How to Submit Medicare Claims Yourself

Medicare claims are formal requests submitted to Medicare to pay for healthcare services. Understanding how these claims are processed helps beneficiaries ensure their medical care is covered. A claim details the services provided by a healthcare professional or facility, allowing Medicare to determine the eligible payment amount.

Understanding Claim Submission Responsibilities

Healthcare providers generally submit claims directly to Medicare on behalf of their patients. This practice simplifies the process for most beneficiaries, as providers are typically responsible for billing Medicare for covered services and supplies.

Beneficiaries might need to submit a claim independently in less common situations. This includes receiving care from a non-participating provider who does not accept Medicare assignment, obtaining emergency care from a provider who does not routinely bill Medicare, or if a provider fails to bill Medicare within the required timeframe. Certain items, such as diabetic test strips, Part B drugs, or equipment paid for under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program, typically require the pharmacy or medical supplier to bill Medicare directly.

Preparing Your Beneficiary-Submitted Claim

Gather all necessary information and documentation before initiating a claim. You will need your full name, current address, and Medicare number as it appears on your Medicare card. Details about the healthcare provider are also required, including their name, address, and National Provider Identifier (NPI); Medicare can often look up the NPI if it is unavailable. Accurate dates of service, a detailed description of services, and the charges for each service are essential. If you have already paid the provider, retain payment information for reimbursement.

The primary document for beneficiary-submitted claims is the CMS-1490S form, known as the Patient’s Request for Medical Payment. This form can be obtained from the Medicare website or by calling 1-800-MEDICARE. When completing the form, fill in Section 1 with your patient information, including your name, Medicare number, date of birth, and contact details. Section 4 requires a description of the illness or injury for which you received treatment, along with an indication if the condition was employment-related or due to an accident.

If you have other medical coverage in addition to Medicare, such as private insurance or Medicaid, Section 5 of the form must be completed with the name and address of the other insurer and your policy number. Section 6 requires your signature and the date; if you are unable to sign, an ‘X’ mark with a witness’s signature is acceptable, or a representative can sign on your behalf, explaining their relationship and the reason for your inability to sign. Attach itemized bills from the provider, as Medicare requires these to process your claim. Photocopies of itemized bills are acceptable for Medicare processing.

Submitting Your Claim

Once the CMS-1490S form and all supporting documents, including itemized bills, are ready, mail them to the appropriate Medicare Administrative Contractor (MAC). The specific address for your MAC is typically listed within the instructions accompanying the CMS-1490S form or can be found by calling 1-800-MEDICARE.

Before mailing, make copies of all submitted documents for your personal records. Consider using a method that provides proof of delivery, such as certified mail. After submission, allow at least 60 days for Medicare to receive and process your request.

Medicare claims must be filed no later than 12 months, or one full calendar year, after the date services were provided. For example, if a service was rendered on March 22, 2024, the claim must be filed by March 22, 2025. Claims submitted after this timeframe are generally denied, with exceptions only for specific circumstances such as administrative errors or retroactive Medicare entitlement. Direct online submission of claims is not an option for beneficiaries.

Tracking and Responding to Claim Outcomes

After submitting your claim, monitoring its progress is advisable. You can check the status of your submitted claims by logging into your secure Medicare account at MyMedicare.gov or by calling 1-800-MEDICARE. Claims typically become visible online within 24 hours after Medicare processes them.

You will receive a Medicare Summary Notice (MSN) in the mail every three months if you have received services during that period. The MSN is not a bill; it is a statement that details all services and supplies billed to Medicare on your behalf, the amounts Medicare paid, and the maximum amount you may owe the provider. Reviewing your MSN helps ensure accuracy and detect errors or fraudulent activity.

If a claim is denied or if you disagree with a decision, the MSN will provide instructions on how to proceed. A common initial step is to contact your provider to understand the reason for the denial, as sometimes it may be due to missing information or incorrect coding that they can correct. If the issue persists, you have the right to appeal the decision. Maintaining thorough records of all submitted documents and communications with both your provider and Medicare is beneficial throughout this process.