If you have Original Medicare (parts A and B), you don’t have to worry about filing claims for reimbursement most of the time. However, Medicare Advantage (Part C) and Part D rules are a bit different.
The Centers for Medicare & Medicaid (CMS) sets reimbursement rates for all medical services and equipment covered under Medicare. When a provider accepts assignment, they agree to accept Medicare-established fees.
Providers cannot bill you for the difference between their usual rate and Medicare-set fees. Most Medicare payments are sent to providers of Part A and Part B services.
Remember, you’re still responsible for paying any copayments, coinsurance, and deductibles you owe as part of your plan.
In some cases, you may need to file a claim if the facility fails to file the claim or if you receive a bill from a provider because the provider or supplier does not participate with Medicare.
You can check the status of all your covered expense claims in two ways:
- through the Medicare summary notice mailed to you every 3 months
- by logging into Medicare.gov to see the status of claims
Some nonparticipating doctors may not file a claim with Medicare and may bill you directly for services. When selecting a doctor, be sure they accept Medicare assignment. Nonparticipating doctors can ask you to pay upfront and file a claim.
Medicare does not pay for services outside the United States except under special conditions, like an emergency when a U.S. doctor or facility is not close by. Medicare determines these cases on an individual basis after you submit a claim.
Medicare will pay for services onboard ships in medical emergencies or injury situations. You can file a claim if you have Part B if the doctor treating you is authorized to practice in the United States, and if you are too far away from a U.S.-based facility when the emergency occurred.
Since Part C is a private insurance plan, you never file for reimbursement from Medicare for any outstanding amount. You will file a claim with the private insurance company to reimburse you if you have been billed directly for covered expenses.
There are several options for Part C plans, including Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Each plan has in-network and out-of-network providers. Depending on the circumstances, if you see an out-of-network provider, you may have to file a claim to be reimbursed by the plan.
Be sure to ask the plan about coverage rules when you sign up. If you were charged for a covered service, you can contact the insurance company to ask how to file a claim.
The pharmacy (retail or mail order) where you fill your prescriptions will file your claims for covered medications. You pay the copayment and any coinsurance.
If you pay for a medication yourself, you cannot file a claim with Medicare. Any claims will be filed with your insurance provider.
In some cases, if the drug is not covered or the cost is higher than you expect, you may need to ask the plan about coverage.
If you’ve paid for a medication, you can ask for a reimbursement by filling out a Model Coverage Determination Request Form.
If you haven’t paid for the medication, you or your doctor can ask your plan for a coverage determination or an exception to get the medication covered. You can also file an appeal in writing to get the medication covered.
Medigap will only pay for items approved by Original Medicare. There are no network restrictions with Medigap plans. If the provider accepts assignment, they accept Medigap.
If you go to a provider that accepts Medicare assignment, once the claim has been filed with Medicare, the balance may be paid by your Medigap plan. Remember to show your Medigap card along with your Medicare card to your provider at the time of service.
After Medicare pays its share, the balance is sent to the Medigap plan. The plan will then pay part or all, depending on your plan benefits. You will also receive an Explanation of Benefits (EOB) detailing what was paid and when.
If you’ve been billed or had to pay upfront, you have 1 year from the date of service to file a claim for reimbursement.
Medicare reimbursement rates are the set amounts that Medicare pays physicians for their services. These payment rates are aggregated in the Physician Fee Schedule (PFS).
To see the rates for specific procedures, check the PFS Look-up Tool on the CMS website.
To view the rates, you’ll need the CPT code for the procedure you’d like to look up and the locality key for your Medicare Administrative Contractor (MAC) area — the PFS includes payment rates for different regions across the country.
As an example, suppose you’d like to look up the rates for arthroscopic knee surgery in the Hudson Valley of New York. The CPT code for the procedure is 29880, and the MAC locality is 1320203. Plugging that information into the Look-up Tool, you find the following details:
- Non-facility price: $610.89
- Facility price: $610.89
- Non-facility limiting charge: $667.40
- Facility limiting charge: $667.40
Under Medicare Part B, Medicare pays doctors 80% of the costs of their services based on the Medicare Physician Fee Schedule (PFS). Enrollees pay the remaining 20% as coinsurance.
