In rare cases, Medicare beneficiaries may need to file a claim for reimbursement. One reason someone may file a reimbursement claim with Medicare is if they paid up-front for services from a health care provider that does not accept Medicare assignment.
Providers that accept Medicare assignment are required by law to accept the Medicare-approved amount as full payment for covered services. Providers that don’t accept assignment can charge up to 15 percent more for covered services, which you are typically responsible for paying.1
If you go to a provider that does not accept Medicare assignment, you may have to pay for the service out of pocket and then file a claim to be reimbursed by Medicare.
Medicare claims must be filed no later than one full calendar year after the date when the services were provided. If your claim is not filed within this timeframe, you may not be granted a refund from Medicare.2
To file a claim, fill out the Patient Request for Medical Payment form and send the completed form to your state’s Medicare contractor.
Instructions for submitting your claim vary depending on the type of claim you’re filing:
When filing a claim, fill out and submit your Patient Request for Medical Payment form, along with:
Some Medicare Advantage plans require you to stay within a specific network of providers. If you go outside of the plan’s network, the services could cost more, or they might not be covered by your plan at all.
If your plan does not cover out-of-network care, you could be responsible for paying 100 percent of the costs out of pocket, and you may not be reimbursed.3
Medicare pays a set amount each month to insurance companies offering Medicare Advantage plans, so Medicare Advantage plans do not file claims directly with Medicare.
Still, there are several advantages to having a Medicare Advantage plan. For instance, many Medicare Advantage plans can offer benefits that aren’t covered by Original Medicare, including:
Medicare Advantage plans also have an annual out-of-pocket maximum, which limits how much you will have to pay out of pocket for health care in a single year.
Original Medicare does not have an out-of-pocket maximum.
To learn more about Medicare or to find Medicare Advantage plans in your area, speak with a licensed insurance agent by calling TTY Users: 711 24 hours a day, 7 days a week.
1 Medicare.gov. Lower costs with assignment. Retrieved from https://www.medicare.gov/your-medicare-costs/part-a-costs/assignment/costs-and-assignment.html.
2 Medicare.gov. How do I file a claim? Retrieved from https://www.medicare.gov/claims-and-appeals/file-a-claim/file-a-claim.html.
3 Medidcare.gov. How do Medicare Advantage Plans work? Retrieved from https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/how-medicare-advantage-plans-work.html.