Navigating the Medicare reimbursement process can be daunting, but understanding the basics can help you manage your healthcare expenses effectively. This guide provides clear instructions on when and how to file a Medicare claim, ensuring you receive the benefits you're entitled to.

When Do I Need to File a Claim?

For most services, you won't need to file a claim if you have Original Medicare. By law, doctors and suppliers are required to file Medicare claims for covered services and supplies on your behalf. However, there are rare instances where you might need to file a claim yourself:

• Medicare Advantage Plan (Part C): These plans don’t require you to file claims because Medicare pays private insurance companies a set amount each month.
• Unfiled Claims: If your provider doesn’t file a claim in a timely manner, you may need to file it yourself. Claims must be submitted no later than 12 months after the service date.

How Do I File a Claim?

If you find yourself in a situation where you need to file a Medicare claim, follow these steps:

1. Complete the Claim Form:
2. Use the Patient Request for Medical Payment form (CMS-1490S). This form is available in both English and Spanish.
3. Gather Necessary Documents:
4. Itemized bill from your doctor, supplier, or other healthcare provider.
5. A letter explaining why you’re submitting the claim (e.g., your provider isn’t able or refuses to file the claim).
6. Any supporting documents related to your claim.
7. Submit the Claim:
8. Send the completed form and supporting documents to the address provided on the second page of the form's instructions or your Medicare Summary Notice (MSN). You can also find this address by logging into your secure Medicare account.

What Should I Include with the Claim?

Ensure you include all necessary information to avoid delays:

• The completed CMS-1490S form.
• The itemized bill from your healthcare provider.
• A detailed explanation for submitting the claim.
• Any additional supporting documents.

Checking Your Claim Status

After filing, you can track the status of your claim by:

• Reviewing your Medicare Summary Notice (MSN), which you receive every three months.
• Logging into your secure Medicare account online.

If your claim isn’t being processed in a timely manner, you can contact your doctor or supplier to remind them to file the claim. If they still don’t file it, call Medicare at 1-800-MEDICARE (1-800-633-4227).

Additional Tips

• Keep Copies: Always keep copies of the forms and documents you send.
• Timeliness: Ensure claims are filed within the 12-month limit.
• Authorization Forms: If you want someone to call Medicare on your behalf, fill out the "Authorization to Disclose Personal Health Information" form.



Understanding and following these steps can help you navigate the Medicare reimbursement process smoothly. If you need further assistance, don't hesitate to Contact Employee Benefits Solutions for professional support and guidance in managing your Medicare claims.