Participating provider
Most healthcare professionals fall into this category. They have signed a contract with Medicare to accept assignment and agree to accept CMS-set rates for covered services.
Participating providers will bill Medicare directly, and you don’t have to file a claim for reimbursement.
In rare cases, a participating provider may fail or refuse to file a claim and may bill you directly for services. However, if they accept assignment, they are responsible for filing the claim.
If you have tried to get the provider to file a claim and they refuse, you can report the issue by calling 800-MEDICARE (800-633-4227) or the Inspector General’s fraud hotline at 800-HHS-TIPS (800-447-8477).
Opt-out provider
These healthcare professionals do not accept Medicare and have signed a contract to be excluded. If you go to an opt-out provider, you must pay for all services.
Rates may be higher than Medicare fees, and you cannot file a claim for these charges unless they are part of emergency medical care. You are responsible for paying the healthcare professional directly.
The opt-out provider should provide you with information about their charges. To avoid higher or unexpected charges, confirm that they accept Medicare assignment.
Opt-out providers are the smallest category. One example of an opt-out provider is a psychiatrist, many of whom do not accept Medicare.
The CMS has a tool that allows users to see which providers have opted out of Medicare. You can search the database by a doctor’s National Provider Identifier (NPI) or name.
Nonparticipating provider
If the provider is not a participating provider, that means they don’t accept assignment. They may accept Medicare patients, but they have not agreed to accept the set Medicare rate for services.
This may mean you have to pay up to 15% more than the Medicare-approved rate for a service. States can limit this rate to a 5% upcharge, also called a “limiting charge.”
This is the maximum amount that can be charged to Medicare patients after the 20% coinsurance. Durable medical equipment (DME) does not fall under the limiting charge rule.
Some nonparticipating providers will bill Medicare, but others may ask you to pay them directly and file your own Medicare claim to be reimbursed.
Special circumstances
In some cases, a healthcare professional may ask you to sign an advance beneficiary notice (ABN). It’s a liability waiver form that explains why a provider believes Medicare may not cover a specific service.
The form must be very specific about why the provider believes a service may not be covered. It cannot be a blanket general notice.
By signing the ABN, you agree to the expected fees and accept responsibility for paying for the service if Medicare denies reimbursement.
Be sure to ask questions about the service and ask your healthcare professional to file a claim with Medicare first. If you don’t specify this, you will be billed directly.
Once you see the outstanding claims, first call the service provider to ask them to file the claim. If they cannot or will not file, you can download the form and file the claim yourself.
Go to Medicare.gov and download the Patient’s Request for Medical Payment form CMS-1490-S. Fill out the form by carefully following its instructions:
- Explain in detail why you are filing a claim (e.g., the doctor failed to file or the supplier billed you).
- Provide the itemized bill with the provider’s name and address, diagnosis, the date and location of service (hospital, doctor’s office, etc.), and description of services.
- Provide any supporting information you think will be helpful for reimbursement.
Be sure to make and keep a copy of everything you are submitting for your records, and then mail the form to your Medicare contractor.
You can check with the contractor directory to see where to send your claim. This is also listed by state on your Medicare Summary Notice, or you can call Medicare at 800-633-4227.
If you need to designate someone else to file the claim or talk with Medicare on your behalf, you must fill out the Authorization to Disclose Personal Health Information Release form.
You can view any outstanding claims by checking your Medicare Summary Notice (mailed every 3 months) or by logging into Medicare.gov.
Original Medicare pays for the majority of your Part A and Part B covered expenses if you visit a participating provider. In this case, you will rarely need to file a claim for reimbursement.
In a few cases, you may have to pay for your services and file a claim to be reimbursed. If you have questions, you can call 800-MEDICARE (800-633-4227) or contact your local State Health Insurance Assistance Program (SHIP).
You do not file Medicare claim forms if you have Part C, Part D, or Medigap plans. For Part C and Part D private plans, you file directly with the plan. It’s a good idea to call the plan and ask how to file a claim. Medigap is paid after Medicare settles the claim.