In most cases, a person does not have to file a claim for their healthcare services. However, there are some exceptions, during which a person may have to file their own claim.
Generally, the doctor or other healthcare professional will fill in the forms to make the claim with Medicare for reimbursement.
This article looks at the Medicare claims procedure, and why and when a person might need to file a claim. It then details those circumstances, the process, and any time limitations.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
A Medicare claim is a document that requests payment from Medicare for services used by a person enrolled in Medicare.
The services covered by original Medicare (Part A and Part B) include inpatient hospital stays and some outpatient services. Typically, the Medicare-participating provider, such as a person’s doctor, fills in the forms and files the reimbursement request.
Medicare does not process claims for Part B drugs or diabetic test strips.
However, there may be some occasions when a person needs to complete and file a Medicare request for reimbursement for medical services. There are several common reasons this may be necessary, outlined below.
Part B services
In most cases, a person’s doctor or healthcare provider submits a claim to Medicare for Part B services such as an office visit or outpatient diagnostic tests.
However, if they do not submit a claim, or delay, or refuse to do so, a person will need to file their own claim to avoid paying out of pocket for the services.
Foreign travel outside the United States, including Canada and Mexico
Usually, Medicare does not pay for services when a person is out of the U.S., which includes anywhere other than the 50 states, the District of Columbia, the U.S. Virgin Islands, American Samoa, Guam, the Northern Mariana Islands, and Puerto Rico.
There are some exceptions, such as:
- If a person is going through Canada by the most direct route and is between Alaska and another state when a medical emergency occurs, then 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 are in the U.S. and require care for a medical emergency, but the foreign hospital is closer than the hospital in the U.S. 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 either be in a U.S. port or have left the U.S. port less than 6 hours previously or will be in the U.S. port within 6 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 covered durable medical equipment (DME), including prosthetics and orthotics, then the supplier will usually put in the claim for services to Medicare.
In some cases, the supplier may not submit the claim, which means the person may have to make a claim for the DME.
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 do so, then a person may file the claim.
Medicare Part B does not cover certain vaccinations, such as tetanus, diphtheria, and pertussis (Tdap) vaccine. 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.
Other reasons to file a claim
In addition to the above reasons, an individual may also file a claim if the treating doctor delayed submitting the claim. Also, if the doctor or healthcare provider refused to submit a claim or if they were unable to file the claim, a person can complete the form.
To file a Medicare claim, a person needs to download and print the CMS form #14906, which is the patient request for medical payment. The form should be completed in full.
The following information will usually need to be sent with the form:
- Medicare ID number
- explanation of treatment received
- 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 a person to make a copy of all the forms and documents, and keep the information with their own records.
A person will then send the completed form to the Medicare administrative contractor in their state. The patient 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 provided services. Medicare will not pay its share of the claim for requests filed after the 12-month timeframe.
If a person gets a bill from Medicare because their doctor or healthcare provider did not submit a claim, several options exist.
A person 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.
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 U.S.
There are timeframes to make a claim.