It is uncommon for an individual to file a claim with Medicare. However, if a person has made a claim and wants to cancel it, there are various ways to do so.
Medicare reimburses healthcare professionals for services and equipment for 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 wants to cancel it.
This article explains how to cancel a Medicare claim, when and why a person can make a claim, and the process for each part of Medicare. It also examines how to check a claim’s status 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, someone may decide to file a claim in rare cases, 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 1-800-MEDICARE (1-800-633-4227) and explain they want to cancel a self-filed claim.
The process
When a person calls Medicare, they will need to provide specific details about the claim. This information will include:
- the person’s name
- the person’s Medicare number
- details about the medical service or equipment
As Medicare usually requires up to 60 days to process a claim, a person may be able to stop the claim from processing if they contact Medicare within this time frame to cancel.
In most circumstances, an individual will not have to file a claim to Medicare, as the medical professional does this. 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 if:
- the medical professional does not accept Medicare, but treatment occurred during an emergency situation
- the medical professional refuses to file a claim
- the medical professional 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.
Usually, an individual’s self-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.
As Medicare allows 1 year for healthcare professionals to file a claim, a person may have to wait until that deadline approaches before following up.
As a first step, someone can contact the medical professional to check on the status of the claim. They can also check their monthly Medicare summary notices for any outstanding claims.
Medicare Advantage Plans
Typically, a person would not need to file a claim if they have a Medicare Advantage plan because Medicare pays the plan provider monthly.
However, if someone with an Advantage plan used an out-of-network healthcare service, they might need to file a claim with their plan provider. Individuals can check their plan details for more information.
Medicare Part D
Medicare Part D is an optional plan to cover prescription drugs for people with Original Medicare. There may be occasions when someone would want to file a claim, such as:
- if a person uses an out-of-network pharmacy
- if someone forgot their Medicare Part D identification card and paid full price at the pharmacy
- if a person stayed at the hospital for observation and could not take their usual medications with them
Medigap
Supplementary insurance, also called Medigap, helps people pay Medicare out-of-pocket costs.
Generally, Medicare claims directly from Medigap. However, some plans state that someone has to make the claim. Individuals can check their plan details for confirmation.
The claim process may vary depending on the Medicare part.
For example, Medicare processes a claim for services or equipment from Original Medicare parts A and B differently from claims for other Medicare parts.
The claims process has several steps, including the following:
- 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 needs to include any additional health insurance coverage and a cover letter that explains why they are making a claim.
A person can then mail the completed form and all documents to the Medicare office on their payment request form.
Learn more about how to file a Medicare claim.
Out-of-country claims
If a person travels 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 United States, where the closest hospital is in Canada
- a medical emergency on a ship less than 6 hours from leaving or arriving at a United States 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.
A person can also check the status of their claim in their MyMedicare account.
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).
Learn more about checking Medicare claim statuses.
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, they must complete a Redetermination request form (RRF) and send it to the address in the appeals information section of the MSN.
Medicare will send an MRN within another 60 days to outline their decision.
A complaint and an appeal are two separate processes. A complaint requests that Medicare investigates a service, while an appeal asks Medicare to reconsider payment for drugs or services.
Medicare provides an appeals service so that if a doctor or other medical professional 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. They can also call Medicare and explain why they would like to file a complaint.
Typically, individuals do not file their own Medicare claims. However, if a medical professional makes a claim on their behalf, 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.