Can I File My Own Medicare Claim If My Doctor Doesn't Bill Medicare?

Start with who is supposed to file. Providers enrolled in Original Medicare must submit claims for covered Part B services on your behalf, and they cannot charge you a fee for doing it. That applies whether they accept Medicare's approved amount as full payment (participating) or not (non-participating). Non-participating providers can bill up to 15 percent above the approved amount for most services, which is called the limiting charge. So if an enrolled doctor or therapist says to pay now and file it yourself, ask them to file instead. If one refuses, call 1-800-MEDICARE to complain.

You file your own claim when the provider will not or cannot. Medicare.gov describes those situations as a provider who is unable to file, refuses to file, or is not enrolled in Medicare. You use Form CMS-1490S, Patient's Request for Medical Payment, and mail it to the Medicare Administrative Contractor for your state, using the address in the form's instructions. This route is for Original Medicare. If you have a Medicare Advantage plan, the plan pays claims, so contact the plan instead.

Two provider statuses block payment. A provider who has opted out signs an affidavit that, for two years, they will treat Medicare patients only under a written private contract and will not bill Medicare. Medicare does not pay for those services, except in emergencies or urgent situations, so filing your own claim will not change that. A provider who never enrolled is a similar dead end. Medicare generally will not pay for services from a provider who is not enrolled, so expect a denial and confirm with Medicare before counting on anything.

This matters most for counseling. Before 2024, licensed professional counselors and marriage and family therapists could not enroll in Medicare. Since January 1, 2024, mental health counselors and marriage and family therapists can enroll, and Medicare pays them 75 percent of the clinical psychologist rate. Some have not enrolled, and some have opted out. A therapist can be fully licensed and still be someone Medicare will not pay.

Reimbursement follows rules, not discretion. The service must be covered by Medicare, medically necessary, furnished by an eligible provider, and filed on time. When those are met, Medicare pays 80 percent of its approved amount after you meet the Part B deductible, which is $283 in 2026, and you owe the 20 percent coinsurance. If a therapist charges $200 and Medicare approves $150, the most Medicare pays is $120, and only once your deductible is satisfied. The claim must reach Medicare within 12 months of the service date, and a claim returned as incomplete does not count as filed, so send it early.

Before the first visit, ask two questions: are you enrolled in Medicare, and do you accept assignment? An enrolled provider should file for you, which saves paperwork and keeps your cost within the limiting charge. If the answer is opted out or not enrolled, plan to pay the full fee and treat any reimbursement as unlikely. If you do pay up front, ask for an itemized bill the same day.

If the provider is enrolled and the service is covered, reimbursement is the rule, not a bonus, but it is a percentage of the approved amount, not a refund of the bill. Budget for the deductible, the 20 percent, and any gap between the fee and the approved amount. If a Medigap policy covers your coinsurance, it may pay the rest once Medicare has paid.

• Paying an enrolled provider up front and filing yourself without first asking them to file, which they are required to do.
• Assuming a licensed doctor or therapist is automatically enrolled in Medicare.
• Expecting Medicare to refund the full amount you paid instead of 80 percent of its approved amount after the deductible.
• Mailing the claim late or incomplete. It must reach Medicare within 12 months of the service date, and incomplete claims do not count as filed.
• Using Form CMS-1490S as a Medicare Advantage member instead of contacting the plan.
• Not keeping copies of the form, the itemized bill and anything else you mail in.