Submitting Medicare claims shouldn’t be complex, but for many skilled nursing facilities (SNFs), home health providers, and post-acute care centers, the process is anything but straightforward.

Mistakes — like missing a required form or using the wrong billing code — can lead to delayed payments, claim denials, and extra administrative work.

If you’re responsible for Medicare billing, you need a process that’s efficient, accurate, and easy to follow. This guide will walk you through exactly that, covering:

• The step-by-step process for how to bill Medicare claims

• Required forms and documentation for accurate billing

• Common billing mistakes that lead to denials — and how to avoid them

Who can bill Medicare?

If your facility provides care to Medicare beneficiaries, you need to know whether you're eligible to bill Medicare — and how to get set up properly. Medicare has strict rules on who can submit claims, what services are covered, and how payments are processed.

Here’s what you need to know:

Eligible provider types

Medicare allows a range of healthcare professionals and organizations to bill for services, including:

Physicians and non-physician practitioners

• Medical doctors (MDs) and doctors of osteopathy (DOs)
  
  

• Nurse practitioners (NPs) and physician assistants (PAs)
  
  

• Clinical nurse specialists (CNSs) and certified nurse midwives (CNMs)
  
  

• Clinical psychologists and clinical social workers

Healthcare facilities and organizations

• Skilled nursing facilities (SNFs) that provide short-term rehabilitation and nursing care

• Home health agencies that deliver in-home care, including therapy and skilled nursing
  
  

• Hospitals and rehab centers, including acute care hospitals, inpatient rehab, and long-term care hospitals
  
  

• Ambulatory surgical centers (ASCs) that perform outpatient surgical procedures

Suppliers (excluding DMEPOS suppliers, who follow a separate enrollment process)

• Independent clinical laboratories
  
  

• Mammography centers
  
  

• Ambulance service providers

Requirements for enrolling as a Medicare provider

To bill Medicare, providers must complete a formal enrollment process. Here’s what it takes:

Obtain a National Provider Identifier (NPI): If you don’t already have an NPI, apply for one through the NPPES. This number uniquely identifies you in Medicare’s system.

Complete the Medicare enrollment application: Submit your enrollment through PECOS (Medicare’s online Provider Enrollment system) or via a paper application.

These are the different form types needed to enroll:

• CMS-855I: Individual physicians and non-physician practitioners
  
  

• CMS-855B: Group practices, clinics, and organizational suppliers
  
  

• CMS-855R: Reassignment of benefits to another entity

Verify enrollment with your Medicare administrative contractor (MAC): Your regional MAC processes applications, may request additional documentation, and determines approval.

Maintain compliance: Medicare requires providers to update their enrollment information regularly. Changes in ownership, legal actions, or practice locations must be reported within 30 days. Other updates (like mailing address changes) must be reported within 90 days.

Medicare Part A vs. Medicare Part B billing

Submitting a claim under the wrong Medicare part can lead to delays, denials, or incorrect payments, adding unnecessary administrative work. Here are key points to know for your provider billing system:

Medicare Part A covers:

• Hospital stays
  
  

• SNF rehabilitation
  
  

• Home health services
  
  

• Hospice care

Medicare Part B covers outpatient services, such as:

• Physician visits
  
  

• Outpatient therapy
  
  

• Preventive screenings
  
  

• Durable medical equipment (DME)

Note: You can learn more about DME billing in this guide.

For SNFs and home health agencies, Medicare Part A is usually the primary payer. However, certain services — such as outpatient therapy — may fall under Medicare Part B once Part A benefits are exhausted.

The step-by-step process of how to bill Medicare

Accurate Medicare billing is essential for ensuring timely reimbursements and avoiding costly denials. Below is a structured process that skilled nursing facilities (SNFs), home health agencies, and post-acute care providers can follow to submit Medicare claims successfully.

Step 1: Verify patient eligibility and coverage

Before providing care, it’s critical to confirm that the patient is eligible for Medicare and determine what services their plan covers. Failing to do so can result in unpaid claims or delayed reimbursements.

To verify eligibility, providers should check:

• Medicare Administrative Contractor (MAC) portal: MACs manage Medicare claims at the regional level and provide up-to-date eligibility verification.
  
  

• ExaCare’s eligibility verification tool: Automates the eligibility check, reducing manual effort and ensuring the patient’s coverage details are accurate.

Once eligibility is confirmed, determine whether the patient has traditional Medicare (Part A and/or Part B) or Medicare Advantage (Part C), a privately managed plan with different coverage rules.

Additionally, verify whether Medicare is the primary or secondary payer. If Medicare is secondary, another insurer will cover a portion of the costs before Medicare processes the remaining charges.

How ExaCare helps: ExaCare eliminates guesswork by automatically verifying a patient’s eligibility, identifying whether Medicare is the primary or secondary payer, and flagging potential coverage issues before claims are submitted.

Step 2: Gather the necessary documentation

Medicare requires complete and accurate documentation to justify services billed. Missing or inconsistent records can lead to claim denials, payment delays, or audits.

