Providers of Medicare including hospitals, skilled nursing facilities, home health agencies, physicians and suppliers are the entities responsible for filing claims for covered services and supplies for those with Medicare health coverage. Generally, the covered person need not 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, the Medicare claim of a person who sees the physician on March 22, 2009, must be filed by December 31, 2010.
It is important for a person to know if his/her pharmacy or supplier is enrolled in Medicare. If the answer is no, the person concerned is responsible for the entire bill for any prescription drugs or supplies purchased. That person is then responsible for filing a Medicare claim only if he/she is in the Original Medicare Plan. A person, who gets his/her Medicare healthcare through a Managed Care Plan or a Private Fee-for-Service Plan, need not file a Medicare claim. Medicare pays these private insurance companies a set amount every month and so, the beneficiary does not need to file Medicare claims.
In case a person’s provider or supplier accepts Medicare assignment, the person concerned will pay his/her share of the bill (coinsurance and deductibles) to the provider or supplier. The provider or supplier then files a Medicare claim. Medicare pays its share of the bill directly to the provider or supplier.
In case a person’s physician or supplier does not accept Medicare assignment, they may require that the person concerned pay most or the entire bill at the time he/she receives services or supplies. However, the physician or supplier is still required to file a Medicare claim on behalf of the person concerned. In such case, Medicare then pays its share of the bill directly to the beneficiary.
It is important to note that Medicare cannot pay the beneficiary its share of the bill until a Medicare claim is filed. The person concerned should therefore take the following steps if the doctor or supplier does not file a 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 Medicare Directly: If your physician or supplier still does not file a Medicare claim after you have called and asked, you should call Medicare. Also ask Medicare for the exact time limit for filing a Medicare claim for the service or supply that you received.
There is a time limit for filing a Medicare claim. If a claim is not filed within this time limit, Medicare cannot pay the beneficiary its share. The time limit may be as short as 15 months or as long as 27 months depending on when the person received the service or supply.
- Step 3 – When You Should File a Claim: You should only need to file a Medicare claim in very rare situations. You should only 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.
A person who needs to file a Medicare claim by her/himself will need to print out and complete the form called Patient’s Request for Medical Payment, Form CMS 1490S. The form is available for download on cms.hhs.gov in the CMS Forms section. Once downloaded, one will need to:
(1) print out the 1490S form;
(2) select and print out the applicable instructions; and
(3) review all of the information on this page about how to file a claim form.