Medicare Reimbursement and Claims

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Medicare Reimbursement and Claims

In most cases, Medicare pays your Medicare providers directly based on the program’s reimbursement rates. In rare cases, Medicare will reimburse an individual directly for expenses related to his or her medical care.

 

Claims for Medicare Part A and Part B

Original Medicare consists of two parts: Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Your doctor will submit part A and Part B claims. If for some reason your doctor has not submitted the claim and you are not able to have the doctor submit the claim, you could then file the claim yourself. To check the status of either a Part A or Part B Medicare claim, visit mymedicare.com and log into your account.

 

Filing Medicare claims for Part C and Part D

Both Medicare Part C (Medicare Advantage) and Medicare Part D (Prescription Drug Coverage) do not require that you file claims directly because Medicare pays the insurance companies an established amount monthly. All copayments, coinsurance, or any deductibles that are part of the established plan will be your responsibility to pay at time of service.

In some cases, individuals may be asked to pay the full cost of the service if the provider is out of network. In these cases, you would file the claims with the plan. When filing these claims, they should be submitted with the plan (Medical Advantage or Prescription Drug Coverage), not with Medicare. It’s best to always check with the plan before visiting a doctor to confirm they are in-network or out-of-network and to understand what the claim process would be.

 

Time limits on Medicare claims

All Medicare claims should be filed within 12 months of when the medical service(s) were provided. The claim must be filed within this timeframe so that Medicare can pay its share. For example, if your doctor provided service on August 1, 2018, you and your doctor have until August 1, 2019 to file the claim. Even if you have paid the doctor your portion of the costs directly, you’ll want to confirm that the doctor has submitted the claim within the allotted timeframe. Deductibles are credited only when the claimed are filed and processed.

To confirm claims are being submitted on time you can log into MyMedicare.gov to check the status. If for some reason it’s not being filed, you should follow-up with your doctor. If they are still unable to submit the claim, you’ll then want to submit it yourself so it’s done within the time allotted.

 

Medicare forms for filing a claim

To submit a Medicare form you’ll want to download the Patient Request for Medical Payment form, known as the CMS 1490S. This form can be downloaded and printed from the web address provided, or it can be picked up from a Social Security office. The form includes directions on how to correctly complete and submit the form. If you have any questions while completing the form, it’s best to contact Medicare directly at, 1-800-MEDICARE. Representatives are available 24/7 to answer questions.

In most cases you’ll need to submit a completed form and the following:

  • An itemized bill from whom you received the service(s)
  • A detailed letter explaining the reason for submitting the form
  • Supporting documents related to the claim

 

Medicare reimbursement

The first step in finding out if you can be reimbursed for your medical expenses through Medicare is to confirm that your doctor accepts Medicare assignments. If your doctor does accept Medicare, you are only responsible for paying the portion of the total cost of service(s) that would be your responsibility. This could include copayments, coinsurance, and deductibles. If the doctor does not accept Medicare, the cost of the services will be your responsibility. If your doctor changes who they work with, and no longer accepts Medicare, you will be notified.

The purpose of this communication is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. www.coveranceis.com

The purpose of this communication is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. Coverance Insurance Solutions, Inc. is not connected with or endorsed by the U.S. government or the federal Medicare program.

Coverance's Medicare Supplement website is operated by Coverance Insurance Solutions, Inc., a licensed health insurance agency.

Medicare has neither reviewed nor endorsed this information.