How Do I File Claims for Medicare Reimbursement?
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Medicare reimbursement is the process by which a doctor or health facility receives funds for providing medical services to a Medicare beneficiary. However, Original Medicare enrollees may also need to file claims for reimbursement if they receive care from a provider that does not accept assignment. In this case, some documents would be required to receive reimbursement for a health procedure.
Most doctors, providers and suppliers accept assignment, but you should always check to be sure.
What is Medicare reimbursement?
Medicare reimbursements are payments from Medicare to hospitals and physicians for services delivered to Medicare enrollees. Medicare reimbursement rates — or allowable charges — are the amounts that Medicare pays to doctors or facilities when they file a claim for health services provided to Medicare patients.
The amounts that Medicare reimburses for services are almost always lower than a provider's usual fee. For example, a provider may normally charge $100 for a blood test, but Medicare may only reimburse $80 for that service. A medical provider that accepts Medicare assignment agrees to accept $80 as payment in full and will not charge the patient for the $20 balance.
Providers who accept assignment are also called Medicare-participating providers, and most do accept Medicare assignment. Generally, you do not need to submit Medicare costs or claims for health care services since a participating provider will file claims on your behalf.
If you receive services from a Medicare-participating provider, you can’t be billed extra for the service and you're not responsible if the provider fails to file the claim properly.
When do I need to file a claim for Medicare reimbursement?
You may need to file for Medicare reimbursement if your medical provider doesn't submit a claim on your behalf. Doctors who don't accept assignment might bill Medicare directly, or they may ask you to pay up front and file your own claim.
The action you must take and what you might pay depend on whether your provider will accept Medicare assignment or file a claim on your behalf.
Provider participation status | Who files the claim? |
|---|---|
| Provider accepts Medicare assignment | The provider will file a Medicare claim, and you're responsible only for the Medicare deductible and coinsurance. |
| Provider doesn't accept Medicare assignment but will file a claim | If the provider files a claim, you may need to pay the full bill up front or just what you would owe in excess charges, deductible and coinsurance. Once Medicare processes the claim, you and your provider would work out any refund or balance due. |
| Provider doesn't accept Medicare assignment or file a claim | You must send an itemized bill with a completed Medicare Form 1490S for reimbursement. You're responsible for any excess charges, deductible and coinsurance. Medicare may pay the provider or pay you directly. Once the claim is processed, you may be due a refund or owe a balance to your provider. |
These steps apply to Original Medicare enrollees, as Medicare Advantage plans work directly with Medicare to pay claims on your behalf.
A provider who doesn't accept Medicare assignment would still provide the health service. They can charge a higher amount, but no more than 15% over Medicare's allowance for most services. This added amount is known as the excess charge or Part B excess charges. For example, if the Medicare-allowed amount is $250, the most your provider can charge is $287.50, or $250 + 15%. Note: The 15% limit doesn't apply to some supplies or to durable medical equipment, so there is no cap on the excess charges for those services.
How long do I have to file a Medicare claim?
You have 12 months from the date you received a health service to file a Medicare claim. This means that if you saw your doctor on March 1, 2022, you must file your claim before March 1, 2023.
If you file the claim yourself and it's received after the deadline, Medicare will not pay its share and you are responsible for paying the provider.
What types of medical expenses do I file with Medicare?
You'll file three main types of medical expenses for Medicare reimbursement, and what you pay depends on the type of care and whether your provider accepts Medicare assignment. For example, if you have a foreign travel emergency that includes a hospital stay, you may be responsible for charges under both Medicare Part A and Part B.
If your provider doesn't accept assignment, you'll pay 15% in Medicare Part B excess charges — or less, depending on where you live. You also will be responsible for any Part B deductible and coinsurance.
If your provider doesn't accept assignment, there is no cap on the Medicare Part B excess amount for medical equipment and supplies. You'll be responsible for any Part B excess charges along with the Part B deductible and coinsurance.
Medicare covers foreign travel care in very limited cases, and a non-U.S. medical provider won't accept assignment or file a Medicare claim. You're responsible for 15% in excess charges, your Medicare deductible and any coinsurance. If Medicare doesn't pay and you have a Medigap plan with foreign travel coverage, you can file a claim with your Medigap insurer.
How do I file a Medicare reimbursement form?
To file for a Medicare reimbursement, complete the following steps.
- Complete Medicare Form 1490S
- Review the itemized bill from the provider
- Send both documents to the Medicare contractor near you
The first and most important step in filing for Medicare reimbursement is to complete Medicare Form 1490S.
Also known as the Patient Request for Medical Payment, Medicare Form 1490S is where you fill out the reason for the claim, the services you received and your health insurance information. You file the same form for Medicare reimbursement whether the services are covered under Medicare Part A (hospital insurance) or Medicare Part B (medical insurance).
Along with the completed 1490S form, include the itemized bill from your provider. Check the bill to be sure it shows the date and facility where you received care, the correct treatment type, the cost and the provider's name and address.
Once your documents are in order, make a copy for your records. Then, send or deliver the documents to a Medicare contractor. Medicare administrative contractors (MACs) are often local insurers that process medical claims and can be found on the Centers for Medicare & Medicaid Services (CMS) website. It can take at least 60 days to process your claim.
Frequently asked questions
Can I submit a claim to Medicare myself?
Yes, you can submit a claim to Medicare yourself. Although rare, you would need to do this if your health care provider doesn't accept Medicare assignment and doesn't file a claim on your behalf.
What is the first step in submitting Medicare claims?
The first step in filing a Medicare claim is to complete Medicare Form 1490S, also called the Patient Request for Medical Payment form. You'll submit that document and an itemized bill to your local Medicare contractor.
How can I find out if a health care provider accepts Medicare?
You can ask a health care provider if they accept Medicare assignment or if they participate in Medicare. You can also use this Medicare Physician Compare tool to find participating providers in your area.
Do Medicare Supplement plans cover Medicare excess charges?Of the 10 Medicare Supplement plans available, only Plan F and Plan G cover Medicare excess charges. Only Plan G is available to new Medicare enrollees.
Methodology and sources
The rules, requirements and resources for filing claims for Medicare reimbursement were obtained from Medicare.gov and CMS.gov.
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