How to File a Medicare Claim 

In most cases, the medical provider will file the claim to Medicare on the patient’s behalf. However, there may be situations where you may need to file a claim for yourself or someone you care for. The steps to take to file a Medicare claim are as follows: 

1. Fill Out the Claim Form
2. Collect Necessary Documentation
3. Send the Claim
4. Check the Status of Your Claim

It is important to know how and when to file a Medicare claim to ensure that the claim is covered and reimbursed in a timely manner.

Maximizing Your Medicare Benefits 

The most common reason you may need to file a claim is that the provider does not accept Medicare. In that case, you must follow the correct steps to be reimbursed. If the provider does accept Medicare and they did not file a claim, it is best to contact them and ask them to submit the claim. 

It takes at least 60 days for a Medicare claim filed by an individual to be processed and paid; the claim must be filed within twelve months of the service date to be reimbursed by Medicare. For example, if you have a doctor’s appointment on March 12th, 2023, the claim must be filed by March 12th, 2024. This is a strict deadline set by Medicare, and claims received after the 12-month period are often denied. It is important to follow each step below carefully to ensure your claim is covered and you are reimbursed. 

1. Fill Out the Claim Form 

The Medicare claim form, also known as the Patient Request for Medical Payment Form, can be printed from Medicare.gov, or you can find it by logging into your Medicare account and selecting the “claims” tab to fill it out electronically. The claim form asks for specific information such as the following: 

• Personal Information: This includes the patient’s name, Medicare ID number, address, phone number, date of birth, and gender.
• Reason for Filing Claim: There are three options to choose from as to why the claim form is being submitted. They are that the provider does not accept Medicare, refuses to file the claim, or is unable to file the claim. 
• Description of Services: This should describe the injury or illness for which the patient was treated, such as the flu or a car accident. 
• Other Health Insurance Information: This portion of the form should be filled out if the patient has health insurance in addition to Medicare, such as private coverage or coverage provided through work.
• Signature: The patient will need to sign and date the form. However, if the patient is unable to sign the form, someone can sign on their behalf. That person will need to fill out the witness section with their full name, address, relationship to the patient, and the reason why the patient is unable to sign. 

2. Collect Necessary Documentation 

In addition to the claim form, you need to provide other documentation to successfully submit the claim and be reimbursed. Submitted claims will need the following items: 

• Claim Form: A fully completed and signed claim form must be submitted. 
• Itemized Bill: An itemized bill may be acquired by calling the medical provider’s billing department. 
• Letter of Reasoning for Claim: This is a letter explaining the reason for the claim, including services provided, dates of services, and provider information; it is not required but may help clarify the reason for the claim. 
• Other Supporting Documents: Additional bills or documents may be needed to file the claim. Contact Medicare to find out what exact documents you need.

3. Send the Claim 

Once the claim form is completed and the documentation is collected, the claim will need to be sent in for processing. There are two options: Submit the documents through your online account at Medicare.gov or mail in the documentation. If you submit them online, you will need to register for an online account at Medicare.gov. Once you log in to your account, click the “claims” tab to submit the form and documentation. 

If you are mailing in the claim, the documents must be sent to the correct place. Many factors — such as where the patient lives, where the patient received services, and what type of services were received — will change where the documents should be mailed. The claim form includes information pages that provide an address for different scenarios. For example, a California resident receiving care in a foreign country will use a different address than a Maine resident receiving in-state services. If it is unclear where to send the form, the Medicare recipient can call 1-800-MEDICARE for assistance. 

4. Check the Status of Your Claim 

Once the claim is submitted, you can check the status of your claim. This will help you ensure that Medicare has received the claim, has no outstanding issues, and has been approved. There are several ways to check the claim status, such as logging into your account at Medicare.gov or calling 1-800-MEDICARE and using their automated system. If you are checking the status online, log on to your account and look for the claim under the “claims” tab. 

If you are calling in to receive an update, you will need the patient’s Medicare ID number and personal information, such as date of birth and the last four digits of the patient. The automated system will run a check for any claim filed within the last twelve months. 

It is essential to check the status of your claim approximately one week after it is filed so you can address any errors or outstanding information. If there is additional information needed or issues with the claim, you can call 1-800-MEDICARE.

Resolving Medicare Claim Issues 

Once you submit the claim, it will take at least sixty days for Medicare to process it. Check the status of your claim regularly to resolve any issues and speed up the process. If any additional information or documents are needed, it is important to provide these to Medicare as soon as possible. If the claim is approved, Medicare will mail a check to the patient at the address indicated on the claim form. However, if Medicare denies the claim, you may need to file an appeal. 

Medicare claims can be denied for several reasons, such as:

• Errors on the claim form
• Missing documentation
• No medical necessity
• Too many visits for the same service
• The care was obtained outside of the coverage area

A denial letter will be sent to the Medicare recipient with an explanation for the denial and how to file an appeal. 

Filing an Appeal

If Medicare denies your claim, you can file an appeal. On the denial letter sent by Medicare, there will be an explanation of the denial and how to file an appeal. There will also be a date by which you must file the appeal and an address of where to send the appeal. The appeal can be filed by either filling out the Redetermination Request Form on Medicare.govor sending a handwritten request. 

If using the form, you must fill out all sections completely, including the patient’s personal information, the service provided, the reason for the appeal, and the signature section. You will also need to include any new documentation that supports the appeal. If sending in a handwritten letter, it must contain certain information, such as:

• The patient’s name, address, and date of birth
• The patient’s Medicare ID number
• The services you are appealing
• An explanation of why you disagree with the denial
• The name of your representative, if applicable

You should also include the denial letter and circle any information you disagree with, and include any supporting documentation that supports your appeal. If possible, you should make a copy of all documents sent to keep for your records. The appeal process usually takes about sixty days after Medicare receives the request. If the appeal is again denied, you can appeal up to four more times. 

Putting it All Together 

Usually, medical providers file Medicare claims, but there are times when you may have to file a claim for yourself or a loved one. While filing a claim yourself may be time-consuming and strenuous, knowing the ins and outs of the claims and appeal process will make it much smoother and less overwhelming. It is important to file the correct documents and send them to the correct location by the due date. Doing so will speed up the process and lessen the likelihood of denial. You can also utilize your or your loved one’s Medicare account online at Medicare.gov to streamline the process. 

Frequently Asked Questions