When and How to File a Medicare Claim
Where you can go for health care, how much you will pay, and the process for filing a Medicare claim varies depending on how you get your Medicare coverage. Original Medicare, Part A and Part B, has different rules than Medicare Part C (Medicare Advantage) and Medicare Part D (prescription drug coverage), where coverage is provided through private insurance companies. Here are some guidelines for when you need to file an Original Medicare claim form and how to do it.
Medicare claims for Original Medicare
If you have Original Medicare, the amount you pay at the time you receive a health service will depend on whether your doctor is a Medicare-participating provider and accepts assignment. Medicare-participating providers are on contract with Medicare to accept and treat patients for all Medicare-covered services and supplies. A provider that accepts assignment agrees to accept the Medicare-approved amount as full payment for a covered service or supply. In this instance, the provider is required to file Medicare claims for any services you received, and Medicare will pay the provider directly for those services. The provider is not allowed to charge you to submit the claim.
You are still responsible for paying the cost-sharing requirements, which may include a copayment (a flat dollar amount), coinsurance (a percentage of the total cost), and/or a deductible (the amount you pay first before your plan begins to pay). You may have to pay all cost-sharing expenses when the services are received, or your health care provider may bill you later for the amount owed.
When to file an Original Medicare claim
If you received services from a Medicare-participating provider, the provider should file the claim. Submitting a Medicare claim yourself should happen rarely and only after you have exhausted attempts to get the doctor to file the Medicare claim. Remember, if you paid the entire bill up front, you cannot receive reimbursement from Medicare until the claim is filed.
If you visited a non-participating doctor, you may have to pay the full cost of the services at the time of your visit. Non-participating providers don't need to accept assignment for all services, but can do so on an individual basis. Providers that aren't enrolled in the Medicare program may not be able to submit the Medicare claim, and in this instance, you may need to submit it yourself. If you receive services from a non-participating provider, ask the office who is responsible for filing the Medicare claim.
The Medicare claim must be filed no later than one calendar year (12 months) after you received the health service. For example, if you went to the doctor on December 1, 2013, the deadline for filing a Medicare claim would be December 1, 2014. If the claim is not received in time, Medicare will not pay its share and you cannot appeal. Please note that if the service was provided by a Medicare provider, you can't be billed for the service or held liable if your provider fails to file the claim properly.
Checking the status of an Original Medicare claim
If your doctor is responsible for filing the claim, you should still follow up to make sure the claim is filed on time. You can check the status of filed or pending claims through:
- The Medicare Summary Notice (MSN) -- Medicare mails this document to you every three months with information on all Medicare-covered services you received in that period and what Medicare covered.
- MyMedicare.gov -- Claims information is typically updated in your personal online portal about 24 hours after Medicare has processed the claim.
How to file a Medicare claim yourself
When you visit a doctor, you should confirm that provider accepts Medicare. If the doctor is a Medicare-participating provider, you won't be held responsible if the claim isn't filed in time. However, if your provider doesn't accept Medicare and tells you that it won't bill Medicare, you will need to file the claim.
To file a claim yourself:
- Go to Medicare.gov to download and print the Patient Request for Medical Payment form (form # CMS 1490S). You can also get this form directly on the CMS.gov website.
- Fill out the entire form, including your Medicare ID number and an explanation of the treatment you received, and include all itemized receipts from your provider for every service received. You will also need to include your health provider's National Provider Identifier (NPI) number, which is the 10-digit number Medicare uses for billing purposes. If you aren't sure what your provider's NPI number is, contact your doctor or call Medicare. Make a copy of your claims form and all supporting documents for your records.
- Mail the form to your state's Medicare contractor to process the claim. Visit CMS.gov for a list of contractors by state. If you are filing a claim for durable medical equipment (DME), you can find the Medicare contractor information here. If you are not sure where to send the form, contact Medicare.
Medicare typically process claims within 60 days. To check the status of a filed claim, go to MyMedicare.gov.
Medicare claims for Medicare Advantage and Part D
If you get your Medicare coverage through a private Medicare plan, such as a Medicare Advantage plan or a Medicare prescription drug plan, you shouldn't need to submit claims to Medicare. However, you may need to file claims with your Medicare Advantage or Part D plan in some instances. Talk to your Medicare plan to find out how to submit claims for covered services.
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Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by private companies approved by Medicare and provide Medicare Part A and Part B coverage. Medicare prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. A Medicare Supplement plan is a health insurance plan provided by a private company that fills in the "gaps" in original Medicare coverage.