When and How Medigap Pays Claims

How Medigap Claims Work

One of the best features of Medigap is that you typically don't need to file claims yourself. The process is mostly automatic.

Step-by-Step Claims Process

Step 1: You Receive Healthcare Services

You visit a doctor, hospital, or other provider who accepts Medicare. Show your Medicare card and let them know you have Medigap.

Step 2: Provider Bills Medicare

The provider submits a claim to Medicare for the services provided.

Step 3: Medicare Processes and Pays

Medicare reviews the claim and pays its share of the Medicare-approved amount.

Step 4: Medicare Notifies Your Medigap Company

Medicare automatically forwards the claim information to your Medigap insurance company. This is called "crossover."

Step 5: Medigap Pays Its Share

Your Medigap company pays its portion directly to the provider based on your plan's benefits.

Step 6: You Pay What's Left

You pay any remaining costs (if any). With comprehensive plans like Plan G, there's usually nothing left for you to pay except the Part B deductible.

You Usually Don't Need To:

• File claims yourself
• Pay upfront and wait for reimbursement
• Deal with insurance paperwork
• Contact your Medigap company about claims

When You Might Need to Get Involved

Provider Doesn't Accept Assignment

If a provider doesn't accept Medicare assignment, you may need to:

• Pay upfront
• Submit claims to Medicare yourself
• Wait for Medicare to process before Medigap can pay

Foreign Travel Emergency

For emergency care outside the U.S.:

• You typically pay upfront
• File claim with your Medigap company
• Get reimbursed for covered expenses (usually 80%)

Understanding Your Explanation of Benefits (EOB)

You'll receive EOB statements from both Medicare and your Medigap company showing:

• What services were provided
• What Medicare paid
• What Medigap paid
• What you owe (if anything)

Keep these for your records, but you usually don't need to take action unless you see an error.

What If There's a Claim Problem?

1. First, contact the provider to clarify the bill
2. Check your EOB to understand what was paid
3. Contact your Medigap company if benefits seem wrong
4. Contact Medicare at 1-800-MEDICARE if needed