Get Mra Pay Me Back Claim Form - Fill Online, Printable, Fillable ...

You must submit proof of Medicare Part B premium payments through the online portal, EZ Receipts app or by fax or mail. Upon approval, you will receive reimbursement by direct deposit or check depending how you set up your account.

Fill out the claim form, called the Patient Request for Medical Payment form (CMS-1490S) [PDF, 52KB).

An electronic version is available at http://.cms.hhs.gov/providers/edi/edi5.asp. The Form CMS-1500 answers the needs of many health insurers. It is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from physicians and suppliers.

You can also call 1-800-624-5060 for more information, claim forms and customer service assistance. The claim form provides detailed instructions for submission of the form and should be mailed to: Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.

Send your completed form, itemized bill, letter and supporting documents (if any) to the Medicare administrative contractor in your state. Medicare claims can't be filed online—they must be submitted by mail.

When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services. The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities.

All you have to do is provide proof that you pay Medicare Part B premiums. Each eligible active or retired member on a contract with Medicare Part A and Part B, including covered spouses, can get their own $800 reimbursement. Download our Medicare Reimbursement Account QuickStart Guide to learn more.

If the provider accepts assignment (agrees to accept Medicare's approved amount as full reimbursement), Medicare pays the Part B claim directly to him/her for 80% of the approved amount. You are responsible for the remaining 20% (this is your coinsurance ).