Get Medicare No Fault Case Closure

Filling out the Medicare No Fault Case Closure form is a vital step in ensuring proper management of medical payments related to accidents. This guide will walk you through each section of the form to ensure a smooth completion process.

Follow the steps to complete your case closure form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred digital editing tool.
2. Enter the beneficiary's name in the designated field at the top of the form. This should be the full name of the individual receiving Medicare benefits.
3. Fill in the Medicare number, which is a unique identification number issued to beneficiaries. Ensure it is correct to avoid delays.
4. Complete the date of incident field, providing the specific date (month/day/year) when the incident occurred.
5. Input the amount of policy limit related to the incident. This figure should reflect the maximum coverage available under the relevant insurance policy.
6. Indicate whether the policy limits were exhausted by circling ‘Yes’ or ‘No’. This information is critical for processing the case.
7. If benefits were not exhausted and the beneficiary has stopped treating, document the date they stopped receiving treatment.
8. Record the date the case is officially closed, ensuring accuracy in documentation.
9. Specify who provided the exhaust information, as this will validate the claims being submitted.
10. Attach a payment ledger/log to the form, detailing what bills were paid related to the incident. The ledger should include the name of the provider paid, the date payment was made, and the amount paid.
11. Before finalizing your form, ensure that if the beneficiary has stopped treating, a doctor's statement confirming this is included.
12. Review all information for accuracy and completeness, then save your changes. You can choose to download, print, or share the completed form.

Complete your Medicare No Fault Case Closure form online today to ensure streamlined processing of your case.