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 Medicare-approved 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 assignment 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. The Medicare “fee schedule” is a list of approved provider reimbursement rates set by the Medicare program for each service; a doctor or hospital that accepts assignment will not charge you above the Medicare fee schedule (although you may still be responsible for cost sharing). In this instance, the provider or supplier 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.
As mentioned, 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 Medicare or your Medicare 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 have Original Medicare and 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, and you may be charged above the Medicare-approved amount. 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.
An Original 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, 2015, the deadline for filing a Medicare claim would be December 1, 2016. If the claim is not received in time, Medicare will not pay its share. Please note that if the service was provided by a Medicare-participating 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 may still need to follow up to make sure the claim is filed on time. Remember, even if you visited a participating provider, Medicare can’t ensure that any deductible amounts were applied correctly to you until the claim is filed.
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 name and address for billing purposes. 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 at 1-800-633-4227 (for TTY services, call 1-877-486-2048), 24 hours a day, seven days a week.
Medicare typically process claims within 60 days. As mentioned, to check the status of a filed claim, go to MyMedicare.gov.
Medicare claims for Medicare Advantage and Medicare Prescription Drug Plans
If you get your Medicare coverage through a Medicare plan, such as a Medicare Advantage plan or a Medicare Prescription Drug Plan, you shouldn’t need to submit claims to Medicare. That’s because the Medicare program reimburses these plans directly with a set monthly amount. However, you may need to file claims with your Medicare Advantage or Part D Prescription Drug Plan in some instances; for example, if your Medicare plan has a provider network and you see a non-network doctor. In this situation, you may need to submit a Medicare claim with your Medicare plan (not the Medicare program). Talk to your Medicare plan to find out how to submit claims for covered services and when you may need to do so.
Hopefully, you now have a better understanding of Medicare claims and how they work. If you’re interested in finding Medicare plans that may offer cost savings, you can use the plan finder tool on this page to start comparing plan options in your locations. Or, to speak with a licensed insurance agent, call the phone number on this page to get personalized assistance with your Medicare questions.