Medicare Reimbursement - Submitting Claims Part A & B

By: Lewis Mark
Published: Thursday, October 18 2018
Last Updated: a month ago

For the most part, you won’t need to worry about filing for Medicare reimbursement. Traditionally, at least for Original Medicare, claims are submitted by your medical provider directly to Medicare, who will then reimburse for the services provided.

Although uncommon, there will be instances where you may have to file for reimbursement on your own. If it ever comes up, here’s everything you need to know about submitting a claim for both Medicare Parts A and B.

What Are Medicare Reimbursements?

Medicare reimbursement refers to the monetary compensation a medical provider will receive from Medicare for services they provide to Medicare beneficiaries. In rare circumstances, Medicare beneficiaries can also submit claims directly to Medicare in an effort to get reimbursed for money that they are owed.

How Does Medicare Reimbursement Work

Before we jump into the details, it’s important to familiarize yourself with the following term, Medicare assignment.

If your medical provider accepts Medicare assignment, then they’ll likely be the one submitting claims on your behalf. By accepting Medicare assignment, providers are agreeing to accept the predetermined Medicare reimbursement rates for any services they provide and legally cannot charge more.

For example, if you go in for a routine physical, the Medicare reimbursement rate may only be $75. So, even if your provider would typically charge $150 for a physical for others, they would legally have to accept the $75 as payment in full.

On the other hand, if your doctor or physician does not accept Medicare assignment, you may end up footing the entirety of the bill up front. Even if you’re provider does not participate in Medicare, they still have certain rules to follow. Meaning, the most they can charge you for medical services is 15% more than the approved Medicare reimbursement rates. When this happens, you may have to file for a Medicare reimbursement on your own.

How To File A Claim

Don’t be intimidated, you’re more than capable of filing a claim for reimbursement on your own. Let’s take it step by step for good measure.

The first thing you want to do is get your hand on a Patient’s Request For Medical Payment form. Make sure read through the form closely, and complete all the necessary fields.

Next, you’re going to have to include a written description of the incident. Including, why you received care from the medical provider, if it was to take care of an injury or illness, and whether or not it took place at work.

After that, make sure you include any additional insurance you have that isn’t Medicare. That can include your employer-sponsored coverage, private health insurance you may be enrolled in, or coverage through your spouse’s plan.

Lastly, you want to include your itemized medical bill. This part is crucial, and needs to include the following information that is pertinent to your claim:

  • Date of service
  • Place of service
  • Description of each medical service you received
  • Charge of each service
  • Name and address of the medical provider
  • Final diagnosis

It may seem like a lot, but submitting a claim, and filing for Medicare reimbursement for Parts A and B is only a few steps when you break it down. The most time-consuming part will be gathering all of the needed documents and information. If you still need help, you can turn to the official Medicare website for additional resources, or as your medical professional for assistance.

Keep in mind, there are limitations to filing for Medicare reimbursements. If you don’t submit your claim within a year of receiving services, chances are you won’t get the money back. Luckily, a full calendar year is plenty of time to get compensated for the money you paid up front.

What It's Based On

As mentioned earlier, compensation will be based on predetermined Medicare reimbursement rates known as the Medicare fee schedule. The fee schedule changes year to year and usually doesn’t impact your out-of-pocket expenses, with the possible exception of your coinsurance. For a full list and breakdown of Medicare reimbursement rates for 2018, you can look here.