It is not typical for an individual to file a claim with Medicare. However, if a person has made a claim and then wants to cancel it, there are various ways to do so.
Medicare reimburses health providers for the services and equipment supplied to Medicare beneficiaries. The supplier is responsible for submitting the bill, also known as a claim, to Medicare for the covered services. However, there may be occasions when a person self-files a claim and then wants to cancel it.
This article explains how a person can cancel a Medicare claim. It also looks at when and why a person can make a Medicare claim and explains the process for each part of Medicare. Finally, it examines how to check the status of a claim, and how to appeal a ruling.
Generally, a person will not need to file a claim to Medicare for any equipment or services, because the doctor will do that for them. However, a person may decide to file a claim for various reasons, such as a doctor refusing to file, or a delay in filing.
If a person then decides to cancel the claim, they can call the general Medicare at 800-MEDICARE (800-633-4227) and explain they want to cancel a self-filed claim.
When a person calls Medicare, they will be asked for specific details about the claim. This information will include:
- a person’s name
- a person’s Medicare number
- details about the medical service or equipment
Because Medicare usually requires about 60 days to process a claim, a person may stop the claim from being processed if they contact Medicare within this 60-day time frame to cancel.
Under normal circumstances, an individual will not have to file a claim to Medicare, as the health service provider does so. Companies that provide Medicare Advantage plans are paid monthly by Medicare.
However, there may be times when a person decides to file a Medicare claim, such as:
- the provider does not accept Medicare
- the provider refuses to file a claim
- the provider cannot file a claim
For example, if a person received healthcare from a clinic that later ceased to be in business, they may have to file a claim.
Because Medicare allows a 1-year period for a healthcare provider to file a claim, a person may have to wait until that deadline approaches before following up to find out if the provider has claimed.
As a first step, a person can contact the provider to check on the status of the claim. A person can also check their monthly Medicare summary notices for any outstanding claims.
How to file a complaint
Medicare provides an appeals service so that if a doctor or other health service provider refuses to file a claim, a person can file a complaint.
To get help with filing a complaint, a person can contact their State Health Insurance Assistance Program (SHIP). They can also call Medicare and explain why they would like to file a complaint.
A complaint and an appeal are two separate processes. A complaint requests that Medicare investigates a service provider. An appeal asks Medicare to reconsider payment for drugs or services.
Depending on the Medicare part used, the claim process may vary. For example, a claim for services or equipment from original Medicare (parts A and B) is processed differently from claims for other Medicare parts.
The claims process has several steps a person should follow:
- Contact Medicare to get the deadline for filing the claim.
- Complete the Patient’s Request for Medical Payment (CMS-1490S) form.
- Get an itemized bill for the medical service as it validates the claim.
- Add documents such as medical history or referrals to specialists.
- Highlight the relevant portions of bills or other documents, and cross out items already paid by Medicare or that do not apply.
In addition, a person should include any additional health insurance coverage and a cover letter that explains why they are making a claim.
The completed form and all documents can be mailed to the Medicare office listed on the person’s payment request form.
If a person traveled outside the United States, they might need to file a claim for healthcare in another country. However, Medicare provides coverage for only specific circumstances, such as:
- a medical emergency in the U.S., where the closest hospital is in Canada
- a medical emergency on a ship less than 6 hours from leaving or arriving in a U.S. port
- emergency treatment in Canada, when a person is traveling between Alaska and another state and takes a direct route through Canada
Medicare will request proof that the treatment was necessary.
Medicare has several parts:
- Medicare Part A, hospital insurance
- Medicare Part B, medical insurance
- Medicare Part C, also known as Medicare Advantage
- Medicare Part D, prescription drug coverage
Usually, a person’s claim is either for medical services, which is original Medicare Part B, or for out-of-country emergency hospital care. If a person has in-hospital care, then original Medicare Part A would provide coverage.
Medicare Advantage Plans
Typically, a person would not need to file a claim if they have a Medicare Advantage plan, because the plan provider is paid monthly by Medicare.
However, if a person with an Advantage plan used an out-of-network healthcare service, they might need to file a claim with their plan provider. A person can check in their plan details.
Medicare Part D
Medicare Part D is an optional plan to cover prescription drugs for people with original Medicare. There may be occasions when a person would want to file a claim, such as:
- if a person uses an out-of-network pharmacy
- if a person forgot their Medicare Part D identification card and paid full price at the pharmacy
- if a person stayed at a hospital for observation and could not take their usual medications with them
Supplementary insurance, also called Medigap, helps people pay the Medicare out-of-pocket costs.
Generally, Medicare claims directly from Medigap. However, some plans stipulate that a person has to make the claim. A person can check their plan details for confirmation.
In general, if there are no delays due to incorrect documentation, Medicare processes claims within 60 days. A person will then get the Medicare decision by mail in a Medicare summary notice (MSN).
A person can also check the status of their claim in the MyMedicare account.
If Medicare denies the claim, a person may decide to appeal.
After checking the details in the MSN, a person must generally file their appeal within 120 days. To do so, a person must complete a Redetermination request form (RRF) and send it to the address listed in the appeals information section of the MSN.
Medicare will send an MRN within another 60 days that outlines their decision.
Typically, individuals need not file Medicare claims. However, if a claim has been made, a person can cancel it.
If someone decides to file a claim, they will need to submit supporting documentation and a claim form to Medicare. If the claim is for a plan other than original Medicare, a person will need to submit the claim directly to the plan provider.