Medical Bills: How It Works
Medicare and secondary insurance (such as Medigap, NJ FamilyCare/Medicaid, or retiree plans) communicate with each other automatically through a system called the Coordination of Benefits Agreement(COBA) crossover. A manual claim option (CMS Form 1490S) also exists to ensure that secondary insurance benefits are applied correctly if the automatic process fails and to protect patients from being billed for costs that their insurance should cover.
The Automatic Billing System (COBA, Crossover)
The Coordination of Benefits Agreement (COBA) is a national system that allows Medicare to share billing data directly with secondary insurers (such as Medigap, retiree plans, or NJ FamilyCare/Medicaid).
- The Process: After Medicare pays its portion of a medical bill, it automatically crosses over (transfers) the claim information to the secondary payer.
- No Action Required: In standard scenarios, patients and providers do not need to file separate claims for the secondary insurer to pay its portion of the bill.
Filing a Manual Claim (CMS Form 1490S)
While healthcare providers are generally required to file claims, there are specific instances where a manual claim must be filed directly with Medicare to trigger payment.
Circumstances for Manual Filing
- Provider Refusal: A physician or medical supplier refuses to submit a claim to Medicare for a covered service.
- Non-Participating Providers: Services were received from a provider who is not enrolled in the Medicare program (often during emergencies or specific travel situations).
- Technical Failures: The automatic crossover failed, and the secondary insurer requires an official Medicare payment notice to process the remaining balance.
How to File a Manual Claim Using CMS 1490S
- Complete the Form: CMS Form 1490S (Patient’s Request for Medical Payment).
- Gather the Itemized Bill, including:
- Date and place of service (e.g., doctor’s office, hospital).
- A description of each medical service or supply provided.
- The specific charge for each individual service.
- The provider’s name, address, and National Provider Identifier (NPI).
- Attach a Statement of Reason:
- The doctor is not enrolled in Medicare.
- The provider refused to file the claim on the patient’s behalf.
- The services were received during foreign travel or in an emergency.
- Mail the Package
- Novitas Solutions P.O. Box 3030 Mechanicsburg, PA 17055-1834
* Time Limit: Claims must be submitted within 12 months (one full calendar year) of the date the services were provided.
* Processing Time: It typically takes Medicare up to 60 days to review and process a manual claim.
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