Medicare Claims and Reimbursement

Medicare Claims and Reimbursement

 

In most cases, you won’t have to worry about filing Medicare claims. Here are some situations where you might or might not need to get involved in the claim process.

There may be a situation where your doctor prescribes a high-cost medication when no substitute is available that would be suitable for your medical condition. If you have prescription drug coverage–whether it’s through a stand-alone Medicare Part D Prescription Drug Plan, or through a Medicare Advantage Prescription Drug plan–and your plan doesn’t cover a drug prescribed for you, you can file an appeal to get your plan to cover the prescription drug or to get it at a lower cost.

Any Medicare claims must be submitted within a year (12 months) of the date you received a service, such as a medical procedure. If a claim is not filed within this time limit, Medicare cannot pay its share.

One reason to make sure that Medicare processes a claim is to ensure that deductible amounts are credited to you. It may be worthwhile for you to contact your doctor’s office to remind them that you’re waiting for them to file a claim. You can also contact 1-800-MEDICARE (1-800-633-4227) to see if they can assist with the claim. If these efforts fail, you may file the Medicare claim yourself. You’ll need to start by filling out the Patient Request for Medical Payment form (CMS 1490S).

Checking the status of a claim

You can check the status of a claim by using the Blue Button feature at MyMedicare.gov.

Avoiding the need for claims

Make sure that your doctor accepts Medicare assignment. For Original Medicare, Part A and Part B, this means that your doctor or provider agrees to be paid by Medicare, and that they accept the Medicare-approved amount for a particular service. When your doctor accepts Medicare assignment, it also means she or he agrees not to bill you for more than the Medicare deductible and/or coinsurance. Private insurance companies contracted with Medicare may bill Medicare differently.

If your health-care provider doesn’t accept Medicare assignment, you may have to pay the full cost for the service up front, and get reimbursed by Medicare. You also might have to pay more than the Medicare-approved amount. In most cases, the doctor’s office should file the reimbursement claim for you.  If you have to file your own claim, see below.

Medicare reimbursement claim forms

Reimbursement claim forms are available from the Centers for Medicare & Medicaid Services (CMS) website. If you need to file a claim for reimbursement, in most cases you’d need form CMS 1490S, Patient Request for Medical Payment.

If you don’t have the ability to access the form online or print it, CMS 1490S is also available at your local Social Security Administration office. Instructions for completing the form are on listed on the back, and you can contact Medicare by calling 1-800-MEDICARE (TTY users 1-800-633-4227) 24 hours a day, 7 days a week, to find out where to mail the completed form.

To learn about Medicare plans you may be eligible for, you can:

  • Contact the Medicare plan directly.
  • Call 1-800-MEDICARE (1-800-633-4227), TTY users 1-877-486-2048; 24 hours a day, 7 days a week.
  • Contact a licensed insurance agency such as Medicare Consumer Guide’s parent company, eHealth.
    • Call eHealth's licensed insurance agents at 888-391-2659, TTY users 711. We are available Mon - Fri, 8am - 8pm ET. You may receive a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day.
    • Or enter your zip code where requested on this page to see quote.