Medicare Reimbursement: When and How to Get Reimbursed

Written by:

Kayla Missman

Reviewed by:

Amy Tran

5 min read

Key Takeaways

Healthcare providers usually file claims to Medicare or your insurance carrier directly.
If you pay out of pocket or get an unexpected bill, you can file a claim for reimbursement on your own.
To complete your claim, you’ll need an itemized bill, provider information, service information, and supporting documents.
If your claim is denied, you can file an appeal with Original MedicareOriginal Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). , Medicare Advantage, or Medicare Part D.
Medicare reimbursement also refers to the Part B Giveback Benefit offered by some Medicare AdvantageMedicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). plans.

You might come across Medicare reimbursement in a few different contexts. First, if Medicare should have covered your care but didn’t, you may need to file a reimbursement claim. Private insurance plans, like Medicare Advantage and Medicare Part D, also have claims processes.

Separately, some Medicare Advantage plans offer partial reimbursement for your Medicare Part B premiums as a benefit.

This article covers all forms of Medicare reimbursement, including how to file claims for each part of Medicare, how to appeal a decision, and how to receive a Part B reimbursement if eligible.

Find the Medicare Advantage plan that meets your needs.

Find Plans Today

Are You Eligible For Medicare Reimbursement?

Situation	Medicare Reimbursement?
You are enrolled in a Medicare Advantage plan with a Part B giveback benefit	Yes, your plan reimburses a set amount
Your doctor participates in Medicare but sent you a bill for your Medicare-covered service	Yes, but first discuss it with your doctor’s office
Your doctor does not participate in Medicare and sent you a bill for your Medicare-covered service	Yes, you may be reimbursed 80% of the Medicare-approved cost of the service
Your doctor opted out of Medicare entirely and sent you a bill for your service	No
Your doctor — regardless of Medicare status — sent you a bill for a benefit not covered by Medicare	No
You received care outside of the U.S.	No, except in very specific circumstances
You are enrolled in a Medicare Advantage plan	All claims must be filed with your insurance company

Medicare Reimbursement When You Have Original Medicare

In most cases, you won’t need to file a Medicare reimbursement claim if you have Original Medicare (Part A and Part B). Medicare sets an approved rate for every service it covers, so healthcare providers know how much to charge when you receive care. However, not all providers accept those rates. Your coverage and costs depend on your provider’s participation in Medicare:

Participating provider: You can see any providers who accept assignment, which means they only charge the Medicare-approved amount for their services. Since the provider knows how much Medicare will pay, you only owe your share of the cost (typically 20%).
Non-participating provider: These providers accept Medicare, but they don’t follow Medicare’s rates for all of their services. Medicare will only cover 80% of its approved cost, leaving you with a 20% coinsurance plus any amount over the approved rate.
Opt out: Some providers don’t accept Medicare insurance at all. If you see a doctor who has opted out entirely, you’ll be responsible for 100% of the cost and are not eligible for reimbursement.

How to File a Claim for Part A and Part B Medicare Reimbursement

If you have Original Medicare, the law requires your provider to file Medicare reimbursement claims on your behalf. But you might still get a bill if the provider doesn’t accept Medicare, gave you services that aren’t covered, or didn’t collect your payment at the time. If you believe Medicare should cover your service, first contact the provider and ask them to file a claim.

If they refuse for any reason, follow the steps below to file a claim yourself.

Call Medicare at 1-800-633-4227. Ask how long you have to file a claim for reimbursement. Typically, you must file within 12 months of receiving service.
Get an itemized bill from your provider. It should show your date of service, place of service, charges, and the provider’s information.
Gather supporting documents. Ask for doctor’s notes or other information from your provider to strengthen your claim.
Fill out 14980S – Patient’s Request for Medical Payment. The form asks for details such as your reason for filing, the services received, and any other insurance you have.
Write a letter of explanation. Detail why you’re submitting the claim.
Mail in your claim. Include your bill, supporting documents, Form 14980S, and letter. Look for the correct Medicare Administrative Contractor address on your claim form.
Check the status of your claim online. Log in to your Medicare.gov account to check your Medicare Summary Notice status.

