You usually don’t have to file a Medicare claim. Doctors or hospitals typically file Original Medicare claims for you. Private insurers that administer Medicare Advantage and Part D plans handle those claims. In the rare cases when you have to file a claim, Medicare provides a form to download and mail in.
What Is a Medicare Claim?
Medicare claims ask Medicare or your insurer to pay for medical services or care you have received. In almost all cases, your doctor or a hospital where you received care will send the claim directly to Medicare if you are covered by Medicare Part A or Part B.
If you have a Medicare Advantage plan, there is no claim. The private companies that administer these plans are under contract with Medicare and are paid a set amount each month.
For Part D prescription drug plans, the insurance company that administers the plan contracts with pharmacies. Both those preferred pharmacies as well as nonpreferred pharmacies not in your plan will bill the insurer. You may have to pay more out-of-pocket if you use a nonpreferred pharmacy.
When Do You Need to File a Medicare Claim?
You generally shouldn’t have to worry about filing a Medicare claim yourself. But in some rare cases, you may have to file one on your own.
In those cases, you must file a claim within 12 months of receiving medical care. If you miss that deadline, you may have to pay all the costs yourself.
You may have to file a claim yourself if you receive care from a nonparticipating Medicare provider or an opt-out provider.
- Participating Providers
- Health care providers that accept Medicare and also accept the Medicare-approved amount for particular medical services or supplies.
- Nonparticipating Providers
- Health care providers who accept Medicare patients but don’t agree to Medicare-approved prices. They may charge you up to 15 percent more than the approved cost.
- Opt-out Providers
- Health care providers who simply do not accept Medicare.
If you receive health care services from a provider who opts out of Medicare, you can file a claim for a Medicare reimbursement. It will cover only the approved amount Medicare pays for the service, so you may have to pay out-of-pocket costs.
If Your Provider Doesn’t File in a Timely Manner
If the 12-month deadline to file a Medicare claim is approaching and your doctor hasn’t filed a claim for your care, you may have to file a Medicare claim yourself.
First you should contact the doctor or supplier and ask them to file a claim. If still they don’t, and the deadline is approaching, you should go ahead and file the claim yourself.
Filing an Appeal
If you file a claim and Medicare or your insurer denies it, you may file a Medicare appeal. There are five levels of appeals. If you fail at one level, you can usually appeal to the next higher one.
- When Medicare or your plan denies your request for a health care service, medical supply or drug you think should be covered, provided to you or continued.
- When Medicare or your plan denies your request for the medical service, product or drug that you already received.
- When Medicare or your plan denies your request to change the amount you pay for a service, product or drug.
Medicare also provides information on finding someone to help you file an appeal.
How to File a Medicare Claim
If you ever have to file a Medicare claim, you will need to fill out a special form and provide other detailed information to Medicare and/or your private insurer.
- A completed Patient’s Request for Medical Payment form you can download from the Medicare website.
- An itemized bill from your doctor, supplier or other health care provider.
- A detailed letter explaining the reasons why you are filing the claim such as why your health care provider refuses to file one, is unable to file one or if the provider is not enrolled in Medicare.
- Any supporting documentation for your claim.
Once you gather the documents and complete the form, you will mail the materials to a contractor in your state who handles claims. You can find the address on the second page of the Patient’s Request form or by logging into your account at MyMedicare.gov.
Medicare Claim FAQs
9 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2019, November 13). Claim Status Request and Response. Retrieved from https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ClaimStatus
- U.S. Centers for Medicare & Medicaid Services. (2019, March). Form CMS-10106. Retrieved from https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10106.pdf
- U.S. Centers for Medicare & Medicaid Services. (2018, January). Patient’s Request for Medical Payment. Retrieved from https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1490s-english.pdf
- U.S. Department of Health and Human Services. (2012, June). Medicare claim Submission Guidelines. Retrieved from http://www.nacns.org/wp-content/uploads/2016/11/CMS_ReimbursementClaim.pdf
- California Health Advocates. (n.d.). How Medicare Part A & B Claims Are Processed. Retrieved from https://cahealthadvocates.org/billing-claims/how-medicare-part-a-b-claims-are-processed/
- U.S. Centers for Medicare & Medicaid Services. (n.d.). How Do I File a Claim? Retrieved from https://www.medicare.gov/claims-appeals/how-do-i-file-a-claim
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Check the Status of a Claim. Retrieved from https://www.medicare.gov/claims-appeals/check-the-status-of-a-claim
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare Summary Notice (MSN). Retrieved from https://www.medicare.gov/forms-help-resources/mail-you-get-about-medicare/medicare-summary-notice-msn
- U.S. Centers for Medicare & Medicaid Services. (n.d.). My Medicare. Retrieved from https://www.mymedicare.gov/