To file a Medicare claim, a person must download and fill out the appropriate CMS form and submit it to the Medicare administrative contractor in their state. It may take up to 60 days for Medicare to review and process a claim.
In most cases, a person does not have to file a claim for their healthcare services. Generally, the doctor or another healthcare professional will fill in the forms to make the claim with Medicare for reimbursement.
However, there are some exceptions, such as obtaining medical equipment or something delays the doctor, during which a person may have to file their own claim.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
To file a Medicare claim, a person needs to download and print the CMS form #14906, which is the patient’s request for medical payment. The person must fully complete the form.
They may need to send the following information with the form:
- Medicare ID number
- explanation of treatment
- doctor or healthcare provider’s name and billing address
- date and place of service
- charges for each service and itemized bill
It is a good idea for people to make a copy of all the forms and documents, and keep the information in their own records.
They must then send the completed form to the Medicare administrative contractor in their state. The patient’s request for medical payment form usually has the contractor’s details or a person can call Medicare 1-800-MEDICARE (1-800-633-4227) for the address.
After a person submits the form, Medicare may take up to 60 days to process and review the claim.
A person must file a Medicare claim no later than one full calendar year or 12 months after the date of the services.
Medicare will not pay its share of the claim for requests that a person, physician, or service file after the 12-month timeframe.
If a person gets a bill from Medicare because their doctor or healthcare provider did not submit a claim, they may contact their doctor or healthcare provider responsible for the supplies or service.
After contacting the provider, if a person still needs to file a claim, they must do so within the 12-month timeframe.
A Medicare claim is a document that requests payment from Medicare for services used by a person enrolled in Medicare.
Original Medicare (Part A and Part B) covers inpatient hospital stays, doctor’s services, and some outpatient services. Medicare does not process claims for Part B drugs or diabetic test strips.
Typically, the Medicare-participating provider, such as the doctor, fills in the forms and files the reimbursement request.
However, sometimes a person needs to complete and file a Medicare request for reimbursement for medical services themselves. Below are some times when this might be necessary.
Delays or refusals
An individual may file a claim if the treating doctor delayed submitting it. Also, if the doctor or healthcare provider refused to submit a claim or was unable to file the claim, a person can complete the form.
Foreign travel outside the United States
Usually, Medicare does not pay for services when a person is out of the U.S., which includes anywhere other than the following:
- the 50 states
- the District of Columbia
- the U.S. Virgin Islands
- American Samoa
- Guam
- the Northern Mariana Islands
- Puerto Rico
However, there are some exceptions.
If a person is going through Canada by the most direct route and is between Alaska and another state when a medical emergency occurs, Medicare may cover services. However, the hospital in Canada must be closer than the U.S. hospital for a person to get coverage.
A person may also file a claim if they live in the United States and a foreign hospital is closer than any other.
Or, when they are in the United States and require care for a medical emergency, but the foreign hospital is closest. Foreign hospitals do not have to file a Medicare claim, so it may be up to the person to do so.
On a ship
Usually, Medicare provides healthcare coverage if a person is on a ship in U.S. territorial waters.
To meet the criteria, the vessel needs to:
- be in a U.S. port
- have left a U.S. port less than six hours previously
- be in a U.S. port within six hours
In addition, the person getting the medical services must be enrolled in Medicare Part B, and the doctor must be able to legally practice medicine in the U.S.
Durable medical equipment
If a person gets durable medical equipment (DME), including prosthetics and orthotics, then the supplier will usually put in the claim for services to Medicare.
However, if the supplier does not or cannot submit the claim, a person may need to do it themselves.
Vaccinations
Medicare Part B covers an annual flu vaccine and pneumococcal vaccines. Typically, the doctor or healthcare provider files the claim for the vaccine. If they do not, a person may file the claim.
Medicare Part B does not cover certain vaccinations, such as:
However, Medicare Part D covers the Tdap vaccine. Depending on their Part D plan, a person may have to pay for the vaccine upfront and then file a claim for reimbursement.
In most instances, a person does not have to file a claim for the supplies or services they get through their Medicare plan, because the treating doctor or supplier files the necessary forms.
Sometimes, it is necessary for a person to make a claim. This may happen when their doctor or healthcare provider delayed filing or refused to do so. It may also happen when a person travels outside the United States for medical care.
People must file claims within the necessary 12 month timeframe. After submitting the claim, Medicare may take up to 60 days to process it.