How do I file a Medicare claim?

Have you received care that was not automatically covered by Medicare? This usually happens if you received the product or service from a provider that did not accept Medicare assignment. Accepting Medicare assignment means that the health care provider is contracting with Medicare and has agreed to accept Medicare’s reimbursement rates in lieu of traditional payment. 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.

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. The provider bill must contain all of the following information:

  • 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

You can get the contact information for your state’s contractor by calling Medicare at 1-800-633-4227. You can find further submission details on the second page of the instructions for the type of claim that you’re filing or on your Medicare Summary Notice (MSN). If you can’t find a paper copy of your Medicare Summary Notice, you can log in to MyMedicare.gov to view an electronic copy of the document.

You will also have to describe your illness or injury, as well as outline whether or not it is related to a work incident. The claim will also require you to disclose information about additional insurance you may have, such as coverage through your employer or your spouse’s employer. Keep in mind that 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.

Different claims have different instructions

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 (also called Medicare Part C) 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 since the federal government pays these companies a predetermined monthly amount. 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 the 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 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.

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