In order to be best covered for any health care you need, it is important that you follow the regulations of your specific Medicare plan plan. Your policy will specify which health care providers, suppliers or pharmacies you may use, and whether or not there are costs you have to pay out of pocket.
It also depends on your plan policy, which process you may have to follow for filing a claim.
If you are covered under original Medicare (Medicare Part A, Part B, and Medigap insurance), you usually do not need to file a claim yourself. If you are enrolled in private health insurance such as a Medicare advantage plan, or a Part D prescription drug plan, you also don’t have to file claims with Medicare, but you may have to file a claim with your insurance provider.
The Medicare Claims Process for Original Medicare (Medicare Parts A and B and Medigap Plans)
Any time you use a health care or medical supply or equipment provider, make sure that they accept Medicare. If they do, the services or supplies you will receive are covered to the extend that depends on your plan, and the provider is by law required to file a claim with Medicare for any covered services, supplies or equipment they provide to you.
However, a provider may choose to accept or not accept Medicare assignment.
Here is the usual process if your provider or supplier does accept Medicare assignment: After receiving your services or supplies and the bill you have to pay your share directly to the provider or supplier. Your share is any coinsurance or deductibles you may have to pay, according to your plan. The provider or supplier then files a claim with Medicare, and Medicare pays its share of the bill to the provider or supplier.
If you use the services of a health care provider or supplier that does not accept Medicare assignment, you usually need to pay most
or all of the bill directly to the provider or supplier out of pocket. The provider or supplier is still required to file a claim with Medicare on your behalf. After the claim is filed, Medicare eventually will pay its share of the bill directly to you.
Medicare claims must be filed within 12 months (or 1 full calendar year) after the date when the services were rendered or the supplies were provided. Medicare will not pay its share, if a claim is not filed within this time period. You may contact Medicare at 1-800-Medicare for the exact time limit for filing a claim for a service, supply or equipment that you have received.
You should always check the “Medicare Summary Notice” (MSN) you get in the mail every 3 months or visit MyMedicare.gov to make sure your claims are being filed in a timely fashion.
If you notice that your health care provider or supplier has delayed filing your Medicare claim, you should first contact them directly and remind them. If they still do not file the claim in a timely manner, you need to contact Medicare by calling 1-800-Medicare (1-800-633-4227) and report the issue.
While you generally do not to have to file any Medicare claims yourself, it is important that you do file the claim yourself if the time limit to filing the claim is getting close, and the provider or supplier still has not filed it. There are no exceptions to the filing dead-line, and Medicare will not reimburse you for its share or credit you your deductible if they do not receive a claim before the dead-line.
If you need to file a Medicare claim yourself, you may download Medicare’s Patient’s Request for Medical Payment form CMS 1490S here. and follow the instructions to complete and file it. You may also authorize somebody else to act on your behalf by submitting an “Authorization to Disclose Personal Health Information” which you can download here .