Medicare reimbursement is not common, however there are times when you will have to file for a reimbursement from Medicare.
When you go to the doctor with Original Medicare Parts A and B, most of the time the Medicare claims will be sent directly to Medicare from the providers office.
Medicare then will pay your doctors the Medicare portion of the Medicare approved amount for the service. From time to time, there could be a circumstance that Medicare will reimburse you directly for expenses in relation to their medical care.
How Does Medicare Reimbursement Work
In a situation in which your provider does not bill Medicare directly, you could be responsible to pay the bill at the providers office and file a claim for the Medicare Reimbursement.
This is very rare, and in most cases, it is due to a doctor not accepting Medicare assignment.
How Do I File A Claim
To file a claim for Medicare reimbursement, you must complete a “Patient’s Request for Medical Payment” form. Once you have completed the form you then must attach an itemized bill from your doctor, to your state’s Medicare contractor. You can look up your state’s Medicare contractor on CMS.gov, or you could call Medicare at 800-633-4227.
You will have to disclose why you obtained medical care from the provider on the request form. You will also have to indicate if the injury or illness was work related. You must include information on additional insurance you may have, such as Medicare Supplement or employer coverage through your, or your spouse’s employer.
- The itemized bill must contain:
- The date and place of service (hospital, doctor’s office, urgent care, etc.)
- The charge and description of each medical service, surgery, or medical supply provided
- The name and address of each doctor or supplier who provided you service
You can find help for filing claims on Medicare’s website.
There are limits on the time you must file a claim. A claim filed by a Medicare beneficiary needs to be filed within a calendar year that the service was provided. If you fail to file the claim within that time, the claim will likely be denied.
If I Have a Medicare Supplement Can I File a Claim
When you are in a situation that will require you to file a claim, your supplement may not pay right away either, because Medicare has not paid yet. If you have this occur, then you can file a claim with your Medicare Supplement to pick up their portion of the bill.
Every supplement companies’ policies could be different, you should contact the claims department of your company to find out the process you need to follow.
Claims for Medicare Advantage and Medicare Prescription Plans
When you are on a Medicare Advantage, or Part D Prescription Plan you would not file claims directly with Medicare. This is because these plans are from private insurance companies that get paid a fixed dollar amount for each Medicare Beneficiary they enroll into one of these plans.
When you are on a Medicare Advantage plan you are effectively replacing your Original Medicare with one of these Health Maintenance Organization (HMO), or Preferred Provider Organization (PPO).
Original Medicare would pay $0 dollars for any service you have due to the fact it is, for a lack of a better word, inactive. You still must pay your Part B premium to enroll into a Medicare Advantage plan.
If you go to a provider that is not in the network, or have a service provided that the plan has not approved you could be required to pay the full cost.
When you have an HMO style Medicare Advantage plan you have no coverage outside of the provider network except in emergency situations. If you are out of network, you are responsible for 100% of the costs you incur for your medical care.
A PPO style Medicare Advantage plan works a little differently. Your cost share is lower if you are using in-network providers. However, if you decide to go out of network you still can receive service at a higher cost share.
You should always refer to your plan details before using out of network services. In some cases, you will have to pay the full bill up-front when out of network, and then file a claim with your plan to get reimbursed by Medicare for the portion that your plan would usually have paid.
While enrolled in a Medicare Advantage plan, any questions you have about Medicare reimbursement costs should be directed to your plan. Additional help can be rendered by a Medicare Beneficiary ombudsman.
To find out more information on your Medicare options and which plans are right for you, call now and speak with a licensed Medicare agent that specializes in Medicare.