Medicare Claims & Reimbursement
Paying your medical expenses: Filing a Medicare claim and paying out-of-pocket expenses
Where you can go for health care, how much you will pay, and the process for filing a Medicare claim varies depending on the Medicare plans under which you are covered. Original Medicare (that is, Medicare Part A and Medicare Part B) works differently than Medicare Parts C and D, which are administered through private insurance companies. It's important to follow the rules of your specific plan. Here are some guidelines:
Medicare Claims for Original Medicare (Medicare Parts A and B)
When you visit a health care provider that accepts Medicare assignments, you will pay directly to the provider only the out-of-pocket costs that are your responsibility. That includes any copays (a flat dollar amount), coinsurance (a percentage of the total cost), and/or a deductible (the amount you pay first before your benefits begin). Check your plan documents to see how much you must pay out of pocket. Your doctor or health care provider may expect this amount at the time of your visit. Or they may bill you later for the amount owed. The health care provider will file any Medicare claims for the services you received and Medicare will pay the provider directly for those services.
Not all physicians accept Original Medicare assignments. Your health care services are still covered when you visit doctors, hospitals, labs and other health care providers that do not accept Medicare, but you may have to pay the full cost of the services you receive at the time of your visit. Your doctor is responsible for filing a Medicare claim so that you can receive reimbursement for any amount that is the plan's responsibility.
There is a deadline for filing a Medicare claim. The Medicare claim must be filed no later than December 31st of the year after you received the health care service. For example, if you went to the doctor on March 1st, 2013, the deadline for filing a Medicare claim will be December 31st, 2014.
Even though it is the doctor's responsibility to file the claim, this action is important to you. If you paid the entire bill up front, you cannot receive reimbursement from Medicare until the claim is filed. Even smaller claims for which you were responsible for the deductible, the claim must be filed so Medicare can credit your deductible.
If your doctor delays filing a Medicare claim, there are steps you can take:
- Call your doctor's office staff to remind them to file the claim.
- If that doesn't work, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week to report the problem and find out the deadline for filing the particular claim.
- If your doctor still does not file the Medicare claim, you may file the claim yourself. However, this should happen rarely and only after you have exhausted attempts to get the doctor to file the Medicare claim.
Download a Medicare claim form. When filing a Medicare claim, you can download and print a Medicare claim form from the Medicare forms website at www.cms.gov/CMSForms/. Look under "CMS forms" for Medicare form #CMS 1490S, Patient's Request for Medical Payment.
Medicare Claims for Part C and D (Private Health Insurance)
Because Medicare Part C (alternative for Original Medicare) and Medicare Part D (prescription drug insurance) are through a private health insurer, you are subject to the rules of that carrier and the plan in which you enrolled. You should never need to file a Medicare claim. However, you may need to file claims with your health plan carrier.
Check your carrier's plan documents to see if you must stay within their network of health care providers. Depending on the plan, you might have these options:
- Network-only coverage - means you must use a health care provider that participates in the plan's network. This is the case with HMO plans. You'll pay any out-of-pocket costs (copay, coinsurance and/or deductible), according to your plan documents, directly to the health care provider. In this case, you won't have to file a Medicare claim - or claims with the private health insurer.
- Network-optional coverage - means you have the choice of visiting a health care provider in or out of the plan's network. This is true with POS and PPO plans. You usually pay less out of picket when you do stay in the plan's network. Be sure to check your plan documents to see what the differences are. Also, when you stay in the network, the health care provider will pay any claims for you. If you go outside the network you may have to file claims with the health care provider, but you will never have to file any Medicare claims. That's because the health plan carrier has an arrangement with Medicare to receive a predetermined amount per covered member each month regardless of claims.
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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.