In certain situations, your health care provider A health care provider is an individual or facility (such as a doctor, hospital, or durable medical equipment (DME) supplier) that provides health care services and/or items. may be unable or unwilling to submit a bill (file a [claim) to Medicare. Listed below are a few reasons why your provider may refuse to file a Medicare claim, along with information about what to do in each situation.
- Your provider believes Medicare will deny coverage.
- Your provider must ask you to sign an Advance Beneficiary Notice (ABN).
- Before signing an ABN, ask additional questions to find out whether your provider considers the service to be medically necessary Medically necessary refers to procedures, services, or equipment that meet accepted medical standards and are necessary for the diagnosis and treatment of a medical condition. , and whether they will help you appeal An appeal is a formal request for review if you disagree with an official health care coverage or payment decision made by a Medicare Advantage Plan, a Medicare private drug plan (Part D), or Original Medicare. Federal regulations and law specify appeals deadlines, processes for handling appeals, what information must be included in a decision, and the levels of review in the appeals process. .
- Ask your provider to still file a claim with Medicare, even if they believe coverage will be denied. You may be able to appeal if Medicare denies coverage.
- Your provider may ask that you pay in full for services.
- If you are seeing a participating provider In Original Medicare, a participating provider is a health care provider who accepts Medicare and always takes assignment. They may not charge you more than Medicare’s approved amount. If you have Original Medicare and see a participating provider, you will pay a 20% coinsurance for Medicare-covered services. See also: Non-Participating Provider. , ask your provider to submit the claim to Medicare. Medicare should let you know what you owe after it has processed the claim. You may also find it useful to contact your state’s medical licensing board to report the issue.
- Non-participating providers are allowed to request payment up front at the time of service. Ask your provider to file a claim with Medicare on your behalf, so you can receive Medicare reimbursement (80% of the Medicare-approved amount See Approved Amount. ).
- Your provider has opted out of Medicare.
- Opt-out providers have signed an agreement to be excluded from the Medicare program. They do not bill Medicare for services you receive.
- You should not submit a reimbursement request form to Medicare for costs associated with services you received from an opt-out provider. You are responsible for the entire cost of care when seeing an opt-out provider.
- Your provider refuses to bill Medicare and does not specify why.
- A refusal to bill Medicare at your expense is often considered Medicare fraud and should be reported.
- To report fraud, contact 1-800-MEDICARE (1-800-633-4227), the Senior Medicare Patrol (SMP) Resource Center (877-808-2468), or the Inspector General’s fraud hotline at 800-HHS-TIPS.
If a provider continues to refuse to bill Medicare, you may want to try filing the claim yourself. Submit a Patient’s Request for Medicare Payment form (also called the CMS-1490S form) to the Medicare Administrative Contractor (MAC) Medicare Administrative Contractors (MACs) are private companies that process Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Original Medicare beneficiaries. Each MAC serves a defined geographic area. To find the MAC in your region, call 1-800-MEDICARE.  in your area. You must send bills or receipts for the service along with the form. After processing your request, Medicare should either send reimbursement or a coverage denial that you can appeal. To find the MAC in your area, call 1-800-MEDICARE.