How do I file a medical claim with Medicare?

on Jan 23, 2025

This week, I went to see my primary care doctor, and his office manager informed me that they are no longer accepting Medicare. I recently enrolled in Medicare and will have to pay the complete bill upfront and be reimbursed by Medicare. His office is a small one, and he will be retiring soon, so I need to find a new doctor. Can you please tell me what I need to do to submit the bill for this doctor visit to be reimbursed? Thanks, Toni.

--Cybil from Louisville, Ken.

Hello Cybil:

I am hearing through the Medicare grapevine from clients who come to the Toni Says office for a Medicare consultation that a few primary care/medical providers are retiring. The office paperwork, whether it is for Medicare-age patients or under 65 medical claims, is very overwhelming.

These offices do not accept Medicare as your doctor is doing and will not bill Medicare for you. They want you to submit the claim to Medicare and wait to be reimbursed.

Did the doctor’s office charge Medicare rates or charge you their rates and want you to be reimbursed from Medicare what Medicare pays rather than what they charged you? I have not heard of this type of problem with larger medical offices, especially those that are part of a hospital system.

My advice to clients who are new to Medicare is to begin searching for medical providers that are accepting Medicare, especially when a serious health issue is involved.

Below are tips from the Toni Says Medicare team which can help you:

-- Before you set the appointment for your medical visit, ask the doctor’s office if they are still accepting Medicare. More specifically, if this is a new doctor’s office, ask if that office is accepting “new Medicare patients” and will that office will bill Medicare directly.

-- If the doctor’s office says “no,” Cybil, you will need to make a decision:

a. Do you want to pay out of pocket and be reimbursed only what Medicare pays? Remember, doctors know they are not paid their asking rates. Medicare is not the only entity that discounts the doctor’s bills. Group and individual health insurance plans with network providers, also discount the doctor’s bills.

b. Or do you want to look for a doctor or specialist who will accept Medicare assignment and bills Medicare directly? Again, you should verify that the office is accepting new Medicare patients. Ask your primary care doctor for more than one doctor or provider that he/she recommends for your specific medical situation.

-- If your doctor does not accept Medicare, it is not hard to file a claim. You may have to pay the complete bill and submit the claim to Medicare. Make a copy of your medical bill to submit to Medicare, along with any information regarding your medical claim.

-- Visit Medicare.gov and in the search bar type “filing a claim.” The information provided will explain how to submit a claim and to download the claim form CMS-1490S “Patient Request for Medical Payment”. The CMS-1490S form has instructions regarding submitting the form with an itemized bill and supporting documents. The form lists by state where you need to send everything.

Cybil, if you need help filing a claim, call Medicare at 800-MEDICARE (633-4227) and ask the Medicare agent for help filing the claim. Medicare will be happy to assist.

Readers, the Medicare.gov website is unique. The website offers those exploring Medicare -- whether turning 65 or past 65 and retiring or laid off -- various options to make finding the correct Medicare plan simple. Also included on www.medicare.gov is a way you can download your current prescriptions to discover the right Medicare Part D plan or Medicare Advantage plan for you, print your current Medicare card, view your Medicare claims, pay your Medicare premium and more.

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Toni King is an author and columnist on Medicare and health insurance issues. She has spent nearly 30 years as a top sales leader in the field. For a Medicare checkup, call the Toni Says call center at (832) 519-8664 or email info@tonisays.com regarding your Medicare plans and options. Toni Says Medicare Survival Guide Advanced edition is available at www.tonisays.com.