How To File A Claim Under Medicare
As a general matter, with either Medicare Advantage or Original Medicare, you do not have to worry about submitting bills. However, what you do have to be concerned about is whether the provider files a claim on a timely basis. If not, Medicare won't pay and you'll be stuck with the bill.
Our discussion is divided into: If you have Medicare, If You Have Medigap, and If You Have Medicare Advantage.
IF YOU HAVE MEDICARE (Original Medicare)
- Medicare Part A and Medicare Part B
- Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals and skilled nursing facilities. Medicare Part B (Medical Insurance) helps cover medically necessary doctor's services and outpatient care.
- With both Medicare Part A and Medicare Part B, the doctor or other health care provider submits the claim -- not you. You will receive a Medicare Summary Notice for each covered service for your information.
- Ask each doctor and other provider whether he/she or it "accepts assignment." If the provider accepts assignment, the amount Medicare pays covers the cost of the service.
- If the provider does not accept assignment, the provider can charge up to an additional 15% over the Medicare approved amount. You may be required to pay the bill. You will be reimbursed by Medicare for the approved amount. You pay the difference.
- Medicare Part D
- Medicare Part D helps covers drugs.
- The pharmacy will submit the claim to your carrier. You will be asked to pay your share of the costs before the pharmacy delivers the medication.
- Medical Supply And Equipment Companies
- These companies are not limited with respect to what they can charge. The companies will submit a claim to Medicare for you. Medicare will send you a check for an approved amount. You pay the medical supply or equipment company.
- Claims Which Are Not Filed
- If you have not received confirmation that a doctor or other health care provider has been paid for a service by three months from the date the service was rendered, find out why.
- Start with the health care provider. Perhaps the bill wasn't submitted. Or perhaps there's a problem. If the bill wasn't submitted, request that it be submitted immediately. Follow up in a few weeks to be sure it's done. If the bill isn't submitted, call the insurance carrier or Medicare at 800.633.4227 to find out what you can do, including submitting the bill yourself.
IF YOU HAVE MEDIGAP
Medigap policies provide coverage supplemental to Original Medicare. For practical purposes, the claims procedure is the same as with Original Medicare.
IF YOU HAVE MEDICARE ADVANTAGE
If you have a Medicare Advantage plan which either has a facility to which you go or a network of providers you use, there is no bill for you to be concerned about.
You will of course have to pay whatever co-pay or co-insurance may be required.
If the plan permits you to go out of network, and receive at least a partial reimbursement, the provider's office will tell you if the provider submits the bill (the usual), or you have to.