If you have any questions or need help filing a claim, call Medicare. Your State Health Insurance Assistance Program (SHIP) can also help you with claim questions.

Medicare Reimbursement When You Have Medicare Advantage

Medicare Advantage (Part C) plans are sold by private insurance carriers, so the Medicare reimbursement claims process works differently. Instead of submitting your claim to Medicare directly, you’ll work with your insurance company. Your coverage, cost, and eligibility for reimbursement depend on what providers you visit.

In-network provider: Insurance companies negotiate lower prices with a network of physicians and facilities. You’ll pay less for services at in-network providers.
Out-of-network provider: If you get care outside of the plan’s network, you’ll pay more. Some plans cover out-of-network care for a higher portion of the cost, while others don’t cover out-of-network care at all.

How to File a Claim for Part C Medicare Reimbursement

If you get care from an in-network provider, you typically don’t need to file a Medicare reimbursement claim. As long as you show your insurance card and ID when you receive care, the doctor or facility will file a claim on your behalf. You’ll receive an Explanation of Benefits from your plan, and if you owe money, you’ll pay your insurer or doctor directly.

Going out of network can be slightly more complicated. Some providers will file a claim on your behalf, but it isn’t required. If you receive a bill, you can request that the provider file a claim for you. But if they refuse, you can file one yourself. The exact process might vary depending on your insurance carrier, but you can follow these general steps:

Call your insurance company. Ask the representative to explain the appeals process, discuss the timeline, and confirm whether your service will be covered.
Sign into your member account online. You may be able to locate and print the form within a Medicare reimbursement claims section in your account.
Gather your documents. You’ll need an itemized bill, provider information, and service information. Contact your provider if anything is missing.
Send the claim to your insurance company. Look for the address on your form, or contact your insurer to ask.
Check your online portal. Once the claim is filed, you’ll receive an Explanation of Benefits.

How the Medicare Part B Give Back Medicare Reimbursement Benefit Works

When you have private insurance, you still need to pay your Medicare Part B premium, which is $185 in 2025. You may also owe a separate monthly premium to your insurer.

However, some Medicare Advantage plans offer an extra perk: a reduction in your Part B premium, often called a giveback benefit. You don’t have to file any claims to receive the Medicare Part B Giveback Benefit if it’s part of your plan. You’ll either get a credit on your Social Security checks or pay a reduced amount to Medicare each month.

We’re here to help you choose the ideal Medicare health plan.

Call Today

Medicare Reimbursement When You Have Medicare Part D

Medicare Part D, which covers prescription drugs, is available as an add-on to Original Medicare. Medicare Advantage Prescription Drug plans include Part D benefits. If you purchase a standalone Part D plan, it will have a separate Medicare reimbursement claims process from your other insurance plans.

Typically, the pharmacy will submit a claim directly to your plan. In a few cases, like visiting an out-of-network pharmacy, you may need to file the claim yourself. Contact your insurance company to get the Medicare Part D: Prescription Claim Form specific to your plan. You’ll need your patient information, prescription details, provider information, and pharmacy receipt. Check with your plan to confirm the correct process and mailing address.

Medicare Appeals for Reimbursement

If your Medicare reimbursement claim is denied but you believe your care should be covered, you can file an appeal. The details differ depending on whether you are filing for Original Medicare, Medicare Advantage, or a Part D prescription drug plan.

First, contact your healthcare provider, explain the situation, and ask for supporting information to bolster your claim. Ask Medicare or your plan for the deadline to file an appeal. Then, fill out the appropriate form. For Original Medicare, you’ll complete CMS Form 20027.

There are five levels of appeals, ending with a judicial review in federal district court if your claim exceeds $1,840.

Putting It All Together

Healthcare providers usually file claims on your behalf, but sometimes, you’ll need to file your own with Original Medicare, Medicare Advantage, or Medicare Part D. If you need help filling out your forms, understanding your coverage, or filing an appeal, contact Medicare, your insurance company, or SHIP for assistance.

Sources

Filing a claim. Medicare.gov.
Filing an appeal. Medicare.gov.
Form 1490S. CMS.gov

This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.

Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Talk to a Licensed Insurance Agent about Your Needs