This checklist organizes the durable, structural readiness steps that apply to a traditional Medicare (fee-for-service) claim before it leaves the billing system. It is a neutral educational reference, not legal, coding, or reimbursement advice, and it does not reflect any single payer's contract terms. Where a rule depends on the beneficiary's Medicare Administrative Contractor, plan type (for example, Medicare Advantage versus Original Medicare), the service billed, or the date of service, the checklist says so and directs readers to the Centers for Medicare & Medicaid Services (CMS) and its Medicare Learning Network (MLN) materials, or the CMS Internet-Only Manuals, for the governing detail. Nothing here should be completed with real patient data.
Confirm beneficiary identity and the current MBI Verify the beneficiary's name matches Medicare records and that the claim carries the active Medicare Beneficiary Identifier (MBI) rather than a legacy identifier. An MBI can change (for example, if CMS reissues one), so the number on file should be re-checked rather than assumed. See the glossary entry for the Medicare Beneficiary Identifier (MBI) at /resources/glossary/medicare-beneficiary-identifier and the article on The Medicare Beneficiary Identifier at /knowledge-base/medicare-billing/the-medicare-beneficiary-identifier. Formatting and eligibility responses are governed by CMS (cms.gov). Verify active coverage, effective dates, and plan type Confirm the beneficiary has active Medicare coverage on the date of service and identify whether the claim should go to Original Medicare or to a Medicare Advantage (Part C) plan, because Advantage plans are billed under the plan's own rules rather than to the MAC. Coverage status and plan enrollment come from CMS eligibility systems (cms.gov). See Eligibility verification at /knowledge-base/eligibility-verification, Verifying Medicare eligibility at /knowledge-base/eligibility-verification/verifying-medicare-eligibility, and Medicare Advantage billing at /knowledge-base/medicare-billing/medicare-advantage-billing. Confirm provider enrollment and billing privileges Confirm the rendering and billing entities have active Medicare enrollment and billing privileges through PECOS before the claim is filed; enrollment gaps or lapsed revalidation can block payment. PECOS is the CMS Medicare enrollment system, and the CMS-855 family is the enrollment application set. See Provider enrollment at /resources/glossary/provider-enrollment, PECOS at /resources/glossary/pecos, and Medicare enrollment and billing privileges at /knowledge-base/medicare-billing/medicare-enrollment-and-billing-privileges. Requirements are set by CMS (cms.gov). Check assignment and participation status Determine the provider's participation status and whether the claim is submitted on assignment, since that affects how the allowed amount, patient responsibility, and payment flow are handled. These are structural Medicare concepts; the specific consequences depend on the provider's agreement with Medicare. See Assignment at /resources/glossary/assignment and Assignment and participation at /knowledge-base/medicare-billing/assignment-and-participation. Participation rules are defined by CMS (cms.gov). Use the correct claim format for the setting Match the claim to the right format: professional services generally use the CMS-1500 (or its electronic 837P equivalent) and institutional services generally use the UB-04 (837I). Field-level content follows the maintainers of those forms and the X12 837 standard (x12.org). See CMS-1500 at /resources/glossary/cms-1500, UB-04 at /resources/glossary/ub-04, and Submitting claims at /knowledge-base/claims/submitting-claims. Do not reproduce code descriptor text on the claim; name only the code sets and their maintainers. Confirm medical necessity and applicable coverage determinations Confirm documentation supports medical necessity and check whether a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) applies to the service. LCD content is set by the responsible MAC and varies by jurisdiction and over time, so the current policy should be consulted rather than a remembered rule. See Medical necessity at /resources/glossary/medical-necessity, Local coverage determination (LCD) at /resources/glossary/local-coverage-determination, and National and local coverage determinations at /knowledge-base/medicare-billing/national-and-local-coverage-determinations. Determinations are published through CMS (cms.gov). Issue an ABN when Medicare coverage is uncertain When a normally covered Part B item or service may be denied as not medically necessary, an Advance Beneficiary Notice of Noncoverage (ABN) may be required before the service so the beneficiary understands potential financial responsibility; corresponding claim modifiers signal the ABN's presence. Whether an ABN applies, and its exact use, depends on the service and CMS instructions. See Advance Beneficiary Notice at /resources/glossary/advance-beneficiary-notice, The Advance Beneficiary Notice (ABN) at /knowledge-base/medicare-billing/the-advance-beneficiary-notice, and the guide Issue an advance beneficiary notice at /resources/guides/issue-an-advance-beneficiary-notice. The ABN form and rules are issued by CMS (cms.gov). Resolve Medicare Secondary Payer order before billing Determine whether Medicare is primary or secondary by applying Medicare Secondary Payer (MSP) rules and coordination of benefits; when another payer is primary, that payer is generally billed first and Medicare processes the remainder. MSP situations depend on the beneficiary's specific circumstances, so they should be screened rather than assumed. See Medicare Secondary Payer at /resources/glossary/medicare-secondary-payer, Coordination of benefits at /resources/glossary/coordination-of-benefits, and Medicare Secondary Payer (MSP) billing at /knowledge-base/medicare-billing/medicare-secondary-payer-billing. MSP rules are administered by CMS (cms.gov). Route the claim to the correct MAC Confirm the claim is directed to the Medicare Administrative Contractor (MAC) responsible for the jurisdiction and claim type (Part A/B versus certain specialty MACs), because edits, LCDs, and submission channels differ by contractor. Jurisdiction assignments are published by CMS (cms.gov). See Medicare Administrative Contractor (MAC) at /resources/glossary/medicare-administrative-contractor, Medicare Administrative Contractors (MACs) at /knowledge-base/medicare-billing/medicare-administrative-contractors, and the MAC jurisdiction lookup at /tools/lookup/medicare-administrative-contractor-jurisdictions. Verify the claim meets the timely filing requirement Confirm the claim will reach Medicare within the applicable timely filing period measured from the date of service, since a late claim can be denied on that basis alone. The specific limit and any exceptions are set by CMS and should be checked against current guidance rather than quoted from memory. See Timely filing at /resources/glossary/timely-filing and Medicare timely filing at /knowledge-base/medicare-billing/medicare-timely-filing. The filing standard is established by CMS (cms.gov).
