Medicare and Superbills: What Therapists Must Know

Traditional Medicare does not work like commercial insurance when it comes to superbills. Whether your client can submit anything to Medicare — and how much they can expect to receive — depends entirely on the provider's Medicare status.

Overview: Medicare and Out-of-Network Mental Health Benefits

Traditional Medicare (Parts A and B) covers outpatient mental health services at 80% of the Medicare-approved amount after the Part B deductible. However, the ability to give a superbill and what happens after depends on which of three provider categories your therapist falls into:

(1) Participating (PAR) provider: The provider has contracted with Medicare and agreed to accept Medicare's fee schedule as payment in full. PAR providers must bill Medicare directly — they cannot give a superbill for Medicare patients. The client receives 80% coverage automatically; a Medigap policy may cover the remaining 20%.

(2) Non-participating (non-PAR) provider: The provider has not contracted with Medicare but has not opted out either. Non-PAR providers can see Medicare patients and may give a superbill for the client to submit. However, reimbursement is limited to 95% of the Medicare fee schedule, and providers can only charge up to 115% of the Medicare fee schedule (the "limiting charge"). The client submits the superbill to Medicare and receives a check directly.

(3) Opted-out provider: The provider has formally opted out of Medicare entirely. Opted-out providers can charge any amount, but Medicare pays nothing — the client is responsible for 100% of the cost. The superbill is useful for recordkeeping or HSA/FSA reimbursement, but it generates no Medicare payment. For more context on the general superbill process, see our step-by-step superbill submission guide. For a full overview of Medicare coverage, visit our Medicare insurance guide.

Step-by-Step Process for Submitting to Medicare (Non-PAR Path)

1. Confirm your provider is non-PAR (not opted-out, not PAR). Ask your therapist directly: "Are you a Medicare participating provider, a non-participating provider, or opted out?" Only the non-PAR path results in a superbill you can submit to Medicare for partial reimbursement.
2. Get your superbill from your therapist. Non-PAR providers may give you a superbill reflecting their actual charges. Note that Medicare will only reimburse based on 95% of the Medicare fee schedule, regardless of what the provider charges — and the provider's charges cannot exceed 115% of the fee schedule (the limiting charge).
3. Submit the claim to Medicare. Log in to your MyMedicare.gov account or call 1-800-MEDICARE to submit a claim. You can also mail a Patient's Request for Medical Payment form (CMS-1490S) along with the superbill to your Medicare Administrative Contractor (MAC).
4. Alternative: paper submission. Download CMS-1490S from cms.gov, complete it, and mail it with the superbill to the address on the form. Use certified mail for your records.
5. Note your confirmation. For online submissions, save the confirmation number. For mailed claims, retain the certified mail receipt. Medicare processes claims from the date received.

What to Include With Your Medicare Claim

Medicare requires the superbill to contain all required superbill fields. Specifically for Medicare, confirm your superbill includes:

• Provider full name, NPI (Type 1), and practice address
• Provider Tax ID (EIN or SSN) and professional license number
• Your name, date of birth, and Medicare Beneficiary Identifier (MBI)
• Date(s) of service
• CPT procedure code (e.g., 90837 for 60-minute therapy) and description
• ICD-10 diagnosis code (e.g., F41.1 for generalized anxiety)
• Place of service code (11 for office; 10 for telehealth)
• Fee charged per session and amount you have already paid

Medicare's Processing Timeline

Medicare typically processes claims within 30 days of receipt. You will receive an Explanation of Benefits (EOB) — called a Medicare Summary Notice (MSN) — by mail or in your MyMedicare.gov account. Payment goes directly to you (the beneficiary) for non-PAR claims.

Medicare's filing deadline is 12 months from the date of service. Claims submitted after this deadline will be denied.

Common Issues When Submitting to Medicare

• Opted-out provider confusion: Clients of opted-out therapists often attempt to submit superbills to Medicare expecting reimbursement. Medicare will deny the claim entirely — opted-out means no Medicare payment under any circumstances.
• PAR providers giving superbills: Participating providers must bill Medicare directly — they are not permitted to give a patient a superbill to submit on their behalf for Medicare services.
• Exceeding the limiting charge: Non-PAR providers who charge more than 115% of the Medicare fee schedule violate Medicare rules. If this happens, you may be entitled to a refund of the excess charge.
• Wrong claim form: Medicare Part B requires form CMS-1490S for patient submissions — not a generic claim form. Using the wrong form will result in rejection.

Tips for a Smooth Medicare Claim

• Clarify your therapist's Medicare status at the very first session — before any services are rendered. This one conversation prevents the most common Medicare billing confusion.
• Use MyMedicare.gov to track submitted claims. Claims appear within a few days of processing.
• If your claim is denied, you have the right to a formal appeal. Medicare appeals go through a multi-level process starting with a redetermination request to the MAC.
• If your therapist is opted-out, ask whether you can use HSA or FSA funds to offset the cost — the superbill still serves as qualifying documentation for those accounts.

Superbilled makes it easy to generate Medicare-compliant superbills with all required fields pre-filled. Once you confirm your therapist's Medicare status, use the steps above to submit your claim — or simply retain the superbill as HSA/FSA documentation if your therapist is opted out.