September 10, 2009

Common Medicare Claims Questions

Information from Senior Health Insurance Information Program (SHIIP)

Why didn’t Medicare pay for my ambulance claim? Can I go to my grandson’s graduation and still qualify as “homebound” so I can get Medicare home health care services? What is an Advanced Beneficiary Notice? Why didn’t my Part D plan cover my emergency room drugs?

“These are just a few of the questions we get from Iowans about Medicare claims,” says Kris Gross from the state of Iowa’s Senior Health Insurance Information Program (SHIIP). “It’s important to talk to medical providers before you receive services to discuss Medicare’s coverage, review Medicare Summary Notices when you receive them and know claims procedures to assure you receive the benefits to which you are entitled,” Gross adds.

Medicare payment for ambulance transport is based on medical necessity and is limited to transport to and from certain locations. Most ambulance coverage has to be related to an emergency or a situation that endangers your health if you were transported by other means.  If your service area does not have a facility that is adequately equipped or capable of treating you, transport to the closest appropriate facility will be covered.

Home health care services are covered by Medicare when you are “homebound” and need part-time skilled nursing services or therapy to help you rehabilitate. Homebound does not mean you can never leave your home. Leaving home for medical treatment and attending a licensed or accredited adult day care or religious service is always permitted. Leaving home for short periods of time or for special non-medical events, such as a family reunion, funeral or graduation, should not exclude you from being considered homebound. Taking an occasional trip to the barber or beauty parlor is also allowed.

An Advance Beneficiary Notice (ABN) is a notice that medical providers and suppliers are required to give you when they offer services or items that they know, or have reason to believe, Medicare will not pay for because it is not medically necessary.  Always read all forms before you sign them. If you’re given an ABN, discuss with the provider or supplier why Medicare may not cover the service or item, and whether it is necessary for you to receive it. Even if you sign an ABN, you can appeal the claim if it is denied.

Hospital pharmacies are considered to be “out-of-network” for Part D plans and will not file claims with your plan. Medicare requires plans to cover drugs when you cannot reasonably be expected to get your drugs at a network pharmacy. An emergency room visit would qualify. In this case, call your Part D plan and ask how you can file an out-of-network claim.

For more information on Medicare benefits and claims call SHIIP at 1-800-351-4664 (TTY 1-800-735-2942) or go to Local SHIIP counselors are also available to answer your questions. Call the SHIIP 800# for the site nearest you. SHIIP services are free, confidential and objective.