A claim is an official request for Medicare or your insurance company to pay for your medical care. Claims are filed to Medicare after you receive care from a doctor or hospital.
In most cases you should not have to make this request on your own as the doctor or provider should file a claim for you. However, there may be times when you do need to file your own claim.
Using a non-participating or out-of-network provider
If you have Original Medicare and choose to see a provider that is “non-participating” you may need to file your own claim. Non-participating means they have not set up an agreement with Medicare. Non-participating providers may charge more for a service and may choose not to file a claim on your behalf. If you visit a non-participating provider, be sure to check their policy. Some items, like diabetic test strips and Part B drugs, must be billed directly from the provider.
When should I file?
If you have a Medicare Advantage plan and visit an out-of-network provider, the same rules apply. Be sure and check with your provider if they will file a claim with Medicare or not. You should only visit an out-of-network provider for urgent situations or if you’ve selected this type of coverage. If you visit an in-network provider they do not need to file a claim because they have a set agreement with Medicare to receive payment each month.
In the rare cases that you need to file a claim with Original Medicare it must be done within 12 months of receiving care. According to Medicare.gov, you should check the “Medicare Summary Notice” (MSN) you get in the mail every 3 months, or log into your secure Medicare account to make sure claims are being filed in a timely way. You may need to file a claim sooner if you have a Medicare Advantage plan. Claims for a Medicare Advantage plan will be sent to your insurer.
If a provider is not filing your claim in a timely manner you can file the claim yourself (and be sure to keep copies of anything you send) or you can file a complaint with 1-800-MEDICARE.
How to file
To file a claim you’ll need to fill out a Patient Request for Medical Payment form. Submit this along with an itemized bill and a letter explaining your reason for submitting the claim. Be sure and keep copies of everything you submit. These items should be sent directly to your Medicare Contractor. If you cannot find the address or do not know who your Medicare Contractor is you can call 1-800-MEDICARE for assistance.
If you’re unsure what services and providers are in-network for your Medicare plan and are looking to make a change. Contact Dee to help walk you through your options.
Diane “Dee” Lee Insurance, is an experienced licensed insurance broker and representative providing Medicare (parts A and B), supplemental Medicare, Medicare Advantage (part C) and Medicare Prescription (part D) plans. Diane Dee Lee Insurance also provides healthcare plans to cover dental vision, hospital stays and more. Serving as a Medicare Broker in Deer Valley, Peoria, Glendale, the Phoenix-metro area, as well as the counties of Pima, Pinal, Coconino, Gila, Mohave, Apache, Navajo, Maricopa and Yavapai. Licensed and appointed with multiple insurance carriers, Dee is available to meet in person (with necessary social distancing guidelines) or virtually. Please call (623) 251-6612 or email firstname.lastname@example.org