Medicare Claims and Appeals in Virginia


A Medicare claim in Virginia is rarely filed by the Medicare participant who has met eligibility requirements for the Medicare program. In VA, Medicare claims are usually submitted by the doctor or medical supplier who provided the service or equipment. Even though claims for Medicare services are typically filed by health care providers, there are certain situations where a Medicare participant must file his or her own claim. When a doctor or other medical care provider fails to submit a Medicare claim form within the required timeframe, the Medicare participant risks being held financially responsible for paying Medicare’s share out of pocket. To avoid this problem, enrollees should keep close track of Medicare claim status and note any that have not been submitted when they should have been. To learn more about Medicare claim status, instructions on how to file a Medicare claim form and what situations warrant filing a claim, participants can review the information organized below. The material below also includes additional information regarding how to file a Medicare claim for appeal after disagreeing with a Medicare service decision.

Reasons for Filing a Medicare Claim in VA

Reasons for filing a Medicare claim in Virginia will vary according to the types of Medicare coverage plans you participate in. You may have to file a Medicare claim for reimbursement if you receive treatment from a provider that does not accept Medicare, but only after you pay your full cost of treatment up front. You may have to file your own Medicare claim if your provider fails to submit a claim during the timeframe mandated by Medicare, if you have Original Medicare, which includes Part A and Part B. If you have a Medicare Prescription Drug Plan or receive medication coverage through a Medicare Advantage Plan, you may have situations where Medicare does not cover the cost of a prescribed medication. If this happens, a Medicare claim for appeal is what you will file to attempt to get reimbursement for your prescription.

You will not need to file Medicare claims yourself if you have Part C, or a Medicare Advantage Plan, because the private insurers who provide Medicare Advantage Plans receive a set payment from Medicare each month. These payments reimburse them for providing Medicare coverage. Learn more about filing a Medicare claim or appeal by downloading our detailed guide.

How to File a Medicare Claim

Medicare claim forms are available online to download and print for anyone who needs to complete the claims submission process. Before filing your Medicare claim, you should make sure to contact your doctor’s office and remind them to file the claim. If you need assistance in getting the doctor to file your Medicare claim, you may call 1-800-MEDICARE and ask for assistance with accomplishing this task. If that does not result in the submission of the claim, follow these tips:

  1. Obtain a copy of a Medicare claim form.
  2. Gather Medicare claim supporting documents from your physician or medical supplier, including an itemized bill for services.
  3. Submit the completed Medicare claim form and supporting documents to Medicare, using the address provided on the form.
  4. Check your Medicare claim status regularly using the instructions below.

When to File a Medicare Claim

Medicare claims must be filed within a certain time frame after you receive a medical service, procedure, equipment or medication. If your Medicare claim is not submitted and processed within that time period, Medicare will not pay its share of your treatment cost and you may have to pay it yourself. It is important to keep track of Medicare claims and submit any that were not taken care of by your doctor or other medical service provider.

How to Check the Status of a Claim

Medicare claim status can be checked at any time through certain methods. Medicare claim status is provided through a Medicare Summary Notice that will be mailed to you periodically for review. You may also obtain up-to-date Medicare claim status by creating an account on Medicare’s website or using their online Blue Button feature. For detailed information on checking the status of a Medicare claim, be sure to download our comprehensive guide to Medicare services in Virginia.

Medicare Appeals

If you disagree with a decision on a Medicare claim, or a doctor’s treatment decision, you have the right to file an appeal. In some cases, denial of a Medicare claim or a doctor’s refusal of your request for a specific medication or procedure cannot be resolved without filing an appeal. While filing a Medicare claim or checking on a Medicare claim status are easy procedures, filing an appeal can be a long and complicated process. As there are different types of Medicare claims, there are different types of Medicare appeals. You must carefully follow the steps for your particular type of appeal to better your chances of receiving the treatment, medication or equipment you need. Each type of Medicare claim for appeal has five levels, which means that if your first step is denied, there are four more steps you can take to resolve the issue. Additionally, if your initial Medicare claim for an appeal is denied, it will be reviewed by an independent organization. Virginia provides Medicare claim and Medicare appeal assistance through the State Health Insurance Assistance Program (SHIP). Understanding Medicare eligibility requirements can help you determine the situations that require you to file a Medicare claim or appeal for medical services.

Virginia Department of Social Services