How do Medicare claims work and do I file my own claims?
The short answer
In most cases you don't file your own Medicare claims. Providers who accept Medicare are required to file claims on your behalf. There are rare situations where you may need to file yourself.
The full explanation
For the vast majority of Medicare beneficiaries, claims are completely invisible. When you see a doctor or get a service, the provider submits the claim to Medicare directly. You'll receive an Explanation of Benefits, sometimes called an EOB, in the mail or online afterward. That document isn't a bill. It summarizes what was billed, what Medicare paid, and what you may owe.The situation where you might file your own claim is if you see a provider who doesn't accept Medicare assignment. Assignment means the provider agrees to accept Medicare's approved payment amount. If you see someone who isn't enrolled in Medicare at all and you still want to try for reimbursement, you can submit a claim using a form called CMS-1490S. That's uncommon but possible.For Medicare Advantage plans, the claims process runs through the private insurance company rather than Medicare directly, but the mechanic is the same for you. The provider handles it.If a claim is denied and you believe it should have been covered, you have the right to appeal. The denial notice will explain the reason and outline your appeal options with deadlines. Missing those deadlines can affect your ability to challenge the decision.
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