Generally, you or your provider have 12 months to file a claim from the time you receive medical care. However, some circumstances can allow for an extension. If Medicare denies the claim, you can appeal, but you must do so within 4 months.

Generally, a health insurance claim is a formal request that you or a healthcare professional submits to your insurance company to pay for medical services or supplies that you received.

If approved, the insurance company pays your provider or reimburses you. If denied, you typically have the right to appeal the decision.

Read on to learn about the deadline for filing a claim for Original Medicare, Medicare Part D, or Medicare Advantage (Part C) plans.

For Original Medicare, which comprises Medicare Part A (hospital insurance) and Medicare Part B (medical insurance, you generally have 1 year to file a claim from the date you received relevant healthcare.

There may be additional time to file under certain conditions, and the length of the extension depends on the specific situation and plan. The Medicare timely filing exceptions typically involve:

  • An administrative error: A delay has occurred due to a mistake or incorrect information from a Medicare employee or contractor.
  • Retroactive Medicare entitlement: Your Medicare coverage has been backdated to cover a time frame before your initial application and enrollment.
  • Retroactive entitlement with Medicaid: You were only covered by Medicaid when you received care, but later got Medicare coverage backdated to that time, and the state Medicaid agency took back its payment.
  • Retroactive disenrollment: This means you were enrolled in a Medicare Advantage plan or Program of All-Inclusive Care for the Elderly (PACE) but were later removed retroactively, and the plan took back payment from the provider.

Generally, the deadline for filing a claim for Medicare Advantage or Medicare Part D plans may be similar to that of Original Medicare. However, the deadline may also vary depending on the specific plan.

Who files a Medicare claim?

In most cases, your doctor, hospital, or clinic will submit a claim to Medicare on your behalf. This applies to Original Medicare, private Medicare Advantage plans, and Medicare Part D plans.

However, you may have gone to a provider who does not accept assignment with Original Medicare or one who is out of network with your private Advantage plan. In these instances, you may need to file a claim yourself using the Patient Request for Medical Payment form (CMS-1490S).

It is important to file Medicare claims on time. If you or a provider submits a late claim without explaining why it’s late, Medicare will assume you are responsible for the delay.

In this case, you can accept responsibility by filing a no-payment claim to document the service. This effectively means your claim will be denied, forcing you to pay the full cost out of pocket.

You can include an explanation of the reason the claim was late in your filing. In this case, Medicare may still deny the claim. That said, you can then choose to file an appeal on the decision.

Your Medicare plan will send you a written notice if your coverage is denied. At that point, you have 120 days from the date you receive the decision to submit your appeal.

The notice you receive will inform you which appeal form to use and where to send it. You’ll usually complete one of the following:

Checking the status of a claim

If you haven’t received notice of the status of your claim from Original Medicare, log in to your account with Medicare.gov to view your claim.

Any decision updates should appear there. You can also check your Medicare Summary Notice (MSN).

For Medicare Advantage or Part D plans, you can contact your plan provider or review your Explanation of Benefits (EOB).

Your appeal must include your name, Medicare number, the denied service or item, the reason you believe it should be covered, and any supporting evidence, such as test results, diagnoses, or certifications. You can also send this information in a letter.

Ensure you write your name and Medicare number on all documents. Medicare generally responds to appeals within 60 days. If your claim is denied for a second time, you have a few more levels of appeal that you can go through before any decision becomes final.

Even if you’re not the one submitting your Medicare claim, there are steps you can take to help ensure your provider files your claim on time.

Before and during your care appointment, confirm that your provider has your correct Medicare information. It’s also important to know what plan you’re enrolled in. If you’re not sure, you can check your Medicare account or plan card (or call 1-800-MEDICARE) to verify whether you’re enrolled in Original Medicare, Medicare Advantage with or without drug coverage, or a stand-alone Part D drug plan.

After your visit, keep detailed records of your appointments and compare your provider’s bills with your MSN to ensure everything matches what Medicare paid. Follow up with your provider’s billing office to confirm that all claims were submitted on time.

A health insurance claim is a formal request that you or your provider sends to your insurance company to cover the cost of medical services or supplies you received.

Typically, Medicare claims must be filed within 12 months of receiving care, though certain situations may allow extra time.

If your claim is approved, your plan pays your provider or reimburses you. If the claim is denied, you have the right to appeal.