What Is a Medicare Claim and How Do I File One?

A Medicare claim is a request for Medicare to pay a medical bill that it handles.

What Is the Usual Procedure?

It’s important to understand that the provider files the claim for you most of the time. There are three types of providers for purposes of filing a claim:

  • Participating providers agree to assign Medicare payment as payment in full (with your 20% copayment, of course). They will file the claim for you and bill you for the copayment or require it when the service is given. They will file a claim within one year of the date the service was given.
  • Non-participating providers accept Medicare but do not accept assignment in all cases. They can charge up to 15% more than Medicare pays (35% including your copayment). This additional charge is limited in some states, such as New York.
  • Opt-out providers have signed an agreement not to accept Medicare and can charge you anything they wish. Medicare will not pay for services provided by an opt-out provider, even if you file a claim. Many psychiatrists are opt-out providers.

How Do I File a Claim?

You send the bill from the provider to the Medicare claims agent who serves your area. You can find the proper Medicare Administrative Contractor (MAC) by calling 1-800-MEDICARE. Once you have that information, you can file the form “Patient’s Request for Medicare Payment,” CMS-1490S, including any bills from the provider.

Once you have filed a claim, you can check the status at www.mymedicare.gov.

What About Part D?

You should have to file a Part D (prescription drug) coverage claim only in very rare circumstances, such as when you receive a drug in a hospital that does not participate in your Part D plan and is also a drug not covered under Part A or Part B. In that case, contact your part D plan for claim filing instructions.

Reach Out to Us Today to Learn More!

The agents with ReLion Insurance Solutions are here to help you learn more about Medicare, the costs associated with each part, as well as how to pay for your out-of-pocket costs or file a claim. If you have any questions, give us a call today, and we’ll provide you with the information you need!