Medicare Claim Reimbursement: How to Request Payment from Medicare

Medicare Claim Reimbursement

Medicare Claim Reimbursement: How to Request Payment from Medicare

If you’d rather wait in line at the DMV than call your insurance company, you’re in luck with Medicare. The entire program is designed to operate without you ever having to call 1-800-MEDICARE to ensure payment for services. The vast majority of the time, it’s the provider who has to worry about Medicare claim reimbursement, not the beneficiary. However, there are exceptions.

In this post, we explain the Medicare reimbursement process. Most of what follows relates to Original Medicare, but we include information specific to Medicare Advantage and Part D plans.

How Are Providers Reimbursed for Their Services?

If your provider (doctor, nurse, lab, etc.) accepts assignment, Medicare pays them for any covered services. That’s what “accepts assignment” means. It is an agreement between your provider and Medicare. The provider agrees to accept the Medicare-approved amount for the service and Medicare agrees to pay for the service.

The provider bills Medicare directly. Once they receive payment, they then bill for the remainder (deductibles and coinsurance). If you have Original Medicare and a Medigap plan, your supplement insurance is next on the list. If you do not have a Medigap plan, or if the service is not covered by Medicare, the provider sends you the bill.

When the service received is one not normally covered by Medicare, you should receive an Advance Beneficiary Notice of Non-Coverage. The provider should give this to you before providing the service. You may refuse the service based on this (or for any other reason). If the provider performs the service, they should still bill Medicare first. If Medicare denies the claim, you may file an appeal.

Medicare Claim Reimbursement

What Do You Pay When Your Provider Accepts Assignment?

Providers who accept assignment agree to charge only the amount Medicare approves for a particular service. In other words, if the provider normally charges $150 for a service, but Medicare sets the rate at $100, the provider cannot charge more than $100.

This approved rate includes the coinsurance amount paid by you. With Part B, your coinsurance rate is 20 percent of the approved cost. Using the above example, that means the provider can only charge you 20 percent of $100, not 20 percent of their standard rate of $150.

If you have yet to meet your annual deductible, your provider should still bill Medicare first.

When Do You File for Medicare Claim Reimbursement?

About the only time you need to file for Medicare claim reimbursement is if the provider does not accept assignment. In this instance, the provider can charge you more than the Medicare-approved amount. However, they can only add 15 percent to Medicare’s approved rate. This is known as an excess charge. Using our $100 vs. $150 scenario again, that means the provider can only charge you $115 for the service: $100 + ($100 x 0.15) = $115.

If the provider does not accept assignment, they may require upfront payment from you. In this case, you can file a claim with Medicare for reimbursement.

How to File a Medicare Claim Reimbursement

To file a claim for reimbursement, you need to submit the proper form and backup documentation. First, download the Patient’s Request for Medical Payment form from the Centers for Medicare and Medicaid Services (CMS).

Fill out this form (known as Form 1490s) as completely as possible. Do not forget to include any other health insurance policies you have (currently found in Section 3).

Medicare Claim Reimbursement

In addition to the completed form, you must submit the bill from your provider. It should include the following information:

  • Place of service (clinic, hospital, lab, etc.)
  • Name and address of the provider
  • Date of service
  • Description and charge for each service provided
  • Any diagnosis you received

Send both documents to the appropriate Medicare contractor. Choose your state from the Contractor Directory on this page. You can also call 1-800-MEDICARE if you need help finding the correct Medicare contractor.

File your claim as promptly as you can after receiving the service. Generally, Medicare allows only 12 months between the date of services and receipt of your claim.

What If You Have a Medicare Advantage or Part D Plan?

The claims reimbursement process is different if you have either a Medicare Advantage or Part D plan. That is because these plans are offered through private insurance companies, not Medicare. The claims process varies according to your insurer. Check with your plan to determine your insurer’s unique claims process.

Most Medicare Advantage plans have a provider network. Part D plans may also have a pharmacy network. Obtaining services from a provider outside your plan’s network typically means you are responsible for 100 percent of the cost of those services. If you receive care from an out-of-network provider and your claim is denied, you should contact your plan, not Medicare. In these instances, coverage is typically granted only if you required emergency care.

Getting Help with Your Medicare Claim Reimbursement

Even if you receive your benefits through an Advantage or Part D plan, you have the same rights as those who have Original Medicare. Contact your Medicare beneficiary ombudsman if you have an issue with your plan.

Of course, if you enrolled in your policy through Medicare Solutions, you qualify for free claims support from one of our licensed agents. Just call us toll-free at 855-350-8101 and we’ll guide you through the Medicare reimbursement process. We can also help you find the right plan for your unique needs.

Chris Gasparini

Chris Gasparini

Licensed Insurance Agent at Medicare Solutions
Chris Gasparini has been a licensed insurance agent since 2005. He enjoys helping Medicare beneficiaries navigate their options to find the best solution for their unique needs. Chris feels as though his work truly helps people. Because he represents multiple insurance companies and plan types, Chris is able to help Medicare beneficiaries find the best, most cost-effective plan. Every day, he leaves work knowing he did what was right for each and every client he serves.
Chris Gasparini
Chris Gasparini

Author: Chris Gasparini

Chris Gasparini has been a licensed insurance agent since 2005. He enjoys helping Medicare beneficiaries navigate their options to find the best solution for their unique needs. Chris feels as though his work truly helps people. Because he represents multiple insurance companies and plan types, Chris is able to help Medicare beneficiaries find the best, most cost-effective plan. Every day, he leaves work knowing he did what was right for each and every client he serves.

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