Medicare Claims

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.

Did You Know?
While you usually don’t have to file a claim with Medicare, you are still responsible for shared costs such as deductibles, coinsurance and copayments.

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.

Types of Providers Defined by Medicare
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.

Check Your Claim Status
You should check your Medicare Summary Notice mailed to you every three months to see if claims have been filed for services or supplies you’ve received. You can also check the status at MyMedicare.gov. Check the deadline for filing your claim by calling 1-800-MEDICARE (1-800-633-4227).
Source: U.S. Centers for Medicare & Medicaid Services

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.

What You Can Appeal to Medicare
  • 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.

What Must Be Included in a Medicare Claim
  • 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.

Did You Know?
If you want someone to call 1-800-MEDICARE on your behalf, and you want Medicare to release your personal information to them, you will need to fill out an Authorization to Disclose Personal Health Information.

Medicare Claim FAQs

How do I check my Medicare claim status?

There are three ways to check your Medicare claim status:

  1. Your Medicare Summary Notice that arrives every three months will show which claims have been filed.
  2. You can log on to your account at MyMedicare.gov.
  3. You can call 1-800-MEDICARE (1-800-633-4227).
Do I need to file a claim if I have Medicare Advantage or Part D?
No. Medicare Advantage plans and Part D prescription drug plans are administered by private companies. They will handle claims related to these plans.
How do Medicare claims work with a Medigap plan?
Medicare will automatically send your claims to most Medigap insurers who will handle the payment. But some Medigap insurers will require you to file the claim with Medicare. If you do have to submit your own claim, you will need to send the insurer a Medicare Summary Notice that shows how much Medicare paid along with an invoice or receipt to show how much you paid out-of-pocket.
Last Modified: September 8, 2020

9 Cited Research Articles

  1. 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
  2. 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
  3. 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
  4. 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
  5. 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/
  6. 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
  7. 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
  8. 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
  9. U.S. Centers for Medicare & Medicaid Services. (n.d.). My Medicare. Retrieved from https://www.mymedicare.gov/