How to Submit Medicare PPO Claims

Date Issued: 10/1/2010

Electronic claims submission
You (the clinician, provider group, facility, etc.) must submit an electronic claim to the Medicare carrier who is the primary insurer. There is no other action you need to take.

Thereafter:

  1. The Medicare carrier adjudicates the claim and sends the processed claim and an explanation of payment (EOP) to you. A remark on your EOP from the Medicare carrier will advise you that they submitted the claim electronically to us.
  2. The Medicare carrier sends an electronic claim for secondary or supplemental payment consideration to us.
  3. We process the claim and send our own EOP and any additional payment to you.

This process, coordinated in partnership with the Centers for Medicare & Medicaid Services (CMS) via the National Coordination of Benefits Agreement (COBA) program, allows claims for Medicare beneficiaries to be paid in an efficient and cost-effective manner.

Do not send duplicate claims to us

  • Submitting a Medicare PPO claim electronically or in paper form directly to us for secondary consideration will result in the delay of payment and may confuse the member — your patient.
  • Allow a reasonable amount of time to complete your accounts receivable reconciliation process.
  • Ensure that your billing system is not set up to re-bill automatically every 30 days or to generate a duplicate paper claim.