Medicare Claims and Appeals in California

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A California Medicare claim must be filed for services rendered and medical supplies purchased. The Medicare claim form is only required for certain plan types and does not apply to all Medicare enrollees in California. Those who do must check on their Medicare claim status to verify that the physician or supplier submitted the request for coverage. California residents should know how to file a Medicare appeal in the event that beneficiaries disagrees with the decision.

Filing Your Medicare Claim Form in California

Medicare claims in California are typically the responsibility of the doctor or supplier. If a beneficiary needs to submit a Medicare claim form, it will most likely be due to receiving health services from a provider who is not participating within the program. Each claim form for Medicare must be filed within a certain time from the date when services were received. If enrollees fail to submit claims by the Medicare claim deadline, then Medicare will be unable to pay its share of the cost.

To file your claim you will need to fill out the Medicare claim form called Patient Request for Medical Payment (CMS-1490S). There are several different instructions that you will need to follow depending on the type of claim you are making. You may make claims for durable medical equipment (DME), Medicare Part B services and services obtained onboard a ship or in Canada, Mexico or other foreign hospital locations.

Along with the Medicare claim form, you will need to submit an itemized bill from your health care provider and a letter explaining why you are submitting the claim. You then need to send the documents to Medicare. At this time, you cannot file a Medicare claim online but you can check Medicare claim status online.

Checking Your California Medicare Claim Status

To check your Medicare claim status you will need to visit the Medicare website and log into your account. You will be able check the status of your Medicare claim online, usually a day after officials have processed it, as well as other up-to-date information about Part A and B claims. You can also check your Medicare claim status on your Medicare Summary Notice (MSN), which will give you the details of all the services and/or supplies received within a three-month period including what Medicare paid and how much you may owe your health care provider.

Discover comprehensive information about Medicare claims and appeals in our detailed California guide here.

How to File a Medicare Claim Appeal in California

Checking your Medicare claim online is the most convenient method to find out if your request was approved. If you disagree with a Medicare claim decision, then you can file an appeal. Officials may deny your Medicare claim form for a variety of reasons and you can file an appeal if any of the below criteria apply:

  • Denial of future services: If Medicare or your plan refuses your request for a health service, medical supplies or prescription medications in which you feel you are entitled.
  • Denial of payment: If Medicare or your plan refuses your request for a payment for health service, medical supplies or prescription medications that you already have.
  • Denial of change: If Medicare or your plan refuses your request to change the amount you must pay for health service, medical supplies or prescription medications.
  • Denial of need: If Medicare or your plan stops providing or covering the cost of part of ahealth service, medical supplies or prescription medications you think you still need.

If you decided to file a Medicare claim appeal, then you should talk to your physician or supplier to identify and obtain any information that can help your case. Contact your health insurance provider and ask for details about your appeal rights. There are five different levels in the Medicare claim and appeal process, which are:

Level 1: Redetermination by the company that handles claims for Medicare – At this level of the Medicare claim for reimbursement, you need to fill out a redetermination request form and send it to your Medicare contractor. You should include the bill and details of any items with which you disagree.

Level 2: Reconsideration by a Qualified Independent Contractor (QIC) – At this level you may fill out a reconsideration request form and submit it to a QIC. You should include the bill and details of any items you disagree with.

Level 3: Hearing before an Administrative Law Judge (ALJ) – To be eligible for an ALJ hearing, the amount of your case must meet the annual minimum of $160 (for 2017). An ALJ hearing is typically held by video conference or telephone. The ALJ will examine your case and listen to your testimony before making an impartial decision.

Level 4: Review by the Medicare Appeals Council (Appeals Council) – If you wish to request a Medicare claim through the Appeals Council, then you must follow the instructions you were given at the ALJ hearing. The instructions will tell you where to send your appeal request.

Level 5: Judicial review by a federal district court – In order to get a judicial review in a federal court, the amount of your case must meet the minimum annual amount of $1,560 (for 2017). In some cases, you may be allowed to combine several claims to meet this amount. To file at this level, follow the instructions you received in the letter from the Appeals Council.

Download our in-depth California guide for detailed information about Medicare claim policies.


What Are the Available Health Services in California?

Low-cost, and even free health benefits are available to a large number of California residents, with some being offered to low-income applicants and others being offered to elderly or disabled individuals. However, before you can access these health services, you need to submit the appropriate application and prove that you meet the necessary qualifications. To learn all about the different health benefits you can receive in California and the application procedures that you must undergo to obtain these benefits, download our free comprehensive guide.


Who Is Eligible to Obtain California Health Benefits?

California’s health programs have various eligibility requirements that applicants must meet in order to successfully enroll. Income, age and other factors are all taken into consideration in the eligibility verification process. Find out which health benefits you qualify for here.