Filing a reimbursement claim with Medicare depends on whether your provider has already billed Medicare or not. Here’s a clear breakdown:

1. When You File a Claim Yourself

Normally, doctors, suppliers, or facilities submit claims directly to Medicare. If they don’t or won’t, you may need to file the claim. This is called a “Patient’s Request for Medical Payment.”

• Use Form CMS-1490S (Patient’s Request for Medical Payment).
  

 

2. What You Need to Include

When sending your claim, you’ll need to attach:

 

• The completed CMS-1490S form.

• An itemized bill from DME Superstore or supplier (with HCPCS codes & products purchased)

• Proof of payment (like receipts or statements). DME Superstore will provide this to you.

• Any supporting medical documentation your doctor provides (e.g., medical necessity notes).

 

3. Where to Send It

• Mail your claim form and documents to your Medicare Administrative Contractor (MAC).

• The address depends on your state — the CMS-1490S instructions will list the correct MAC.

 

4. Deadlines

• You generally have 12 months from the date of service to file a claim.

 

5. After You File

• Medicare reviews your claim.

• If approved, they send you a Medicare Summary Notice (MSN) explaining what was covered and what reimbursement you’ll receive.

• Reimbursement usually goes to you (since you paid out of pocket).

 

Can we file an "Out of network" reimbursement claim?

 

Yes — but with Medicare, “out of network” works a little differently than with private insurance. Here’s how it breaks down:

1. Original Medicare (Part A & B)

• Medicare doesn’t really have networks the way private insurance does.

• If you see a provider or supplier who accepts Medicare assignment, they bill Medicare directly.

• If they don’t accept assignment, you may have to pay up front and then file a reimbursement claim yourself (using the CMS-1490S form). Medicare will then reimburse you directly for the approved portion.

• If a provider or supplier doesn’t participate

 

2. Medicare Advantage (Part C)

• These plans do have networks, similar to private insurance.

• If you see a provider outside your plan’s network, whether you can get reimbursed depends on your plan:

  • HMO plans usually don’t cover out-of-network care (except emergencies/urgent care).

  • PPO or POS plans may allow out-of-network care, but at a higher cost, and you might need to file a claim for reimbursement.

   

• Each plan has its own claim form and process — you’d request it from your plan directly, not Medicare.

 

3. What You’ll Need to File (if eligible)

• Completed claim form (CMS-1490S for Original Medicare, or your plan’s form for Medicare Advantage).

• Itemized bill from the provider or supplier.

• Proof of payment (if you paid up front).

• Medical documentation if required (e.g., notes showing medical necessity).

Here is a Step-by-Step Guide on how to file a "Out of network" Claim

 

 

1. Original Medicare (Part A & B)

 

Medicare doesn’t technically have networks, but this applies when you pay out of pocket because the provider didn’t bill Medicare directly.

 

✅ Steps to File a Claim:

 

1. Confirm provider status

   • Make sure the provider is Medicare-enrolled (if they opted out completely, Medicare won’t reimburse you).

    

2. Get an itemized bill

   • Ask your provider for a bill that lists:

      

     • Patient name

     • Date(s) of service

     • Diagnosis codes (ICD-10)

     • Procedure codes (CPT/HCPCS)

     • Total charges

      

    

3. Complete CMS-1490S form (Patient’s Request for Medical Payment)

   • Available here: CMS Form CMS-1490S

   • Choose the correct packet based on whether the claim is for medical, DME (durable medical equipment), or hospital services.

    

4. Attach supporting documents

   • Proof of payment (receipt, canceled check, credit card statement).

   • Any doctor’s notes that show medical necessity.

    

5. Send everything to your Medicare Administrative Contractor (MAC)

   • The address depends on your state (listed in the instructions that come with the CMS-1490S form).

    

6. Wait for processing

   • You’ll get a Medicare Summary Notice (MSN) explaining what was covered and how much you’ll be reimbursed.

    

Deadline: File within 12 months of the service date.

 

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🟩 2. Medicare Advantage (Part C)

 

Medicare Advantage plans do have networks. Out-of-network coverage depends on your plan type.

 

✅ Steps to File a Claim:

 

1. Check your plan’s rules

   • HMO: usually no out-of-network coverage (except emergencies/urgent care).

   • PPO or POS: often covers out-of-network care, but at a higher cost.

    

2. Get the plan’s claim form

   • Call your plan’s member services (number is on the back of your card).

   • Ask for their “Medical Claim Form”.

    

3. Collect your documents

   • Itemized bill from the provider (with diagnosis & procedure codes).

   • Proof of payment (if you paid up front).

    

4. Complete and submit the claim form

   • Send it to your plan’s claims department (address will be on the form).

    

5. Follow up

   • Your plan will send an Explanation of Benefits (EOB) showing what they paid and what you owe.

    

Deadline: Usually 90–180 days after the service (varies by plan — always confirm).

 

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Key Difference:

• Original Medicare → You use the CMS-1490S form and file with Medicare directly.

• Medicare Advantage → You use your plan’s own claim form and file with the insurance company, not Medicare.