Q: How do I file a healthcare claim with Medicare or my insurer?
A: Medicare beneficiaries occasionally have to submit their own healthcare claims instead of relying on a provider to submit them. Here’s what you need to know about filing a Medicare claim.
What is a Medicare claim?
A claim asks Medicare or your insurer to pay for your medical care. Claims are submitted to Medicare after you see a doctor or are treated in a hospital. If you have Original Medicare, your Medicare Part A and Part B claims are processed by the federal government. If you have a Medicare Advantage, Medigap, or Part D plan, claims under those plans are processed by the private insurer that sold you the plan.
Who files Medicare claims?
In almost all cases, your healthcare provider — doctor, hospital, pharmacy, etc. — will file claims for you, so you will not need to file your own claims. But you might have to file a claim yourself, in “rare cases” where the provider didn’t file the claim. This could also be the case if you have a Medicare Advantage plan that covers out-of-network care (a PPO, for example), and you see an out-of-network provider.
Beneficiaries can submit their own claims for certain services when a provider won’t file a claim. However, you cannot file a claim with Original Medicare for diabetic test strips, Part B drugs, or equipment paid for under the DMEPOS Competitive Bidding Program. Your pharmacy or medical supplier must bill Medicare directly for these items.
When do I need to file Medicare claim?
Original Medicare has both participating and non-participating providers. Participating providers accept Medicare’s reimbursement plus your coinsurance as full payment, and have agreed to always bill Medicare for your care. Non-participating providers can charge you up to 115% of Medicare’s rate (in most states) and don’t have to file claims with Medicare, although some choose to do so. This means you may have to submit your own healthcare claim if you see a non-participating provider. (A small number of clinicians are opt-out providers. Medicare will never pay for care from these providers, even if you file a claim.)
If you have a Medicare Advantage plan and go outside the plan’s network to receive care, the plan may or may not provide coverage. It will depend on the plan’s rules, and many Medicare Advantage plans do not cover out-of-network care unless it’s an emergency. If the plan does cover out-of-network care, the out-of-network provider might be willing to submit a claim on your behalf, but they might require you to pay up-front and submit a reimbursement claim to your Medicare Advantage plan. If you have a Medicare Advantage plan and you want to see an out-of-network provider, make sure you clearly understand the ramifications ahead of time: Will your plan cover any of the cost, and if so, who will submit the claim, do you need to pay upfront, and how much will your out-of-pocket costs be.
How long do I have to file a claim?
Original Medicare claims have to be submitted within 12 months of when you received care. Medicare Advantage plans have different time limits for when you have to submit claims, and these time limits are shorter than Original Medicare. Contact your Advantage plan to find out its time limit for submitting claims.
What should I do if my provider doesn’t file my claim?
Before receiving care, ask your provider’s office whether they will submit your bill to Original Medicare. If the provider participates with Medicare, they are required to file the claim with Medicare (in most cases, a Medigap plan, if you have one, will get the claim information directly from Medicare and pay their share after Medicare pays its share). Non-participating providers aren’t required to file claims on your behalf, but some will do so. Before receiving care, make sure you understand whether the provider participates with Medicare, and if not, how they handle claims.
The same situation applies for Medicare Advantage enrollees who see out-of-network providers. These providers don’t have to file claims with your Advantage plan, but may choose to do so. (Medicare Advantage enrollees can see out-of-network providers for routine care only if their plan includes out-of-network coverage, but all Advantage enrollees have coverage for out-of-network urgent and emergency room care. You may have to file your own claims when you receive any of these types of out-of-network care.)
If you have Original Medicare and a participating provider refuses to submit a claim, you can file a complaint with 1-800-MEDICARE. Regardless of whether or not the provider is required to file claims, you can submit the healthcare claims yourself. You can file an Original Medicare claim by sending a Beneficiary Request for Medical Payment form and the provider’s bill or invoice to your regional Medicare Administrative Contractor, or MAC (here’s where you can see the MAC for your state). Keep copies of everything you submit.
Original Medicare providers have to give you an advance beneficiary notice (ABN), Home Health Advance Beneficiary Notice, or Skilled Nursing Advance Beneficiary Notice if they believe Medicare will not cover your care. Providers normally will not bill Medicare after they issue an ABN.
You have the right to demand bill, which is when you demand that the provider or facility submit a claim to Medicare for your care. In order to demand bill, you must sign the ABN and agree to pay the charges if Medicare denies coverage. Demand billing can be used to generate a formal Medicare coverage denial, which gives you further appeal rights.[/hio_question]
Are claim filing requirements different if I have Medicare Advantage or Medigap?
If you have Medicare Advantage, providers in the plan’s network have to bill your insurer for your care. As mentioned above, you may have to submit your own claims if you go out-of-network.
If you decide to file a claim yourself, first contact your insurer for its claims mailing address and any forms to include with your claim. (You’ll send Advantage plan claims to your insurer rather than to Medicare.) Because Advantage plans have different time limits for filing claims than Original Medicare, be sure to follow your insurer’s rules to avoid a denial.
Original Medicare will automatically send your claims to most Medigap insurers for secondary payment, but some Medigap insurers require plan holders to manually file claims. If you have to submit your own Medigap claim, you’ll need to at least send the insurer a Medicare summary notice (MSN) showing the payment Medicare made, and you may need to provide other documentation, such as an invoice or receipt. You don’t have to submit an MSN when filing claims for Medigap services that aren’t covered by Original Medicare (e.g. emergency care while traveling internationally). Contact your Medigap insurer if you have questions about Medigap claims.
What if I’ve already paid for my care?
You may have already paid in full for your care when you filed your claim. Be sure to note that you’ve paid on your submission, so Medicare or your insurer reimburses you rather than your provider. Keep copies of everything you submit.
Do I need to file Part D claims?
Medicare Part D plans contract with pharmacies where you can fill your prescriptions. Both preferred and non-preferred pharmacies can bill your Part D insurer, although your cost will be lower if you use a preferred pharmacy. If you have to fill medications at a pharmacy outside your plan’s network because of an emergency, you may be able to receive partial reimbursement by submitting your receipt and supporting documentation to your Part D insurer. Contact your insurer for instructions if you need to file an out-of-network claim.
You may also have to file a Part D claim if you receive medications during an observation stay in the hospital (which is considered outpatient rather than inpatient). Whether you need to submit the claim yourself depends on whether the hospital’s pharmacy has a contract with your Part D plan.
How do I check on my claim to make sure it was processed?
Original Medicare beneficiaries should receive an MSN every three months detailing their recent Medicare claims. Medicare Advantage and Part D enrollees receive Explanation of Benefits (EOB) statements after receiving care. Review all your statements to ensure claims are being filed and processed in a timely manner.
You can call 1-800-MEDICARE or your insurer to check on your claims. If you have Original Medicare, you can check claims status at MyMedicare.gov. Medicare Advantage and Part D plans also have online portals where you can view claims activity.
How should I ensure my claims are also filed with Medicaid?
Many Medicare beneficiaries also qualify for Medicaid due to having limited incomes and resources. Medicaid pays for Medicare co-pays, deductibles and coinsurance for enrollees who see providers that accept both Medicare and Medicaid.
Show your health care provider your Medicare and Medicaid I.D. cards when you check in for your office visit. You should also show the provider your Medicaid managed care plan card (if you have one).
Read more here about Medicaid benefits (i.e., Medicare premium assistance and long-term care) for Medicare enrollees.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including as an associate at Sachs Policy Group, where he worked with insurer, hospital and technology clients.
Footnotes
Tags: Medicare Part A, Medicare Part B, Medicare summary notice, Original Medicare
