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Medicare Refresh: Understanding the Medicare Reimbursement Process

How does Medicare reimbursement work?

Posted on June 19, 2023 by Larry Johnson

The Medicare reimbursement process can seem confusing and hard to navigate at times. We can help clarify it. Call us today at (800) 950-0608 to connect with a licensed insurance agent.

Medicare Reimbursement Isn’t as Complex as It Seems

If you’re a Medicare beneficiary, you’ve probably heard of something called Medicare reimbursement. You may not have needed to go through the process yourself, but odds are good that you know someone who has. Odds are even better that this person has told you that the process for getting Medicare reimbursements is a bigger hassle than it’s worth.

The process for filing a claim to receive Medicare reimbursement seems more complex than it actually is. There are a series of rules you have to follow to file a claim. You have to meet certain criteria. There’s a Medicare reimbursement form.

Sounds like a lot, right? It can be, but if you’re owed money, it’s worth your time to get it back. Besides, when the process is demystified, it’s really nowhere near the hassle that some people make it out to be.

So, as a Medicare beneficiary, it’s very important for you to learn about the Medicare reimbursement process. At MedicareInsurance.com, it’s our mission to clarify some of the concepts related to Medicare that can seem tough to understand. That’s why, in this article, we’re going to demystify the Medicare reimbursement process.

Medicare Reimbursement is the Process of Filing a Claim

The Medicare reimbursement process is just another term for the process of filing a claim. More often than not, your medical provider is the one who files a claim for Medicare reimbursement related to treatment costs. You, as a beneficiary, should rarely, if ever, need to file a claim.

More than likely, you receive care through a provider that accepts Medicare assignment. Little of the cost that is paid to the provider comes directly from your pocket. In order to receive full payment for their services, your provider must file a claim with Medicare to receive Medicare reimbursement.

2023 Medicare reimbursement rates refunded to providers or individuals still depend on the service or item type being reimbursed. The Centers for Medicare and Medicaid Services (CMS) update their Medicare reimbursement rates each year, so it is possible for rates to fluctuate depending on certain factors.

How do I file a Medicare reimbursement claim?

The Medicare Reimbursement Process for Beneficiaries - Original Medicare

As a beneficiary, you should only need to file a Medicare reimbursement claim in very rare instances. However rare they may be, you will likely need to file a claim for Medicare reimbursement at some point. Before you file a claim, we’ll walk you through the process step by step.

Before you file a claim, it’s important to be able to recognize the instances in which you may need to do so. Some of the instances in which you’ll need to file a Medicare reimbursement claim include:

  • Choosing a provider who opts out of Medicare
  • Choosing a provider who doesn’t accept Medicare assignment
  • A provider asks you to sign an Advanced Beneficiary Notice, requiring you to pay for a service that they believe isn’t covered by Medicare

Also, before filing a claim, you should first ask your healthcare provider to file the claim. If your provider can’t file the claim, or they refuse to do so, you’ll need to file the claim yourself if you want to be reimbursed for costs that you’ve paid. The process for filing a Medicare reimbursement claim is as follows:

  • Visit Medicare.gov and download Form CMS-1490S, Patient Request for Medicare Payment
  • Fill out the form following the provided instructions
  • Explain why you’re filing the claim in detail
  • Include an itemized bill which includes the following information:
    • Provider’s name
    • Provider’s address
    • Diagnosis received
    • Date of service
    • Location of service
    • Description of services
  • Provide supporting information or documentation that you believe may help your claim for Medicare reimbursement
  • Mail the form to your Medicare contractor

To find your Medicare contractor, you can check with Medicare’s contractor directory to find out where you’ll file your claim. The Medicare Summary Notice also contains this information, and you can call Medicare’s hotline: 1(800) 633-4227.

Once you’ve filed your claim, you’ll be able to follow it through two different methods. Your Medicare Summary Notice, which is mailed to you quarterly, will contain information regarding your outstanding claims. You can also visit MyMedicare.gov to check the status of your claim.

The Medicare Reimbursement Process for Beneficiaries - Medicare Advantage, Medicare Part D, and Medigap

Are you enrolled in a Medicare Advantage, Medicare Part D, or Medigap supplemental insurance plan? If so, your process for filing a claim for Medicare reimbursements will look a little different.

These plans are not offered by the federal government. They are private health insurance plans offered by private health insurance companies. As such, your claim for Medicare reimbursements will not need to be filed through CMS.

Instead, you’ll need to submit your claim for Medicare reimbursements through the company offering your Medicare plan. As always, before submitting a claim on your own, you should call your provider to see if they’ll file a Medicare reimbursement claim first. As with the claim process for Original Medicare, if your healthcare provider cannot or refuses to file a claim, you may then file a claim for Medicare reimbursement.

The process for filing Medicare reimbursement claims may differ from insurance company to insurance company. Be sure to call your Medicare plan carrier to find out what all you’ll need before filing a reimbursement claim. They’ll be able to help you obtain and fill out all of the necessary forms.

Medicare reimbursement process

Remember - Never File a Claim for Medicare Reimbursement Unless Absolutely Necessary

It’s important to remember that your healthcare provider will almost always be the one who files a Medicare reimbursement claim. You should rarely ever need to file one, unless you regularly see a provider that doesn’t accept Medicare assignment.

Do you have additional questions about Medicare reimbursement? Are you looking for Medicare plans in your area? Reach out today to connect with one of our licensed insurance agents. We’re always happy to help!

About the Author

Larry Johnson

Larry Johnson

Larry is a content writer with several years of experience in creating informative content for a variety of industries on topics that matter. He is a 2009 graduate of the University of North Carolina School of the Arts.

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