If you are in the Original Medicare Plan, providers (e.g., hospitals, skilled nursing facilities, home health agencies, and physicians) and suppliers are required by law to file Medicare claims for covered services and supplies that you receive. You should not need to file any Medicare claims. Medicare claims must be filed within one full calendar year following the year in which the services were provided. For example, if you see your physician on March 22, 2004, the Medicare claim for that visit must be filed by December 31, 2005.
Is your pharmacy or supplier enrolled in Medicare?
If the answer is no, you will be responsible for the entire bill for any drugs or supplies purchased. Important information you need to know before you make your purchase.
Note: This information on filing a Medicare claim only applies if you are in the Original Medicare Plan. If you get your Medicare health care through a Managed Care Plan or a Private Fee-for-Service Plan, Medicare claims are not filed. Medicare pays these private insurance companies a set amount every month. Therefore, they do not need to file Medicare claims.
My Provider or Supplier Accepts Medicare Assignment
You pay your share of the bill (coinsurance and deductibles) to the provider or supplier.
The provider or supplier files a Medicare claim. Medicare pays its share of the bill directly
to the provider or supplier.
My Physician or Supplier Does Not Accept Medicare Assignment
Note: Only physicians and suppliers can decide not to accept assignment.
If your physician or supplier does not accept assignment for covered services,
your physician or supplier may require that you pay most or all of the bill at the time you
receive services or supplies. However, the physician or supplier is still required to file
a Medicare claim on your behalf. Medicare then pays its share of the bill directly to you.
Medicare cannot pay you its share of the bill until a Medicare claim is filed.
You should take the following steps if your doctor or supplier does not file the Medicare claim in a timely manner.
Step 1 - Contact Your Physician or Supplier: Call your
physician or supplier directly and ask the physician or supplier to file a Medicare claim.
Step 2 - Contact 1-800-Medicare: If your
physician or supplier still does not file a Medicare claim after you have called and
asked, you should call 1-800-Medicare (1-800-633-4227). 1-800-Medicare will work with the Medicare contractor that processes your claims to contact the physician or supplier on your behalf. This will ensure that the physician or
supplier is aware of the responsibility for filing a Medicare claim. Also ask 1-800-Medicare
for the exact time limit for filing a Medicare claim for the service or supply
that you received.
IMPORTANT: There is a time limit for filing a Medicare claim. If a
claim is not filed within this time limit, Medicare cannot pay you its share. The time
limit may be as short as 15 months or as long as 27 months depending on when you received
the service or supply. It is important that you ask 1-800-Medicare what the time
limit is for filing your claim.
Step 3 - When You Should File a Claim: You should only
need to file a Medicare claim in very rare situations. You should contact 1-800
Medicare and ask for the forms to file a Medicare claim yourself when:
- you have completed steps 1 and 2 above; AND
- the physician or supplier still has not filed the Medicare claim; AND
- it is close to the time limit for filing your Medicare claim. (For example, if your time
limit is 15 months, you should consider filing a Medicare claim if the physician or
supplier has not filed the Medicare claim 12 months after you received the service or
To file a Medicare claim yourself, call 1-800-Medicare and ask for the proper form for a Medicare
beneficiary to file a claim. The form is called Patient’s Request for Medical Payment, CMS 1490S.
1-800-Medicare can answer your questions about how to complete the claim form.
The form is also available for download on cms.hhs.gov in the
CMS Forms section.
Instructions for filling out the form and where to send it are included as well.
If you want Medicare to give your personal health information to someone other than you, you need to let Medicare know in writing. You can fill out the "1-800 Medicare Authorization to Disclose Personal Health Information" form. Call 1-800-MEDICARE (1-800-633-4227) to get a copy of the form, or you can download the form in the Medicare Online Forms section of this web site.
For a list of physicians in your area who always accept
assignment, use the Physician and Other Healthcare Professional Directory on this web site.
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