Providers should collect and review:

• Medical records, which includes physician notes, care plans, and other supporting documentation
  
  

• Orders and prescriptions, such as physician-ordered treatments or medications
  
  

• Consent forms, including signed documents from the patient authorizing care and billing
  
  

• Diagnostic test results, including lab reports, imaging, and other tests supporting the necessity of treatment

All documentation must align with the billed service codes to prevent discrepancies that could trigger denials.

How ExaCare helps: ExaCare scans referral packets and medical records to ensure documentation is complete and correctly mapped to billing codes. The system flags missing signatures, incomplete records, or inconsistencies before claims are submitted, reducing administrative workload and rework.

Step 3: Choose the correct Medicare claim form

Selecting the right claim form ensures Medicare processes the claim without unnecessary delays, so remember:

• CMS-1500: Used by individual healthcare providers, outpatient clinics, and non-institutional practitioners such as physicians and therapists.
  
  

• UB-04 (CMS-1450): Used by institutional providers, including SNFs, home health agencies, and hospitals.

Providers must also include the correct ICD-10, CPT, and HCPCS codes to ensure proper reimbursement.

How ExaCare helps: ExaCare ensures that key referral data — such as diagnoses, medications, and clinical details — is correctly extracted and structured before reaching the billing team. By presenting a clear, AI-generated summary of patient information, we help providers streamline documentation and reduce errors in downstream billing processes.

Step 4: Apply correct coding and modifiers

Accurate coding is essential for Medicare billing. Claims must include:

• CPT/HCPCS procedure codes to help identify the service provided.
  
  

• ICD-10 diagnosis codes to justify the medical necessity of the service.
  
  

• Modifiers provide additional details about the service, such as the GA Modifier, which indicates that an Advance Beneficiary Notice (ABN) is on file, and a KX Modifier, which shows that medical necessity requirements have been met.

Providers should also follow National Correct Coding Initiative (NCCI) edits, which prevent improper coding combinations that could lead to billing errors.

How ExaCare helps: ExaCare extracts, summarizes, and organizes referral data, ensuring that essential clinical and financial details are readily available for coding teams. By flagging high-cost medications, reimbursement risks, and missing clinical details, we reduce the likelihood of errors and rework in the coding and billing process.

Step 5: Submit the Medicare claim electronically and track claim status

Once all documentation and coding are verified, the next step is to submit the claim for processing. Medicare requires most claims to be submitted electronically for faster processing and fewer errors. Providers can submit claims through:

• Medicare Administrative Contractors (MACs)
  
  

• EHR and billing systems integrated with Medicare portals
  
  

• ExaCare’s electronic claims submission tool, which streamlines the process and reduces manual data entry

While paper claims are permitted in limited circumstances, electronic submission is the preferred method due to its speed, security, and accuracy.

After submission, providers must actively monitor the claim’s status to address any issues before they cause payment delays. Medicare offers online tracking tools, including:

• The MAC portal, which allows providers to check claim progress
  
  

• ExaCare’s real-time claim tracking, which automatically alerts staff to processing delays, denials, or required corrections

If a claim is rejected or denied, providers must identify the error code and reason for denial, correct any missing or incorrect information, and resubmit the claim promptly to avoid payment delays.

Step 6: Receive payment and reconcile accounts

Once Medicare processes a claim, payments are issued via:

• Electronic Funds Transfer (EFT) for direct deposits
  
  

• Paper checks, if EFT is not set up

Providers will receive a Medicare Remittance Advice (RA) or Explanation of Benefits (EOB) detailing approved and denied charges. Reviewing these statements ensures correct reimbursement.

Step 7: Handle claim denials and appeals (if necessary)

If a claim is denied, providers must review the remittance advice to determine the reason. Common denial reasons include:

• Missing documentation
  
  

• Incorrect coding
  
  

• Services deemed medically unnecessary

Providers can appeal denied claims by following Medicare’s five-level appeals process, starting with a redetermination request from the MAC. If an overpayment occurs, providers must refund Medicare within the required timeframe.

How ExaCare helps: ExaCare helps providers proactively prevent denials by ensuring compliance before submission. It also tracks denials, providing automated insights on appeal options and necessary corrections.

ExaCare simplifies Medicare billing for providers

ExaCare is an AI-powered admissions and financial screening solution designed for SNFs and post-acute care providers. By automating key aspects of the referral and intake process, ExaCare helps facilities reduce errors, streamline financial assessments, and improve operational efficiency.

Here’s how ExaCare supports the reimbursement process:

• Accurate patient data extraction: ExaCare extracts critical clinical and financial details from referral packets, helping facilities make informed admissions decisions and reducing errors that could impact reimbursement.
  
  

• Proactive documentation review: The system flags missing signatures, incomplete referral data, and high-cost medications, helping providers address potential financial risks before claims are submitted.
  
  

• Real-time financial risk alerts: ExaCare identifies potential reimbursement issues early, such as high-cost patients or unclear payer information, allowing providers to adjust their intake decisions accordingly.
  
  

• Seamless integration with EHRs and referral platforms: ExaCare works with platforms like PointClickCare, Aidin, Aida, and EPIC Link to streamline referral management and decision-making.

Mastering how to bill Medicare correctly is key to maximizing reimbursements and ensuring a smooth claims process — let technology help you stay compliant and efficient.

Ready to see how ExaCare can help your facility? Talk with our team to learn more.

Schedule a demo.