How to File Your Request for Medical Payment

Most of the time, if you have original Medicare coverage, your healthcare providers, doctors, and specialists will send claims directly to your Medicare provider on the day you receive care. Your providers are required by law to submit any and all claims related to your medical treatment, and all the claims are subject to reimbursement rates put into place by federal legislature.

But on rare occasions, Medicare will reimburse a patient directly for his or her care. This will generally only happen if you end up going to a hospital, doctor, or specialist that is outside of your Medicare network. You probably already paid for treatment up front out-of-pocket, so in order to receive reimbursement, you’ll need to complete and submit a “Patient’s Request for Medical Payment” form. When you fill out the form, make sure you attach the itemized bill from the out-of-network doctor who treated you (keep a copy of it for your records), and send them along to your state’s Medicare department (You can eFax it right from your PDFfiller account). Keep in mind that your claim will be governed using the standard federal Medicare reimbursement rates, despite the fact that your bill total may have been higher than the amount reimbursed.

When you go to fill out the Patient’s Request for Medical Payment form, make sure you have these pieces of information on hand:

  • The date you received medical care/service
  • Place of service (doctor’s office, hospital, etc.)
  • Description of every surgical/medical device or supply furnished to you
  • Name & Address of doctor and/or supplier of medical service
  • Your diagnosis, unless you’ve written a sufficient description of your illness on the form already.

Be sure to submit your Patient Request for Medical Payment form within one year (365 days) of the date the medical care was provided. There’s a good chance that your claim will be denied if it’s turned in any later than that.

Note: If you are enrolled in Medicare Advantage (which does not file claims directly with Medicare) and you have any questions about filing a claim, we recommend you contact your specific plan provider.

Click here to fill out, save, print, and eFax your Patient’s Request for Medical Payment Form.