Medicare Claims and Appeals in Florida

A Medicare claim is an official document that is filed whenever the recipient of Medicare benefits is provided with a healthcare or a medical service. The Medicare claim form is usually filed by the doctor or healthcare specialist on behalf of the Medicare recipient who received the service. After the Medicare claim is filed, it will receive one of three specific claim statuses. The recipient can check the Medicare claim status over the internet. If the Medicare claim status shows it was denied, the recipient can submit an appeal toward his or her Medicare claim online in Florida. To learn more about the process of Medicare claims and appeals in Florida, review the following topics:

  • How to File a Medicare Claim in Florida
  • How to File a Medicare Appeal in Florida
  • Status of Claims and Appeals in Florida

How to File a Medicare Claim in Florida

Although a Medicare claim would generally be filed by a doctor or a healthcare professional, the Medicare recipient may have to file the Medicare claim on his or her own if expecting to get a Medicare reimbursement of some kind. Most of the time, those who are receiving Medicare Part A and Medicare Part B benefits should be able to have their Medicare providers file Medicare claims for them. It is very rare for Medicare to directly reimburse the recipient who has benefits from Medicare Part A and Medicare Part B. In fact, federal law requires medical suppliers and medical providers to submit the Medicare claims directly to Medicare. Each Medicare claim then gets filed electronically.

If, for some reason, the health care provider was supposed to file a Medicare claim but did not, then the recipient would need to call the Medicare office and ask a customer service representative how much time is left to file the Medicare claim in Florida. If it looks like the provider is never going to file the claim, or if it has to be done quickly, the recipient can fill out a Patient Request for Medical Payment form that is available on the Medicare website and then mail it to the local Medicare office. The Medicare claim form must also include an itemized bill from the health care provider and a detailed letter that explains why the form is being submitted. Download our free guide to review tips on what should be included in a claim letter. Those with Medicare Part C do not have to file a Medicare claim, because private insurance companies get paid a fixed amount by Medicare each month.

How to File an Appeal in Florida

If a Medicare claim is denied, then an appeal can be filed. An appeal for Medicare can also be filed if the payment or coverage provided by Medicare was not enough to cover the Medicare claim that was filed. However, an appeal may only be filed if certain conditions apply. For example, if the recipient requests a particular health care service, a prescription drug or an item and is denied the request, an appeal can be filed. Another scenario is simply when a recipient files a Medicare claim for a health care service, a prescription drug or a health care item, and he or she does not get the amount requested. Anyone with a Medicare Medical Savings Account Plan can appeal as well, but only if the deductible amount has been reached.

A Floridian who wants to file an appeal can get help with this through the Florida SHINE website. The Florida SHINE program is comprised of trained volunteers who understand Medicare claims and appeals very well. They can walk patients through the process of appealing Medicare claims denials by providing them with the papers and information necessary. The only alternative for a recipient is to have a representative appointed. This could be a doctor, an attorney, a friend, a family member or anyone else who can perform on the claimant's behalf. To declare a representative for a Medicare claim, a recipient would have to fill out a form called an "Appointment of Representative" and then submit a written request to Medicare along with the appeal.

Status of Claims and Appeals in Florida

Medicare claim online status checks are available in the state of Florida. Medicare claim status for Medicare Part A and Part B can be reviewed on the Medicare website, which is run and operated by the federal government. Recipients will have to register for an account online if they have not already done so. Medicare claim and appeal statuses get updated within 24 hours after a Medicare claim or an appeal is processed by Medicare. Those who have Medicare Part D can see their Medicare claims or appeal statuses by clicking on the Blue Button through their online Medicare accounts. The status is also included on the Explanation of Benefits form received in the mail each month. As for Medicare Part C, this status can only be checked by contacting the health plan provider directly. For more details on how to review claim and appeal statuses through Medicare, download our free guide.

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What Health Services Are Available in Florida?

Health services are available for a wide variety of Florida residents and the benefits range from low-cost to free health care. However, the claimants and families that are interested in these benefits typically need to submit applications and documents that prove their eligibility for program benefits. Learn about the various health programs available in the state of Florida and find out how to qualify for affordable health care or medical coverage that is free of charge by downloading our guide.


Who Can Receive Florida Health Benefits?

Health service programs in Florida have a variety of eligibility requirements. Some of the factors taken into consideration when evaluating an applicant's eligibility include age and household income. However, even if petitioners do not qualify for health care in one program, they are often eligible for the benefits of another.