If you received care that was not automatically covered by Medicare, you may need to file a Medicare reimbursement claim. A beneficiary rarely has to file a reimbursement claim with Medicare, but it can occur.

This typically occurs when a Medicare beneficiary sees a medical provider that accepts Medicare but does not accept Medicare assignment.

Filing a Medicare Reimbursement Claim

If you received care from a provider that did not accept Medicare assignment, you likely had to pay the full bill before receiving the service. However, you might still be able to get reimbursed for part of the cost. On those occasions, you can file a Medicare claim for a medical product or service to recoup a portion of those funds.

How Do I File a Medicare Reimbursement Claim?

To file your claim, you’ll need to fill out a Patient’s Request for Medical Payment form. You then send both this form and the bill from your provider to your state’s Medicare contractor.

What the Medicare Provider Bill Must Include

  • the date you received service
  • the place you received service
  • a description of each service or supply that was furnished
  • the charge for each service
  • the name and address of the providing doctor or supplier
  • the diagnosis

What To Submit With The Claim

When filling out the form, you must choose the service type then provide the following information:

  • Itemized bill
  • The provider or supplier’s National Provider Identifier (NPI) If known
  • Description of illness or injury
  • Date of service
  • Place of service
  • The doctor’s or supplier’s name and address
  • Description of each surgical or medical service or supply furnished
  • Charge for each service

If the itemized bill is for orthotics, prosthetics, or DME, the ordering and referring providers’ legal name must be on an itemized bill.

Where to Send Your Medicare Claim

Each state has a different address to send your claim. There are two places where you can find the address. You can find the address on the claim form on page two, or on your quarterly Medicare Summary Notice.

Suppose you’d like to have someone call Medicare on your behalf. In that case, you may need to fill out an Authorization to Disclose Personal Health Information.

You must also submit your claim within one calendar year of the date that your medical product or service was administered. If you submit your claim after a year has elapsed, you will very likely be denied any reimbursement.

What if My Healthcare Provider is Not Sending the Claims Promptly?

The first thing you should do is call the provider and ask them to send your claim. If they do not file the claim, call Medicare and find out how much time is left to file the claim. If it’s close to the end of the allowed time and your healthcare provider has not filed the claim, you should go ahead and file the claim.

Types of Medicare Reimbursement Claims

Not every claim is the same. Medicare’s official website lists separate instructions for Part B services, claims for durable medical equipment (DME), claims for services that you received aboard a ship, claims for services you received in Mexico or Canada, and claims for services that you received in a foreign hospital. Be sure to follow the correct set of instructions for your situation.

Reimbursement claims for Medicare Advantage or Medicare Part D prescription drug coverage may also be different than for Medicare Parts A and B. Third-party companies who sell Advantage and Part D plans don’t file claims directly to Medicare.

This is why you may be required to pay the full cost of any services that you receive from providers outside of your network. Due to a large number of Advantage and Part D plans available, it is outside the scope of this document to list all of the variables involved in submitting a claim.

Your best course of action is to contact the administrator of your Advantage or Part D plan and ask them how to go about submitting your claim. You may also contact a Medicare ombudsman who can help you with Medicare-related complaints, grievances, and information requests.

FAQs

How do I submit a claim to Medicare?

When a claim is submitted to Medicare, it should come straight from the doctor or other provider of services. If for some reason they don’t submit the claim on your behalf, then you can call Medicare and submit it yourself. You can also submit the claim online.

What is the first step in submitting Medicare claims?

The first step is the doctor or provider filing these claims for you. In the rare case that your doctor or provider doesn’t or refuses to, then your first step is to get a form to fill out and submit to Medicare.

How do I make an online Medicare claim?

The claim itself cannot be submitted online. However, you can log in to your Medicare account and get a Medicare Summary Notice that can help your claim along.

What form is used to send claims to Medicare?

You will fill out and send in a Patient Request for Medical Payment form to the CMS in order to send a claim to Medicare.

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by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.