![]() IMPORTANT: Do not use a Provider Inquiry Resolution Form (PIRF) to submit an Appeal. Please allow 30 days for a response to an Appeal. Please mail your Appeals to the following addresses:Īll Appeal decisions are answered in writing. Supporting clinical notes or medical records including: lab reports, X-rays, treatment plans, progress notes, etc.Īn Appeal must be submitted within 180 days or 6 months from the date of the Explanation of Benefits.A copy of the original claim or EOB denial information and/or denial letter/notice.Admission and discharge dates (if applicable) or date(s) of service.Please submit an Appeal via a letter on your office letterhead describing the reason(s) for the Appeal and the clinical justification/rationale. Attach a copy of the claim with any additional information that might assist in the review processĪn Inquiry must be submitted within 180 days or 6 months from the date of the Explanation of Benefits.īefore sending an Inquiry, consider submitting a corrected claim that will replace the original claim submitted.Īn Appeal is a formal written request to the Plan for reconsideration of a medical or contractual adverse decision.Include the entire subscriber identification number, including the prefix.If you cannot access CareFirst Direct, please use the Provider Inquiry Resolution Form (PIRF) to submit an Inquiry. Inquiries should be submitted electronically through CareFirst Direct’s Inquiry Analysis and Control System (IASH) function. You need to fill out an " Authorization to Disclose Personal Health Information (PDF) if you want someone to be able to call 1-800-MEDICARE on your behalf or you want Medicare to give your personal information to someone other than you.Inquiries may include issues pertaining to: Authorizations, Correct Frequency, ICD-10, Medical Records, Procedures/Codes and Referrals. ![]() On your "Medicare Summary Notice" (MSN). You can also log into your Medicare account to sign up to get your MSNs electronically and view or download them anytime.On the second page of the instructions for the type of claim you’re filing (listed above under "How do I file a claim?").The address for where to send your claim can be found in 2 places: Any supporting documents related to your claim.A letter explaining in detail your reason for submitting the claim, like your provider or supplier isn’t able to file the claim, your provider or supplier refuses to file the claim, and/or your provider or supplier isn’t enrolled in Medicare.The itemized bill from your doctor, supplier, or other health care provider.The completed claim form (Patient Request for Medical Payment form (CMS-1490S) ).Generally, you’ll need to submit these items: What do I submit with the claim?įollow the instructions for the type of claim you're filing (listed above under "How do I file a claim?"). You can also fill out the CMS-1490S claim form in Spanish (PDF). If it's close to the end of the time limit and your doctor or supplier still hasn't filed the claim, you should file the claim.įill out the claim form, called the Patient Request for Medical Payment form (CMS-1490S) [PDF, 52KB). TTY: 1-87. Ask for the exact time limit for filing a Medicare claim for the service or supply you got. If they don't file a claim, call us at 1-800-MEDICARE (1-80).Contact your doctor or supplier, and ask them to file a claim.If your claims aren't being filed in a timely way: Check the "Medicare Summary Notice" (MSN) you get in the mail every 3 months, or log into your secure Medicare account to make sure claims are being filed in a timely way. For example, if you see your doctor on March 22, 2019, your doctor must file the Medicare claim for that visit no later than March 22, 2020. If a claim isn't filed within this time limit, Medicare can't pay its share. Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. When do I need to file a claim? You should only need to file a claim in very rare cases , these plans don’t have to file claims because Medicare pays these private insurance companies a set amount each month. If you have a Medicare Advantage Plan (Part C) S for covered services and supplies you get. , the law requires doctors and suppliers to file Medicare claim
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