Filing a Medicare Claim
WebMD Medical Reference
You should not have to file any claims for hospital and other services covered under Medicare Part A. Providers must be certified by Medicare and must file claims for you. If a Part A provider is not Medicare certified, Medicare will not pay for the service. Part A providers include:
You should not to have to file any claims for doctor and other services covered under Medicare Part B. Providers must file the claims for you. Part B providers include:
If your healthcare provider does bill you for services that Medicare should cover, call his or her office. Ask your healthcare provider to send a claim to Medicare directly. If he or she keeps trying to bill you, call Medicare at (800) 633-4227.
You will get Medicare Summary Notices (MSNs) in the mail after you use any Medicare Part A or B covered services. These aren't bills. They are records of what services your healthcare provider charged to Medicare during the last thirty days.
Filing a Medicare Claim
Before you see a doctor or healthcare provider, you should see if they "accept assignment." Medicare determines what it will pay for any particular medical service. This is called the Medicare-approved amount. If your doctor is willing to accept what Medicare pays and won't charge you any more, he or she is said to "accept assignment."
Not all healthcare providers accept assignment. If the provider doesn't accept assignment, you may have to pay the bill up front and wait for Medicare to reimburse you for its share.
Doctors and providers who don't accept assignment may charge up to 15% more than Medicare-approved amount. You pay that extra amount, as well as your 20% co-payment. Since you pay whatever Medicare won't, you will have higher out-of-pocket costs. Medical supply and equipment companies can charge as much as they want. Here's how it works:
The provider must file your claim within one year or Medicare will not pay. If you do not receive reimbursement from Medicare within several months, the provider may not have submitted the bill. Here are steps you can take.
Step 1. Call the provider and ask them to file your claim. If you have contacted the provider about your claim and it still hasn't been filed with Medicare, proceed to Step 2.
Step 2. Call your local Medicare Carrier. You can find this number by visiting the Medicare Helpful Contacts page. The Medicare Carrier will contact the provider and ask them to file the claim.
There is a time limit for filing a claim -- from 15 to 27 months depending on the service. If the claim hasn't been filed and you are nearing the end of the time limit, you may go to Step 3.
Step 3. Call the Medicare Carrier and ask for a claim form to file yourself.
Traditional Medicare Plan
You get a Medicare Summary Notice (MSN) when Medicare pays (or does not pay) for a product or service. If Medicare did not pay, the notice will tell you why.
If Medicare has declined to pay for something that you think it should or if you think it hasn't paid enough:
The time limit for filing an initial appeal is 120 Days -- about four months -- from the date on the MSN.
Medicare Advantage Plans (formerly Medicare + Choice)
If you think that waiting through the normal appeals process will seriously harm your health, you may request a fast-track appeal.
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