HIPAA Claims Filing

HIPAA Claims Filing Requirements For Palmetto GBA Providers

HIPAA Claims Filing requirements by Palmetto GBA require providers to submit claims for all Medicare patients for services rendered. HIPAA Claims Filing requirements apply to all physicians and suppliers who provide covered services to Medicare beneficiaries. You may not charge your patients for preparing or filing a Medicare claim. The requirement to submit Medicare claims does not mean you must accept assignment. Compliance of the claims mandatory claim filing requirements is monitored by carriers. Violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation and/or Medicare program exclusion.

Exceptions to Mandatory Filing

You are not required to file claims on behalf of Medicare beneficiaries for:

  • Used DME purchased from a private source
  • Medicare Secondary Payer (MSP) when you do not possess all the information necessary to file a claim
  • Foreign claims
  • Services billed to the third party insurers (indirect payment provisions)
  • Opting out of the Medicare Program by signing private contracts with Medicare beneficiaries
  • Other unusual services (evaluated by Palmetto GBA on a case-by-case basis)
  • Reference – CMS Medicare Claims Processing Manual (Pub. 100-02), chapter 1, section 

You are not required to file non-covered Medicare services. However, many Medicare supplemental insurance policies pay for services that Medicare does not allow and they may require a Medicare denial notice.

False Claims Act: Prohibits knowingly filing a false or fraudulent claim for payment to the government, knowingly using a false record or statement to obtain payment on a false or fraudulent claim paid by the government, or conspiring to defraud the government by getting a false or fraudulent claim allowed or paid. See 31 U.S.C. 3729(a) of the Act for additional details/exclusions/statutory exceptions.

Methods of Submission: Claims may be filed to Palmetto GBA electronically (this applies to most Medicare providers) or on paper (if certain conditions or exceptions exist).

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