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For the most part, your medical provider is responsible for filing claims with Medicare
You should only be filing claims for yourself in very rare circumstances
If a claim has not been filed in a timely manner by your medical provider, you should first contact them and then you can file a claim yourself if the time limit is running out
You may able to file a claim for reimbursement if you received care from a provider that did not accept Medicare
The form you need to use to file your claims is available on the Medicare website
There are different instructions for the different type of claim you are filing and you will need to choose the appropriate form for the service you received
You may need to send additional documentation with your claim
The address to send the claim to can be found on the Medicare website or on your Medicare Summary Notice
Typically, your Medicare claims should be sent directly from your provider to Medicare. Your provider will then be paid a reimbursement rate according to the program’s regulations and legislation. Your medical provider is required by law to submit these claims so it is typically not your individual responsibility.
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If you saw a provider that does not accept Medicare assignment at all, then you may be able to file a reimbursement claim with Medicare. If your provider does not accept Medicare, you will most likely be required to pay for the services up front and out of your own pocket.
Your claim is subject to the Medicare reimbursement rates, regardless of how much more the medical bill may actually cost. Providers that do not participate with Medicare may charge up to 15 percent above the amount that Medicare approves.
Another specific and unusual circumstance in which you may need to file a Medicare claim on your own is if your medical provider has not filed the claim within the appropriate timeline. Medicare claims are expected to be filed within 12 months of the original date of service. If the claim was not filed within this 12-month limit, Medicare will not pay their portion of the bill.
If you find that your claims are not being filed within the appropriate timeline, the first thing to do is contact your provider, whether it be a doctor or medical supplier, and request that they file the claim.
If they still do not file the claim, your next step would be to contact Medicare directly. If the time limit is coming to a close and it looks like they still may not submit the claim, you can then file it on your own.
To file a claim, you will need to fill out the Patient Request for Medical Payment form. You will need to follow the specific instructions depending on what claim you are going to be filing.
On the Medicare website, there are instructions available for filing a claim for Medicare Part B services, which are typically doctor’s visits or medical supplies, as well as instructions for filing a claim for durable medical equipment, for shipboard services, which would be medical services you received on board a ship, for services you got in Canada or Mexico, and for services you got in another foreign hospital.
Depending on the type of claim you are filing, the required documentation can vary. Generally, you will at least need the completed Patient Request for Medical Payment form and the itemized bill from your doctor or medical provider that shows the exact services provided.
Additionally, Medicare will most likely require a detailed letter that explains why you are submitting the claim personally. Reasons for filing your own claim that you may want to put into the letter include your provider not filing the claim in a timely manner, the provider or supplier does not participate in Medicare, or that they are just refusing to file the claim entirely.
You may also want to send any additional documents that you think will support your claim and that are relevant.
You can find the address that you need to send your claim on the Medicare website where the instructions for filing your particular claim are listed.
You can also find the address on your Medicare Summary Notice which is typically sent in the mail every three months but also available for viewing online.
Your health insurance provider should always be able to help with claims and any other questions; if you want to find the best Medicare providers in your state and guarantee you’re always covered, enter your zip below!
