I have Original Medicare. Is my health care provider required to bill Medicare for the care I receive?

Question 2 of 4 (use "Last" or "Next" buttons to see more)

Yes, as long as your health care provider (e.g., your doctor) accepts Medicare. All providers who accept Medicare are required to submit a bill (medical claim) to Medicare for health care services and items they provide to you if you get your Medicare benefits through Original Medicare. Note that the following information does not apply to individuals who get their Medicare benefits through a Medicare Advantage plan, also known as a Medicare private health plan. Click here to learn more about Medicare Advantage plans.

There are two types of health care providers who accept Medicare and must therefore, submit a bill to Medicare for care you receive: participating providers and non-participating providers.

  • Participating providers are providers who accept Medicare and take assignment. This means that they accept the Medicare-approved amount for a health care service as full payment. When you see a participating provider, you are generally responsible for paying a 20 percent coinsurance for a covered health care service.

Participating providers are required to bill Medicare for any care they provide to you.

  • Non-participating providers are providers who accept Medicare, but do not routinely take assignment. This means that they can charge you up to 15 percent more than Medicare’s approved amount for non-participating providers for most health care services.

Note that while non-participating providers are allowed to ask you to pay for the full cost of your care upfront, they must still submit a bill to Medicare on your behalf. This is true, even if they do not take Medicare assignment for a health care service or item you receive. After they submit the bill to Medicare, you should receive a Medicare Summary Notice (MSN), along with a check reimbursing you for Medicare’s share of the cost of care you received.

Providers who accept Medicare generally must submit a bill to a Medicare Administrative Contractor (MAC) within one calendar year of the date of service (i.e., the date in which you receive care). They must submit the bill in a timely manner in order for Medicare to pay them for providing you with care. MACs are entities contracted by Medicare to process medical bills/claims.

Providers who miss the filing deadline (i.e., one calendar year after the date of service) cannot bill Medicare for care they provided to you. However, they can still charge you a 20 percent coinsurance (i.e., 20 percent of the cost of the Medicare-approved amount for the care you received) and any amount you owe towards meeting your Part B deductible.

Note that opt-out providers are providers that do not accept Medicare. These providers are not required to bill Medicare for health care services they provide to you. These providers have officially opted out of the Medicare program and can charge you whatever they want for services you receive.


Related Questions
Can my state give me more rights and protections than federal law regarding Medigap plan enrollment?

Donate Now
 
 
Go to previous question Go to next question
 
GO TO
What can I do if my health provider is unable or refuses to file a Medicare claim?

Medicare Summary Notice (MSN)

Advance Beneficiary Notice (ABN)

 
LINKS
Directory of State Medical Boards

Directory of State Attorneys General

Find a Medicare Durable Medical Equipment Supplier (Medicare.gov)

National Directory of Medicare Regional Carriers and Intermediaries

Medicare.gov: National A/B MAC Information

 
< Last | Next >