas
  • How to file an appeal in Texas

How to File a Medicare Claim in Texas

Candidates who wish to file a Medicare claim can do so by completing a Patient Request for Medical Payment (form CMS-149OS). However, instructions vary depending on the type of Medicare claim being submitted. 
Medicare claims for Part B services in Texas should be sent to Novitas Solutions in Mechanicsburg, Pennsylvania. The completed CMS-149OS Medicare claim form should be mailed along with the patient’s itemized bill and any supporting documents. Medicare claims for services received while aboard a ship, in a foreign hospital or while in Canada or Mexico should be sent to the same address. 
Medicare claims for the use of durable medical equipment in Texas should be sent to CGS Administrators, LLC in Nashville, Tennessee. The completed CMS-149OS Medicare claim form should be mailed along with the patient’s itemized bill and any supporting documents. 

How to Submit a TX Medicare Claim Form 

To accurately submit a Medicare claim form, the applicant must be sure to complete the CMS-149OS. The claimant must also include the itemized bill from the doctor, supplier or health care provider. In addition to the Medicare claim form, the claimant must also include a letter explaining the reason for the claim, along with supporting documents related to the claim. The Medicare claim form should be mailed to the organizations listed above. The claimant cannot submit a Medicare claim online. 

How to Check Medicare Claim Status in Texas

An applicant may check the status of his or her Medicare claim online. Medicare claim statuses are usually visible online within 24 hours after Medicare processes the claim. Additionally, a claimant’s Medicare claim status can be found on the Medicare Summary Notice, which is mailed out every three months. Medicare claimants can also sign up to receive the Medicare Summary Notice electronically. 
To check the Medicare claim status of a Part D claim, claimants should view their explanation of benefits. Explanation of benefits are mailed each month that a prescription is filled. To check the Medicare claim status of a Part C or other Medicare claim, petitioners should contact their specific Medicare plan.

How to File an Appeal in Texas

Medicare claims may be filed in the form of an appeal if a petitioner disagrees with a coverage or payment decision made by Medicare. Appeals may be filed if a Medicare claimant is denied services, supplies, items or prescription drugs that he or she believes should be covered under the plan.  
Appeals may also be filed if a Medicare claimant is denied a request for payment regarding health care services, supplies, items and prescription drugs that he or she has already received. Additionally, appeals may be filed if a Medicare claimant is denied of his or her request to change the amount of payment for a health care service, supply, item or prescription drug. 
Medicare claimants can file an appeal in five different levels, including the following:

  1. Original Medicare appeals
  2. Medicare health plan appeals
  3. Medicare prescription drug appeals
  4. Special needs plan appeals
  5. Medicare claim state representative assistance

If the Medicare claimant disagrees with a decision made during any of the five levels, the claimant may move on to the next level. If Medicare services are ending too soon, Medicare claimants have the right to a fast appeal. Medicare claimants can file a fast appeal for services involving a hospital, nursing facility, home health agency, outpatient rehabilitation service or hospice care.


What are benefits for Texas residents?

The State of Texas offers a wide array of benefits and services to the residents of Texas at home and abroad. These benefits include health care, housing assistance, unemployment assistance and a variety of programs for families to assist with food and health expense. Many individuals and families qualify for several of these programs. Complete the survey and download our guide to find helpful information on all of Texas Benefits along with details about eligibility and instructions for how to apply here.


Who is eligible for Texas benefits?

The State of Texas extends benefits to those who qualify. Families, individuals who have lost their job, persons with disabilities and elderly residents are usually those who will benefit the most from Texas's social welfare programs. For a comprehensive list of the requirements for each of Texas' programs please complete the survey and download our guide.



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