Medicare Reimbursement & Claims

Medicare Reimbursement & Claims: Although your doctor or other health care provider is usually responsible for filing a Medicare claim for each health care treatment, you may need to fill out a Medicare claim yourself to obtain compensation from Medicare.

Medicare reimbursement for claims under Medicare Part A and Part B

You will need to file a claim with Medicare for Original Medicare (Part A for hospital coverage and Part B for medical coverage) only if your doctor has delayed filing and you have exhausted all other options. Although this is an uncommon occurrence, you should be prepared.

Medicare reimbursement for claims for Part C and Part D

There are no Medicare claims for Medicare Part C (Medicare Advantage plans) or Part D (prescription drug coverage) because Medicare already pays a specified sum each month to the health insurance plan contracted to handle your benefits. You will, however, be responsible for the Medicare Advantage or Prescription Drug plan’s cost sharing (copayments, coinsurance, and/or deductible).

You may be required to file claims with the plan, and the procedure varies each plan. If your health-care plan includes a network of providers, and you see a doctor who is part of that network, the doctor will usually file your claim for you.

Some plans allow you to see any doctor outside the network who accepts Medicare assignments. In these circumstances, you’ll almost certainly have to file your own claims. These claims are submitted to the Medicare Advantae gor Prescription Drug plan, rather than to Medicare.

Check your plan documentation to see which doctors you are allowed to see, as well as when and how to file claims.

Time limits on Medicare claims

Medicare claims must be submitted within 12 months of the date the service(s) were rendered. If you obtained health care services on March 3, 2022, for example, your doctor has until March 3, 2023 to file a claim. Of course, waiting that long is not a good idea.

Even if you don’t expect a refund (i.e., you merely paid the doctor your half of the bill), you should check to see whether any deductibles have been applied to your account. This occurs only when Medicare claims are submitted.

If your doctor has not yet filed your Medicare claims and you are waiting for reimbursement or have a deductible to pay, you can call the doctor’s office and remind them to do so. Call 1-800-MEDICARE if it doesn’t work (1-800-633-4227; TTY users should call 1-877-486-2048). Representatives from Medicare are available 24 hours a day, 7 days a week. If all other options for getting the doctor to file the claim have failed, you can file the Medicare claim yourself.

Medicare forms for filing a claim

On the website of the Center for Medicare & Medicaid Services, you can find Medicare forms. You can download and print CMS 1490S, Patient’s Request for Medical Payment, by searching for it on the internet. A form is also available at your local Social Security office. On the back of the form are instructions for filling it out. Call 1-800-MEDICARE for more information (1-800-633-4227; TTY users should call 1-877-486-2048). Representatives from Medicare are available 24 hours a day, seven days a week to help you figure out where to send your completed form.