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When is it your responsibility to file a Medicare claim?

Finance & Planning | May 23, 2016

As a Medicare beneficiary, you are generally not in charge of filing your own claims after visits to a doctor or hospital. However, there are a few situations where you will need to file one yourself. It is best to understand the claim filing process in case the situation ever arises.

Who normally files the claims?

For those who have Original Medicare, meaning Medicare Parts A and B, claims are typically filed by the doctors and suppliers. This is true as long as your healthcare providers accept Medicare assignment. Accepting Medicare assignment means they have agreed to charge a Medicare-approved price for a product or service to beneficiaries, even if their normal prices are higher. When this is the case, the beneficiary is responsible for the co-pay and other fees but will not have to pay any other upfront costs.

If you have Medicare Part C and/or Part D, neither you nor your private insurance provider will have to file a direct claim with Medicare. In these cases, the providers receive monthly payments from Medicare to cover their services.

"If a claim has not been filed, contact the supplier or physician responsible for filing it."

When is filing a claim your responsibility?

If your provider is unable or unwilling to file your claim for any reason, filing will become your responsibility. You should keep track of the status of any claims by either logging into your online Medicare account or reading your Medicare Summary Notice. You should receive this notice in the mail - or via email if you signed up for the electronic version - every three months. Remember, this is simply a detailed summary of the recent service you have received, as well as the amount paid and amount owed. It is not a bill.

If you notice that a claim has not been filed, the first step is contacting the supplier or physician responsible for filing it and asking them to do so. If they still do not take action, contact Medicare directly and find out how much time you have left to file the claim. In general, a claim must be filed within 12 months after a service is provided. If your year is almost up, it is time to do it yourself.

Another situation that may require you to file a claim on your own is if you visit a physician that does not accept Medicare assignment and had to pay the full costs upfront. Now, you are seeking reimbursement. In some cases, the non-participating provider may file a claim for you if you ask. Make sure it is very clear who will be responsible for filing the claim so it gets done on time.

"To file a claim on your own, fill out the Patient Request for Medical Payment form."

How to file a claim

To file a claim on your own, you will need to fill out the Patient Request for Medical Payment form. Read the instructions carefully, as the form will explain all you must submit along with it. This includes a letter detailing the reason you are submitting the claim on your own and an itemized bill. This bill will need to display several pieces of information about the care provided to you, like the date, cost of each service, location and doctor or supplier's name.

Once you have completed the form and gathered all other necessary paperwork, you can find the address for where to send it on your Medicare Summary Notice. If you cannot figure out where to send your claim or you are having trouble filling out the form, do not hesitate to contact Medicare for help.