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Medicare Reimbursement: What Medical Services Qualify?

If you’re enrolled in Medicare, it’s highly unlikely that you’ll have to handle any reimbursement forms. However, for the unique situations in which you may have to submit for Medicare reimbursement, there are some resources to help you out.

What is Medicare Reimbursement?

Medicare reimbursements are payments that physicians and hospitals receive for treating patients that have Medicare. Medicare payments to doctors and healthcare providers tend to be lower than what a private insurance company would pay. The amounts are set by Medicare, and providers must agree to them to be in their network.

What Do I Need to Know About Filing a Medicare Claim for Reimbursement?

Your health care provider is typically responsible for filing a Medicare reimbursement claim. Once Medicare receives this claim, they’ll forward on any necessary information to your Medicare Supplement plan carrier, if you have one. The process usually requires no action on your end. However, if your healthcare provider has delayed filing for a claim that falls under Medicare Part A or Part B, you can file it yourself.

If you find yourself in the rare situation in which you need to file a Medicare reimbursement claim, you must do it within 12 months from the service date. Claims submitted after that time may not be accepted. For example, if you received health care services on June 15, 2019, your doctor has until June 15, 2020, to file the claim.

You can access Medicare forms on the Center for Medicare and Medicaid Services website. Search for CMS 1490S, on the forms list page,  then download and print the form. These forms are also available at your local Social Security office.

Even if the reimbursement is not coming directly to you, you can follow up on the claim to make sure it was filed. If you have any questions about this process, or are experiencing any difficulty, you can call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. This will direct you to speak to a Medicare representative 24 hours a day, seven days a week. They can assist you if you need help understanding how to file a Medicare claim.

Can I File a Medicare Reimbursement Claim for Medicare Part D or Medicare Part C?

No, you can’t file a Medicare Reimbursement claim for Medicare Part C (Medicare Advantage Plans) and Part D (prescription drug coverage plans). These plans are operated by private companies, so you need to contact them directly.

Can I File a Medicare Reimbursement Claim for a Doctor Who Doesn’t Accept Medicare?

Some physicians choose not to accept Medicare because the reimbursement rates they receive are often lower than what they receive from private insurance carriers. However, even non-participating providers can agree to accept Medicare reimbursement for certain procedures. In these cases, you may have to cover the cost of the bill up front and then seek reimbursement from Medicare for a portion. The provider is paid 95 percent of the fee schedule amount, and can only bill you up to 15 percent more than the Medicare reimbursement amount.

Because it’s so rare, the prospect of filing a Medicare reimbursement claim might seem a little intimidating at first. Fortunately, Medicare makes it easy for you to research and ask questions regarding your coverage, and to take matters into their own hands when necessary.

Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

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