Ron Elledge is a seasoned Medicare consultant and author of “Medicare Made Easy.” As a Medicare expert, he regularly consults beneficiaries on Medicare rules, regulations, and strategies.
Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). Under this program, your Medicare providers typically send your claims directly to Medicare and you won’t see a bill. In most cases, you pay a coinsurance or copayment and don’t have to pay for the entire medical service upfront. Medicare providers and suppliers must send their claims to Medicare for reimbursement.
There may be occasions when you need to pay for medical services at the time of service and file for reimbursement. For example, if your health care provider isn’t “Medicare-assigned,” you might have to pay for the service or supply and file for reimbursement.
Medicare Advantage Plans, Medigap, and Part D Claims
Private insurance companies administer Medicare Advantage, or Part C, plans, as well as Medigap and Part D. With these plans, you’ll follow the claims process of the insurance company.
Like Original Medicare, members generally do not need to file a claim for medical expenses, although you will pay upfront the amount of contracted out-of-pocket expenses, such as copayments, coinsurance, and deductibles.
One exception is for services rendered during overseas travel. Both Medicare Supplement (Medigap) and Medicare Advantage Plans which cover worldwide emergency and urgent care services require the recipient to pay for services upfront. A claim for reimbursement is then filed with the carrier. The claim process is outlined in the Plan’s Evidence of Coverage (EOC).
If you have Medigap, be sure to present both your Medicare and Medigap cards when you receive health care services. Medicare must approve the traditional Medicare claim before they submit it to the insurance carrier for their share of payment. If your provider does not submit a Medigap claim, you’ll have to submit it yourself. To do so, you request a claim form from your insurance provider, complete the form, attach copies of the itemized bills for service, and submit the claim to your Medigap carrier. Be sure to include a copy of the Medicare Summary Notice (MSN) received from Medicare.
The Medicare Claim Process
Once you have received services and paid upfront charges, your service provider has one year to submit a bill for their services to a Medicare Administrative Contractor who will then process your claim. If the provider does not file within the time limit, you must complete the Patient Request for Medical Payment Form CMS-1490S. This form comes with instructions for filing. You must submit itemized bills and a letter explaining why you are submitting the claim personally.
You can monitor the process with your Medicare Summary Notice (MSN). This outlines any claims for reimbursements and is received by mail every three months. The MSN can also be accessed by logging into MyMedicare.gov.
Your Medicare Claim Rights
Medicare and You, the official United States government handbook, lists the following rights and protections for Medicare beneficiaries seeking payment for claims:
- Get a decision about health care payment, coverage of services, or prescription drug coverage.
- Request a review (appeal) of decisions about health care payment, coverage of services, or prescription drug coverage.
- File complaints (sometimes called “grievances”), including complaints about the quality of care.
Help is Available for Claims, Reimbursements, Complaints, and Appeals
Need help with a Medicare claim? Know where to start:
- If you’re covered by a Medicare Advantage Plan or Medigap, contact your carrier as directed in your Explanation of Benefits.
- For those covered by Original Medicare Parts A and B, call Medicare directly at (800) 633-4227.
Other resources available to you to make sure your claims are satisfied, and your rights are protected, include:
The Medicare Beneficiary Ombudsman
If you’ve called your carrier and/or Medicare with your concern but still need help, ask the (800) MEDICARE representative to send your question or complaint to the Medicare Beneficiary Ombudsman (MBO). The Ombudsman staff helps make sure that your questions or complaints are resolved.
The MBO offers help concerning making health care decisions that are right for you, your Medicare rights and protections, and how to get issues resolved.
State Health Insurance Assistance Program
State Health Insurance Assistance Programs (SHIPs) offer local, personalized counseling to people with Medicare and their families. They provide free information and counseling to help you with your Medicare questions. This includes your benefits, coverage, premiums, deductibles, and coinsurance. They will help you find information regarding the filing of claims and complaints (grievances). You can locate information for your local SHIP office here.
Learn More From Our Sources
- Medicare | How Original Medicare Works | Last accessed April 2023
- Medicare | Medicare Advantage Plans | Last accessed April 2023
- Medicare Interactive | Medicare Summary Notice | Last accessed April 2023
- SHIP | Office Finder | Last accessed April 2023