How to File a Medicare Claim

Getting any covered services and supplies can help the overall process of Medicare and make one’s life a lot easier. However, the law requires a claim to be filed for beneficiaries enrolled in Original Medicare any time these actions are being done. If failure to file a claim within the same year thar the services were provided, then Medicare may not step in to help with coverage. Here are a few considerations to keep in mind as you file your Medicare claim on your own.

Why Do I Need a Medicare Claim?

Medicare claims contain the information that is needed for Medicare to review and pay for the services that your provider performs. The claims can only be sent to Medicare after you have received care from your provider. If you have a Medicare Advantage plan or Part D drug coverage, the claims are sent to the insurance company that oversees your specific plan.

Who Usually Files Medicare Claims?

Medical providers typically file insurance claims on your behalf. However, it can be different for each plan:

Some providers, such as skilled nursing facilities, hospitals, and hospice providers always submit their claims to Medicare Part A on the patient’s behalf.
For outpatient claims, which are handled by Medicare Part B, providers may not submit their claims to Medicare.
If you have Original Medicare and receive services from a doctor who does not participate in Medicare, you may have to file your claim.
If you have Medicare Advantage coverage and receive services from a provider who is out-of-network, the doctor is unlikely to submit a claim to Medicare for you.

When Am I Unable to Submit My Own Medicare Claim?

For most services, you can submit your claims. However, there are a few instances where you are unable to submit your claim form to Original Medicare. They include:

Part B drugs
Durable medical equipment that is covered through the DMEPOS Competitive Bidding Program.
Diabetic test strips

The pharmaceutical supplier is required to file claims directly with Medicare for these supplies.

When Am I Required to File a Medicare Claim on My Own?

If you receive care from a non-participating provider, you may have to send your claim to Medicare yourself. It’s important to note the following:

If you see a provider who has opted out of Medicare, Medicare does not pay for services from opt-out providers even if a claim is submitted.
Providers who serve Medicare beneficiaries may be participating or non-participating. A participating doctor has agreed to accept Medicare’s approved charge as reimbursement for their services. Thus, you are only responsible for your coinsurance when you see a participating provider.
Providers who do not participate in Medicare are allowed to charge you 15% above Medicare’s approved charge.
Non-participating doctors are not required to file your Medicare claim for you. Still, some non-participating providers do file with Medicare as a courtesy.

Do I Have to Submit Claims to Medicare Within a Certain Timeframe?

If you have Original Medicare, your claim must be filed within 12 months of the time that you received the health care service. Timeframes for claim submissions vary with Medicare Advantage plans, but the time limits tend to be shorter than they are with Original Medicare. To learn about your specific time limits for Medicare Advantage coverage, contact your plan administrator.

Should I Ask My Doctor if They Submit Medicare Claims?

Prior to receiving medical services, ask your doctor’s office if they submit claims, to Original Medicare. Even if the doctor does not participate in Medicare, they may still file claims on your behalf. Likewise, if you have Medicare Advantage and see a non-network provider, the doctor is not required to file your claim with your Advantage plan but can if they decide to.

Advantage plans do pay for out-of-network routine care if the plan that you select offers non-network coverage. Additionally, every Medicare Advantage plan provides out-of-network coverage for urgent care and emergency room services. However, if the provider is out-of-network, you may be responsible for filing your claims when you receive care in those instances.

What Should I Do if My Participating Provider Refuses to File My Claim?

If you are an Original Medicare enrollee and have seen a participating provider who refuses to file your claim, you can submit a complaint by calling 1-800-MEDICARE. In any case, if the provider fails to submit your claims, you can file them yourself.

To file an Original Medicare claim, submit a Beneficiary Request for Medical Payment form along with the doctor’s bill to the Medicare Administrative Contractor for your region. Be sure to make and keep copies of the documents that you send to Medicare.

What Is an Advance Beneficiary Notice (ABN)?

If a provider that participates with Medicare believes that the services that they are providing may not be covered by Medicare, they give you an advance beneficiary notice. The notice advises the following:

Medicare is unlikely to pay for your care. Home health and skilled nursing providers must also provide an ABN when they feel that the services are not covered by Medicare.
If you decide to have the uncovered services after receiving an ABN, you may still demand bill. When a beneficiary demand bills, they demand that their doctor or facility file a Medicare claim for the services rendered.
To demand bill, you are required to sign an ABN and confirm that you will pay all charges associated with the services if Medicare does not approve coverage.

For more detailed information visit Advanced Beneficiary Notices: How to Deal With Noncoverage.

What Are the Filing Requirements for Medigap?

If you have Original Medicare, your insurer forwards your claims to your Medicare Supplement automatically. However, some Medigap plans require you to file your claims manually, be sure to submit the following:

Be sure to submit the Medicare Summary Notice (MSN) that shows how much Medicare paid for the services.
It may also be helpful to submit additional documentation, such as the invoice that you received from your provider.
If Medicare does not pay for the services that you received, there is no need to submit an MSN to your Medigap insurer.

What Are the Filing Requirements for a Medicare Advantage Plan?

With Medicare Advantage, you should only have to submit a claim on your own if you receive services from a non-network provider. When filing your claim, you may want to consider:

Confirming the mailing address for claim submissions by contacting your Advantage plan insurer first.
Be sure to ask your plan carrier about any documentation or forms that need to be sent in with the claim.
Your claims should not be sent to Medicare. Instead, they should be sent to the insurer who provides your Advantage plan coverage.
It is important to stay within the timeliness guidelines for filing your claims. The time limits may differ for different Advantage plans, so check your insurance company’s rules before filing to avoid having a claim denied for a late submission.

Do I Have to File My Own Part D Claims?

If you visit a pharmacy that contracts with Medicare Part D, the pharmaceutical provider should file your claims. Even non-preferred pharmacies may bill your Part D carrier. Nevertheless, there may be instances where you have your prescription filled at a pharmacy that is not a part of your Plan D network. In those cases, you can submit your receipt along with any other documentation that supports your claim to your Part D insurer.

Where Do I Send Medicare Claims?

When you file your claim, it must be mailed, along with any supporting documentation, to Medicare. Here are the steps for submitting your claim to Medicare:

Complete a Patient’s Request for Medical Payment form.
Get a copy of the invoice or itemized bill for the services you received.
Add any supporting documentation, such as your provider referrals.
Mail the claim to your Medicare insurer. You can find the address in your MyMedicare account.

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