How Do I File Claims for Medicare Reimbursement?
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Most doctors will bill Medicare directly for medical services.
You typically won't have to file a reimbursement claim if you have Original Medicare (Parts A and B). Instead, your doctor will ask Medicare for payment after you get a covered service.
However, in some cases you may need to fill out and send Medicare Form 1490S to a local insurance company, called a Medicare administrative contractor (MAC). You'll usually get reimbursed for your medical costs within 60 days of filing your paperwork.
How do I file a Medicare reimbursement claim?
To file for Medicare reimbursement, you'll have to print and fill out an online form from the Centers for Medicare and Medicaid's (CMS) website. You'll send that document by mail, along with your medical bill, to your local Medicare contractor.
- Complete Medicare Form 1490S
- Get a copy of the bill you want reimbursed
- 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 called the Patient Request for Medical Payment.
On Medicare Form 1490S, you'll write down why you're filing the claim, what services you received and some personal 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).
You'll need to include a copy of your itemized medical bill along with this form. Make sure the bill has the correct date, treatment type, cost, doctor's name and hospital address.
It's a good idea to make a copy of these documents for your own records before you send them off.
Next, you'll mail your documents to a local insurance company that processes medical claims, called a Medicare administrative contractor (MAC). You can look up your local MAC on the Centers for Medicare & Medicaid Services (CMS) website.
After submitting your paperwork, you can expect to get reimbursed within the next 60 days.
How long do I have to file a Medicare claim?
You have one year from the date you received care. So if you went to the doctor on March 2, 2024, you would have until March 2, 2025, to file your claim.
Keep in mind that claims filing isn't a fast process. It's a good idea to file a claim as soon as possible, so you can get paid faster.
What is Medicare reimbursement?
Medicare reimbursement is the process of getting Medicare to pay you back for covered medical care.
This usually isn't necessary. Most doctors have agreed to accept the prices set by Medicare. These doctors are supposed to bill Medicare directly for their services.
That means people who have Original Medicare typically don't have to take any special action when getting medical care, aside from paying for their Medicare Parts A and B deductible , copays and coinsurance.
You can eliminate most or all of your Medicare deductibles, copays and coinsurance by enrolling in a Medicare Supplement (Medigap) plan. Medigap plans help you pay for the costs you're responsible for with Original Medicare.
The most popular Medigap plan for new enrollees, Plan G, will help you pay for regular Medicare.
When do you need to file a Medicare claim?
You'll need to file a Medicare claim if your doctor fails to do so on your behalf, or if you get care from a doctor who doesn't accept Medicare or its normal prices.
People who need to file a Medicare claim typically fall into one of three groups. The first group of people have doctors who accept Medicare, but refuse or are unable to file a claim. You may belong to the second group if your doctor accepts Medicare, but charges more than what Medicare will pay.
Finally, in some cases, Medicare will pay for care from a doctor who doesn't accept Medicare. However, you'll have to pay out of pocket and then ask Medicare for reimbursement later.
Participating doctors
In America, 98% of doctors have agreed to accept the prices offered by Original Medicare . If your doctor accepts the Medicare-approved amount as full payment for a service you get, this is called accepting assignment. In this case, your doctor will typically bill Medicare directly for the cost of your care.
However, in some rare cases, these doctors may choose not to bill Medicare, or they may be unable to do so. When this happens, you'll have to pay for your care out of pocket, then ask Medicare to pay you back later. This process is called Medicare reimbursement.
You can also ask for help by calling 800-MEDICARE.
Nonparticipating doctors
These doctors may accept Medicare patients, but they don't accept the prices set by Medicare. That means you could be responsible for paying up to a 15% difference between the price set by Medicare and what the doctor charges you, called an excess charge.
For example, let's say Medicare set the price of an X-ray at $100. You would pay up to $15 in excess charges if you have a nonparticipating doctor.
Some nonparticipating doctors will bill Medicare directly. Others will expect you to pay upfront. In that case, you would have to get reimbursed by Medicare afterward.
Medigap plans F and G will pay for excess charges. However, you can qualify for Medicare Supplement plan F only if you became eligible for Medicare before Jan 1, 2020.
Opt-out doctors
Roughly 2% of doctors nationwide choose to opt out of Medicare. If you visit a doctor who has opted out of Medicare, you'll be responsible for your hospital bill unless you're getting emergency care.
It's a good idea to confirm that your doctor accepts Medicare before you schedule a visit. That's because paying out of pocket can quickly become expensive.
Some specialties are more likely to opt out of Medicare than others. For example, roughly 8% of psychiatrists choose not to accept Medicare patients.
What types of medical bills should I file with Medicare?
Medical bills eligible for Medicare reimbursement filing fall into three broad categories.
You may have to ask for reimbursement through Medicare if your doctor doesn't accept the prices set by Medicare. In this case, you could be responsible for paying an extra 15% of your medical bill out of your own pocket, even after you get reimbursed by Medicare.
Medicare doesn't cap excess charges for medical equipment and supplies. That means you could pay far more than 15% extra if you need to get reimbursed by Medicare for a wheelchair or scooter.
Medicare covers foreign travel care in very limited cases, such as if you're in Canada or you're on a cruise ship that's close to the U.S. If one of those cases applies to you, you'll have to pay out of pocket and file a reimbursement claim after you return to the U.S.
Some Medigap plans offer emergency medical coverage outside the U.S. for up to 80% of your bill or $50,000 total.
Frequently asked questions
How do I submit a bill to Medicare for reimbursement?
You'll have to print and fill out a 1490S form from the Centers for Medicare and Medicaid (CMS) website. Afterward, send it to your local Medicare administrator along with your medical bill and wait up to 60 days for processing.
Can I file my own claims with Medicare?
Yes, it's possible to file a claim directly with Medicare. This is unnecessary in most cases, because your doctor will usually handle this for you.
When do I need to file a claim with Medicare?
You may need to file a claim with Medicare if your doctor doesn't accept Medicare or if they don't accept the prices set by Medicare. Patients sometimes file claims directly with Medicare if their doctors have refused or forgotten to file a claim on their behalf.
Methodology and sources
Medicare reimbursement claim filing guidelines came from Medicare.gov and CMS.gov.
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