How Medicare claims get paid

Health care providers, the Medicare program and insurance companies work together to make sure your Medicare claims are paid correctly. Many situations affect how your Medicare claims get paid, such as workers’ compensation, Veterans’ benefits, COBRA, group health insurance or supplemental Medicare plans.

Learn how it works with this official government booklet.

VIEW MEDICARE GUIDE (PDF)

 

Here are simple definitions to explain how Medicare claims get paid.

• Medicare primary payer: Pays for your health care costs up to the limits of your coverage.
• Medicare secondary payer: Pays the rest of your health care costs up to the limits of your coverage.

 

Medicare claim payments at a glance

How your Medicare claims get paid also depends on whether you have just Original Medicare or if you are enrolled in a supplemental Medicare plan. This chart provides a summary of who pays for Medicare Part A and Part B costs:

*For eligible services covered by Medicare or the health plan

If you're a Blue Cross Medicare member, sign in or register to check your claim status.

 

Medicare claim process

Medicare and insurers work together to pay claims. But how it works depends on the type of plan you have.

Original Medicare plan:

• You present your Medicare ID card to your health care provider
• Your provider sends your claim to Medicare
• Medicare pays first and sends payment directly to the provider
• Medicare sends you a statement saying what you owe
• You pay the balance to the provider directly

Medicare supplement and Medicare Cost plans:

• You present your Medicare ID card and insurance ID card to your health care provider
• Your provider sends your claim to Medicare and your insurer
• Medicare is primary payer and sends payment directly to the provider
• The insurer is secondary payer and pays what they owe directly to the provider
• Then the insurer sends you an Explanation of Benefits (EOB) saying what you owe, if anything
• You pay the balance to the provider directly

Medicare Advantage plans:

• You present only your insurance ID card to your health care provider (store your Medicare ID card someplace safe)
• Your provider sends the claim to your insurer only
• The insurer is primary payer and pays what they owe directly to the provider
• Then the insurer sends you an EOB saying what you owe, if anything
• You pay the balance to the provider directly

Remember that if you use a provider in your plan network, the provider will submit claims for you. If you use an out-of-network provider, you will need to submit your own claim.

 

More about Medicare claims and coverage

What Medicare covers
Types of Medicare plans
Finding and paying for home health care