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 contracted to administer your benefits a set amount each month. You will, however, be responsible for the cost sharing (copayments, coinsurance, and/or deductible) established by the Medicare Advantage or Prescription Drug 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 doctor who accept Medicare assignment outside the network. In these cases, you will likely have to file the claims yourself. These claims are filed with the Medicare Advantage or Prescription Drug plan, not with Medicare.
You should check your 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 no later than 12 months after the date when the service(s) was provided. For example, if you received health care services on March 3, 2018, your doctor has until March 3, 2019 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; TTY users should call 1-877-486-2048). Medicare representatives are available 24 hours a day, seven days a week. 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 (1-800-633-4227; TTY users should call 1-877-486-2048). Medicare representatives are available 24 hours a day, seven days a week to find out where to mail the completed form.
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 be responsible for all the charges associated with your visit.
The provider network may change at any time. You will receive notice when necessary.