Filing a Medicare claim is usually a task that your doctor or medical supplier will complete on your behalf, especially if you receive coverage under Original Medicare. Federal law requires health care providers to file your Medicare claims in a timely manner unless you received care for a service that was not covered under your plan. If you receive a medical service or treatment from an out-of-network provider, then you may need to file the claim manually. To do so, you need a Medicare claim form and supporting documentation from your medical provider.
When requesting financial reimbursement for a service, you must provide your Medicare claim number (also known as your Health Insurance Claim Number/HICN). To locate this number, refer to your most current Medicare insurance card or a recent Medicare Summary Notice (MSN).
By updating its Medicare claims numbers, the CMS aims to protect you and other Medicare beneficiaries from instances of fraudulent activity. To learn more about the claims process, review the information below.
When do you need to file a Medicare claim?
You may need to submit a Medicare claims form to your local Medicare Administrative Contractor (MAC) if you wish to receive financial reimbursement for the medical services and supplies you received. Unless you receive coverage under Original Medicare or your medical provider fails to file your Medicare claim in a timely manner, you are typically not responsible for the manual submission of these claims. Instead, your medical provider may submit the claim on your behalf.
For Medicare timely filing, your health care provider must file these medical claims within 12 months from the date on which you received any services covered under Medicare. If your health care provider does not file the claim within this time limit, then Medicare cannot pay for these covered services unless you were to file the claim manually. In any of the following situations, you may be responsible for the manual submission of your insurance claims:
- Your doctor or medical provider fails to file the Medicare insurance claim within the time limit or the end of the 12-month period is near and your provider has not filed the claim.
- Your medical provider refuses to file the claim.
- You received medical care from an out-of-network provider.
- You received medical care from outside of the country.
When are Medicare appeals necessary?
After submitting your Medicare claim form, you must allow at least 60 days for the processing of your request. If Medicare denies your claim for coverage or you disagree with the determination that was made, then you may choose to file an appeal within 120 days.
The Medicare appeals process consists of five levels, but the specific steps you must take to appeal the decision will vary depending on the type of Medicare plan you have. If you receive coverage under Original Medicare, then these five levels include a:
- Redetermination
- Reconsideration
- Hearing
- Review
- Judicial review
When completing a Medicare reimbursement form, what information do I need?
When making a Medicare claim, you must complete a form and submit it to your state’s MAC at the address provided on the application. Depending on where you live, you may need to submit your Medicare claim form to Palmetto GBA, Noridian Healthcare Solutions, Novitas Solutions or National Government Services. You can also obtain your local MAC’s address by referring to your MSN or logging into your online MyMedicare account. When completing your claims application, you must provide the following information:
- A reason for your request (for example, you visited an out-of-network provider).
- The claim type (such as “Part B services” or “Durable Medical Equipment”).
- A reason for receiving these medical services.
- Patient information, including a Medicare claim number, date of birth, street address and telephone number.
- Additional health insurance information (if you also receive coverage under another policy).
- A signature.
In addition to your Medicare claim application, you must submit the form along with an itemized bill from your medical provider, any documents that can help to support your claim and a detailed letter that describes your reasons for filing the claim. If you wish to share your claims information with another individual, then you may need to submit an official authorization form. For more Medicare information, download this detailed guide.
How to Check Your Medicare Claim Status for Part A and B Services
To check the status of your Part A or B Medicare provider claims, you may refer to the most recent MSN you received by mail or email or you may log into your online MyMedicare account. When reviewing your most recent MSN for Part A and B claims, refer to the page titled “Your Inpatient Claims for Part A” or “Your Claims for Part B” depending on the type of medical care you received. This page includes the following information:
- The claim type.
- The date(s) on which the service was received.
- A description of the services you received.
- Whether your service was approved or denied by Medicare.
- The maximum amount you will need to pay for these services.
If your Medicare claims status shows that your request has been denied, then you will receive a bill in the mail, and you will be responsible for paying for these uncovered services. However, you may choose to file an appeal if you believe that these services should be covered under your Medicare plan.
How to Check Your Medicare Claim Status for Part C and D Services
To check the status of your Part D (prescription drug) claims, you may refer to the recent month’s Explanation of Benefits (EOB) or you may contact your plan administrator for the most up-to-date information. As another option, you may log into your MyMedicare account to check the status of your claim online.
If you receive coverage through a Medicare Advantage Plan, then you must contact your plan administrator directly to check the status of your claim. While you rarely need to file Medicare claims for Advantage Plans, you may need to do so in some situations. Download this comprehensive Medicare guide to get more information about the medical program.