Medicare Claims & Reimbursement

Although your doctor or other health care provider is generally responsible for filing a Medicare claim for each health care service, sometimes you will have to fill out a Medicare claim yourself to receive Medicare reimbursement.

Claims for Medicare Part A and Part B

With Original Medicare (Part A for hospital coverage and Part B for medical coverage), you will need to file a claim with Medicare only when your doctor has delayed filing and you have exhausted all efforts to otherwise get the claim filed. This situation is rare, but you should be prepared.

Filing Medicare claims for Part C and Part D

With Medicare Part C (Medicare Advantage plans) and Part D (prescription drug coverage), there are no Medicare claims because Medicare already pays the health insurance plan a set amount each month. You will, however, be responsible for the cost sharing (copayments, coinsurance, and/or deductible) established by the health insurance plan.

You may need to file claims with the plan, and the filing process varies from plan to plan. Usually, if a plan includes a network of health care providers, and you visit a doctor who participates in that network, the doctor will file the claim for you.

Some plans let you go to any licensed doctor outside the network. In these cases, you will likely have to file the claims yourself. These claims are filed with the health insurance plan, not with Medicare.

You should check your health insurance plan documents to see which doctors you may visit and when and how to file claims.

Time limits on Medicare claims

Medicare claims must be filed by the end of the year (December 31) following the year in which the health care service occurred. For example, if you received health care services on March 3, 2014, your doctor has until December 31, 2014, to file the claim. Of course, it's best not to wait that long.

Even if you're not expecting a reimbursement (that is, you only paid the doctor your share of the cost), you still want to make sure any deductibles are credited to you. That only happens when the Medicare claims are filed.

If your doctor has not yet filed your Medicare claims -- and you are waiting for reimbursement or were responsible for a deductible -- you can call the doctor's office to remind them to file the claim. If that doesn't work, call 1-800-MEDICARE (1-800-633-4227). If all attempts to have the doctor file the claim have failed, you may go ahead and file the Medicare claim yourself.

Medicare forms for filing a claim

Medicare forms are located on the Center for Medicare & Medicaid Services website. Search for CMS 1490S, Patient's Request for Medical Payment, then you can download and print this form. You can also pick up a form at your local Social Security office. Instructions for completing the form are on the back. Call 1-800-MEDICARE (TTY users 1-800-633-4227) to find out where to mail the completed form.

Medicare reimbursement

It's essential to find out if your doctor accepts Medicare assignments so you can receive Medicare reimbursement. If your doctor does accept Medicare, then you should only have to pay the amount that is your responsibility. This includes copays, coinsurance, and/or deductibles.

If the doctor or other health care provider that performed the service does not accept Medicare, you may have to pay all of the cost up front, directly to the health care provider. You will receive Medicare reimbursement after the doctor files a Medicare claim for the services.

eHealth Medicare is operated by eHealthInsurance Services, Inc., a licensed health insurance agency certified to sell Medicare products.

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