A Medicare claim is a request for payment that you submit to Medicare when you receive health-care services and items you believe to be covered. In most cases, if you’re a Medicare beneficiary, you won’t have to file your own Medicare claims.
However, there may be rare cases when you’ll need to file a Medicare claim; this article will explain when and how to do so.
Medicare-approved providers typically will file Medicare claims for you
Data confirms that most health-care providers participate in the Medicare program. According to the Kaiser Family Foundation, less than 1% of all U.S. doctors in clinical practice have formally opted out of the Medicare program entirely.* Because so many health-care providers generally accept Medicare assignment, you usually won’t have to file your own claims because Medicare-assigned providers are required to file them for you.
In summary, doctors who accept assignment have agreed to accept Medicare-approved payments in return for services and:
- File Medicare claims directly to Medicare without charging patients a filing fee
- Charge only applicable coinsurance (usually 20% after you’ve met the Medicare Part B deductible)
Why would you have to file a Medicare claim?
In most cases, you don’t have to file Medicare claims, but there are times you may have to. Perhaps your provider has chosen to not accept Medicare assignment and you end up having to submit your own claim. Or you may have to file your own claim because your doctor or supplier still hasn’t filed it and it’s close to the end of the yearly time period.
How do you file a Medicare claim?
If you need to file a Medicare claim, you must do so no later than 12 months after services were given. If you believe you need to file a Medicare claim or just want to find out how to do it in case the situation arises, you can get more information and instructions at Medicare.gov.
In general, to file a Medicare claim you would need to:
- Fill out a Patient’s Request For Medical Payment form (CMS-1490S).
- Include an itemized bill from the health-care provider.
- Include a detailed letter that lists why you’re submitting the claim; for example, your provider isn’t able or refuses to file it.
- Include relevant supporting documents.
- Send the claim to the appropriate address listed on the claim instructions (see above Medicare.gov link) or on your Medicare Summary Notice (electronic version available on gov).
If you have questions about Medicare claims, you might start by calling Medicare at 1-800-MEDICARE (1-800-633-4227; TTY users, call 1-877-486-2048), 24 hours a day, seven days a week.
What if you have a Medicare Advantage plan?
If you have a Medicare Advantage plan, you’re also unlikely to have to file any Medicare claims on your own. Medicare Advantage plans are offered by Medicare-approved private insurance companies, which are paid a flat amount each month, so they generally don’t file claims. However, a Medicare Advantage plan may require you to receive care within its provider network (except for emergency care). If you go outside the plan’s network, and you see a provider who doesn’t accept Medicare assignment, you might need to file a claim.
If you have any concerns about payments or claims, you should check with your insurance company to resolve the issue.
Medicare Advantage plans are an alternative way to receive your Original Medicare benefits (except for hospice care, which Part A still provides). Please note that you’ll still need to continue paying your Medicare Part B premium, along with any premium the Medicare Advantage plan requires, as well as any coinsurance, copayments, or deductibles.
You may want to find a Medicare-assigned provider to avoid filing Medicare claims yourself and reduce out-of-pocket expenses. I can help answer your questions about Medicare plan options. To get started, simply click the Get Quotes button to schedule a phone call or to request a personalized email.
*Medicare Patients’ Access to Physicians: A Synthesis of the Evidence, Kaiser Family Foundation, December 10, 2013. Data cited was from September 2013; the term “doctors” in this case refers to physicians with an M.D. or D.O. and non-physician doctors such as chiropractors, podiatrists, and optometrists.