How to File a Medicare Claim Yourself

Medicare generally handles claims directly with healthcare providers, ensuring a streamlined process for beneficiaries. However, there are specific instances where an individual may need to submit a claim to Medicare themselves. Understanding these situations and the necessary steps involved helps ensure proper reimbursement for covered services. This guide walks you through the process, from identifying when to file a claim to understanding the response you receive.

Understanding Who Files Claims

Healthcare providers, including doctors, hospitals, and medical suppliers, typically file claims with Medicare on behalf of their patients. This is the standard procedure, especially when providers accept Medicare assignment, meaning they agree to Medicare’s approved amount for services. Most beneficiaries will find their claims handled automatically by their providers.

However, a beneficiary must sometimes file a claim. You may need to submit a claim yourself if your doctor or supplier does not accept Medicare assignment and you have paid for the service in full.

Another scenario is having other insurance, such as a Medigap policy, an employer group health plan, or a retiree plan, that needs to be billed before Medicare. If Medicare has not received the necessary information from your primary insurer, you might need to facilitate the claim. Additionally, if you paid directly for covered services and require reimbursement, filing a claim is your responsibility. Medicare requires claims to be filed within 12 months of the service date.

Gathering Information for Your Claim

Before submitting a Medicare claim, compile necessary information and documents. Your Medicare card details (full name and Medicare number) are fundamental. An itemized bill from the provider is also required, clearly showing services received, dates of service, charges, and relevant diagnosis or procedure codes.

If you have other insurance billed prior to Medicare, include an Explanation of Benefits (EOB) from that insurer. This EOB details what your other insurance paid or denied. You will also need the provider’s full name, address, and Medicare provider number (if available).

The Patient Request for Medical Payment form (CMS-1490S) is used by beneficiaries to request Part B medical payment reimbursement. This form can be obtained from the Medicare website. Review the form’s instructions to accurately complete fields like your personal information, provider details, and service description, cross-referencing with your itemized bill and any EOBs.

Submitting Your Medicare Claim

Once you have gathered all required information and completed the CMS-1490S form, submit your claim. Mail this form, along with all supporting documentation, to the appropriate Medicare claims address for your region. The mailing address for your Medicare Administrative Contractor (MAC) is typically provided with the CMS-1490S form instructions or on the official Medicare website.

Make copies of your completed CMS-1490S form and all supporting documents (e.g., itemized bill, EOBs) for your records. This ensures you have a complete submission history if questions or discrepancies arise. While regular mail is acceptable, certified mail with a return receipt is an option, though not required. Ensure all items are securely packaged to prevent loss during transit.

After Filing Your Claim

After your Medicare claim is submitted, Medicare processes the information. You will then receive an Explanation of Benefits (EOB) or a Medicare Summary Notice (MSN), depending on your Medicare plan. An EOB is typically sent by private insurers for Medicare Advantage and Part D plans, detailing medical care received and how costs were covered or denied. If you have Original Medicare (Parts A and B), you will receive an MSN, which summarizes services or items received and how they were covered.

These notices are not bills; they provide a breakdown of what was billed, the Medicare-approved amount, the amount Medicare paid, and any remaining amount you owe. Review your EOB or MSN for accuracy.

Check the status of a filed claim by logging into your MyMedicare.gov account, which usually displays claim information within 24 hours of processing. Alternatively, contact Medicare directly by phone for status updates. If you find discrepancies or disagree with a claim decision, information on the appeals process will be outlined in the notice, guiding your next steps.