Is my health care provider required to file a Medicare claim?

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Unless your provider has opted out of Medicare, yes. All providers who take Medicare—providers who take Medicare assignment and providers who take Medicare but do not accept assignment—are required to file Medicare claims. Generally, doctors and suppliers of medical equipment file claims with Medicare soon after they provide services. Providers are allowed to wait to file your Medicare claim, but there is a limit on how long they can wait to file.

If your provider does not think that the service will be covered by Medicare for you, she may have you sign an Advance Beneficiary Notice (ABN). When you sign the ABN, there will be an option on the ABN to check whether or not you want your doctor to submit a claim to Medicare for the service. You should always select that you want your doctor to submit the claim to Medicare. If you do not, your doctor is not required to submit the claim. You should check this option, because Medicare may still pay for the services after all.

If you sign an ABN but ask your doctor to bill Medicare, and Medicare then denies coverage, you can always appeal.

After you receive a service, your health care provider generally must file a claim with Medicare by the end of the next calendar year. However, if the service was provided between October and December, your provider has until the end of the second calendar year to file a claim with Medicare. For example, if you received a service on March 15, 2007, then the provider has until December 31, 2008 to file. If you received the service on October 1, 2007, then the provider has until December 31, 2009 to file.

Providers who miss the filing deadline for a service cannot bill Medicare for its share of the service. However, they can still bill the patient for their portion of the coinsurance (generally 20 percent of what Medicare would have allowed for their services) and any portion of the deductible they may owe.


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