Medicare Reimbursement10 minute read

10 minute read

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Updated for July, 2019

In most cases, your healthcare providers will file claims for services provided to you with Medicare directly, seeking reimbursement for covered expenses without any involvement on your part. However, if you obtain care for services that Medicare covers but have received a bill for instead or your provider is not filing a claim on your behalf in a timely manner, you may have to go through the claims process yourself.

Reimbursement

Before filing a claim on your own, Medicare.gov says that participants should first contact the healthcare provider or medical equipment supplier directly and ask them to file a claim for reimbursement. They are required by law to do this for all Original Medicare participant services.

If you have Medicare Advantage (Part C)—which means you’re receiving basic Medicare benefits through a private insurance company—this same mandate doesn’t apply. That being said, Medicare.gov says that having to file a claim generally only occurs “in very rare cases.” This suggests that even Plan C providers are still likely to request reimbursement from Medicare directly versus making participants take this action on their own behalf.

Either way, if the healthcare provider or business does not file a claim and you have filed it yourself, you only have up to 12 months from the date of service to do this. So, if you’re close to the end of this timeframe, it’s recommended that you file the claim yourself. And if you’re unsure when this one-year period ends, you can call Medicare at 1-800-MEDICARE (1-800-633-4227) and they’ll provide this information.

There are some instances where Medicare provides different claim submission instructions other than those included with the standard Patient’s Request for Medical Payment.

There are some instances where Medicare provides different claim submission instructions other than those included with the standard Patient’s Request for Medical Payment. While they all use the same form, what changes from one type of claim to the other is where they’re sent for processing.

These include:

When you’re filing Part B services claims. Instead of sending Part B service claims to your Medicare carrier, they must be submitted to an address that is determined based on the geographical location where the service was provided.

Claims related to durable medical equipment (DME). This type of claim also goes to a different address based on location. However, this address is determined based on where the participant lives.

Claims arising while you were on a ship. If you obtained medical services while on a cruise or similar vessel, most will submit directly to Medicare. If they don’t and you have to submit them yourself, the submission address is based on where you live. The one exception to this is if the doctor’s office is outside the U.S. In this case, the form needs to be sent directly to Medicare, but Medicare may only cover services provided while the ship was within U.S. waters.

Claims for medical services received in Canada or Mexico. If you recently visited Canada or Mexico and received medical services while there, Medicare generally will not pay the claim. However, there are some instances it may pay. These include if you were in the U.S. at the time but the foreign hospital was closer, or if you were traveling through Canada to get to another U.S. territory “without delay” and an emergency occurs. In either case, claims are sent to an address based on where you reside.

Stay Healthy Lifestyle

Claims for services received in a foreign hospital. These claims are also sent to an address based on where you live and, again, may not be covered unless it was a hospital used because it was closer than a U.S.-based hospital (even though you were in the States at the time), or if you were traveling through Canada “without delay” to reach another state in the U.S.

Most claims are processed within 60 days.

Although Medicare.gov indicates that most claims are processed within 60 days, if you’d like to check the status of your claim after it has been filed, the way to go about this is dependent upon which part of Medicare the claim is for.

Part A – Hospital Insurance

To check the status of a claim on a Part A benefit, simply log-in to your account on MyMedicare.gov and the claim should be visible within 24 hours of being processed.

Alternatively, you can review your Medicare Summary Notes (MSN). Participants under Original Medicare receive this notice every three months unless no medical services were provided during that time period.

The MSN provides information regarding:

  • The services billed
  • The amount paid by Medicare
  • The maximum amount you may be responsible for to individual providers

This notice is not a bill, but more so an inventory of all of the health-related actions that have taken place on your Medicare account within that specific three-month period.

Take the MSN and compare it against your calendar, receipts, and bills to ensure that all of the information is correct. And if you already paid a bill listed on the MSN directly to the provider, double check to make sure you paid the correct amount.

Part B – Medical Insurance

If you filed a claim on a Part B service, you can check its status by following the same process as you would with a Part A claim. Either log-in at MyMedicare.gov or review your Medicare Summary Notes.

Part C – Medicare Advantage

Because Medicare Advantage policies are provided through private insurance companies, checking claims on these plans requires that you contact your individual plan directly.

If you’re unsure how to reach them, you can do a search on Medicare’s website and you’ll be provided the information you need.

Part D – Medicare Prescription Drug Plan

To check a prescription drug claim, you have three options. You can:

  1. Review your Explanation of Benefits (EOB)
  2. Check MyMedicare.gov
  3. Contact the Part D plan directly

The first step is to contact the billing agency and verify that the information they submitted was correct.

If a service or supply claim is denied by Medicare, the first step is to contact the billing agency (whether that is a doctor’s office or medical supply company) and verify that the information they submitted was correct. If not, ask them to resubmit the claim with the corrected information.

If the information submitted was accurate and your claim was still denied, but you still believe you were entitled to some reimbursement according to your Medicare plan, you can file an appeal.

Step-by-step directions for this process are provided on the last page of the MSN. Additionally, there are five levels of appeal available, so if you disagree with the decision made on any of these levels, you can appeal to the next one by filling out the forms required for that specific level.

These levels are:

  1. Redetermination by the company handling Medicare claims
  2. Reconsideration by a Qualified Independent Contractor
  3. Hearing before an Administrative Law Judge
  4. Review by Medicare Appeals Council
  5. Judicial review by federal district court

If you need to file an appeal and would like some help, you can either contact your State Health Insurance Assistance Program (SHIP) for assistance or you can appoint a family member or friend to act on your behalf by filling out an Appointment of Representative form (form CMS-1696).

couple meeting for insurance

In some cases, Medicare participants may ask a loved one or other trusted person for help with completing and submitting a Medicare claim, or to check its status. In this instance, an Authorization to Disclose Personal Health Information form must be completed first.

Once submitted, this form enables another person to deal with Medicare on your behalf. They can then give and receive personal information related to your care.

The goal of filing a claim for Medicare reimbursement is to ensure that costs covered under the Medicare program are paid according to your specific plan or policy. This reduces your out-of-pocket expenses related to mental and physical healthcare.

Yet, Medicare.gov reminds participants that these out-of-pocket expenses can be reduced simply by using healthcare providers and companies enrolled in Medicare and willing to file claims directly. This keeps you from having to worry about any additional expenses (or how to figure out the claims process).