Filing a Medicare claim: Deadlines and rules

Usually, a person or their healthcare professional must file a claim within a year of the person receiving care, but certain situations may extend timely filing. If Medicare rejects the claim, a person must appeal the decision within 120 days.

A health insurance claim is a formal request that an individual or their healthcare professional submits to an insurance company to pay for medical services or supplies received.

If the claim is approved, the insurer reimburses the provider or the individual. If denied, the individual can appeal the right to appeal the decision.

This article explains the filing deadline for claims under Original Medicare, Medicare Advantage (Part C), and Medicare Part D prescription drug plans.

For Original Medicare, a person must generally file a claim within 12 months of receiving relevant care. The claim filing deadlines for Medicare Advantage and Part D plans are often similar but may differ depending on the specific plan’s rules.

It is important to remember that, in most situations, a doctor, hospital, or clinic submits Medicare claims on a person’s behalf. This applies to Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance), as well as to private Medicare Advantage and Part D plans.

However, if the provider does not accept assignment for Original Medicare or is out of network for a Medicare Advantage plan, the person may need to file a claim themselves using the Patient Request for Medical Payment (CMS-1490S) form.

In some cases, Medicare allows extra time to file a claim, with the length of the extension depending on the situation and plan. Common exceptions include:

Timely Medicare filing is essential. If a person or provider submits a late claim without an explanation, Medicare assumes the filer is responsible for the delay.

The provider has the option to accept responsibility by submitting a no-payment claim, which documents the service but does not result in reimbursement.

They can include a reason for the delay, but Medicare can still deny the claim. If this happens, the filer has the right to appeal the decision.

Individuals have 120 days from the date of the notice to file an appeal after a denial. When Medicare denies coverage, the person’s plan usually sends a written notice explaining the decision.

The notice of denial will specify which form a person needs to use for the appeal and where to send it. Typically, this is the Redetermination Request Form for Original Medicare, the Model Coverage Determination Request Form for Part D, or a plan-specific form for Medicare Advantage.

That said, if a person has not received a notice of a decision from Original Medicare, they can log in to their Medicare.gov account to check the claim status or review their Medicare Summary Notice (MSN).

For Medicare Advantage or Part D plans, a person can find claim updates in the Explanation of Benefits (EOB) or by contacting the plan provider directly.

Even if the Medicare beneficiary is not submitting the claim directly, there are things they can do to help ensure that their provider submits their claims on time.

Prior to and during any medical services or care, a person may wish to confirm that their provider has their correct Medicare information and correct any errors. They may also want to check their Medicare account or plan card, call 1-800-MEDICARE, and verify whether they are enrolled in Original Medicare or Medicare Advantage, an Advantage plan with drug coverage, or a stand-alone Medicare Part D plan.

After receiving care, people should keep detailed records of visits and compare provider bills with their MSN to ensure claims match what Medicare paid. They should then follow up and confirm with their provider’s billing office to ensure claims are submitted on time.

A health insurance claim is a formal request submitted by a health insurance enrollee or their healthcare professional to their plan for payment of medical services or supplies received.

Under Medicare, claims generally must be filed within 12 months of receiving care, although certain exceptions may allow additional time.

If the claim is approved, the insurer pays the provider or reimburses the individual. If denied, the individual has the right to appeal the decision.