Medicare claims are formal requests for payment submitted to the federal program for services provided to beneficiaries. The submission process is highly structured and governed by regulations set forth by the Centers for Medicare & Medicaid Services (CMS). Knowing precisely where to send a claim determines whether a provider receives timely payment for the healthcare they have delivered.
Identifying the Processing Entity
Medicare does not use a single federal office to process the millions of claims submitted annually. Instead, the Centers for Medicare & Medicaid Services contracts with private health insurance companies known as Medicare Administrative Contractors (MACs). MACs act as the primary link between the Medicare Fee-For-Service program and participating providers. Their responsibilities include enrolling providers, educating them on billing requirements, and establishing local coverage policies for their assigned regions.
MACs are assigned specific geographic regions, or jurisdictions, where they administer Medicare Part A and Part B claims. A provider’s location determines which contractor will process their claims. The system differentiates between claims for institutional services (hospitals) and professional services (physicians).
Part A MACs manage claims for institutional providers, while Part B MACs process claims for professional services and supplies. Some contractors, referred to as A/B MACs, manage both types of claims within their defined jurisdiction.
Determining Your Specific Jurisdiction
The definitive answer to “where do I send the claim” is the Medicare Administrative Contractor (MAC) assigned to the provider’s physical location. The correct jurisdiction is determined by the service provider’s geographic area, not the beneficiary’s address. Submitting a claim to the wrong MAC causes significant delays in payment and processing.
Providers must confirm their assigned MAC before submission to avoid administrative setbacks. CMS maintains resources, such as a ZIP code lookup tool, to help providers identify their specific MAC jurisdiction. This tool allows for the precise determination of the contractor responsible for a provider’s area.
Specialized contractors exist for specific types of claims outside the standard A/B geographic split. Durable Medical Equipment (DME) MACs process claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) nationwide. There are four DME MACs, each covering a large, multi-state region.
Required Methods for Claim Submission
Once the correct Medicare Administrative Contractor is identified, the next step is determining the required method of transmission. Current federal regulations, specifically the Administrative Simplification Compliance Act (ASCA), mandate that most Medicare claims must be submitted electronically. This requirement is enforced through Electronic Data Interchange (EDI), which is the automated transfer of data in a specific, standardized format between the provider and the MAC.
Electronic submission uses standardized transaction sets, such as the ANSI X12 837P for professional claims and the 837I for institutional claims. This process accelerates the review process and reduces the administrative cost for both the provider and the Medicare program. Providers typically utilize a billing service, a clearinghouse, or a direct connection to the MAC to transmit these electronic files.
Paper claims are permitted only in very limited circumstances, generally for providers with specific religious exemptions or in cases of exceptional technical issues. When paper claims are necessary, they must be submitted on specific forms to the correct MAC address. Professional services claims are filed using the CMS-1500 form, while institutional services are submitted on the UB-04 form (also known as the CMS-1450). The MAC provides the precise mailing address for these limited paper submissions.