Blank Cms 1490S Template

The CMS 1490S form is a document used by Medicare beneficiaries to request payment for medical services received that were not billed directly to Medicare. This form can be especially important when providers refuse or are unable to submit claims on behalf of the patient. Completing this form correctly is essential to ensure timely Medicare reimbursement.

To get started with your claim, please click the button below to fill out the CMS 1490S form.

Article Guide

Understanding the CMS 1490S form is essential for Medicare beneficiaries seeking reimbursement for medical services. This form, officially titled the "Patient's Request for Medical Payment," serves as a crucial tool for individuals to submit claims directly to Medicare when their healthcare providers have not done so. Alongside the form, applicants must include an itemized bill detailing services rendered, such as dates, descriptions, and associated charges. Certain items, including diabetic test strips and services covered under specific competitive bidding programs, are not eligible for reimbursement through this form. Users must also specify the reason for their claim submission, which could range from a provider's unwillingness to file a claim to issues regarding the provider's Medicare enrollment status. Additionally, the form requires detailed patient information, including Medicare numbers and health insurance coverage beyond Medicare, making it a comprehensive yet straightforward process for ensuring medical payments. The importance of accurate and complete submissions can't be overstated; mistakes can lead to delayed payments or outright denials of claims. For those needing assistance along the way, resources such as the Medicare helpline are readily available, ensuring that beneficiaries can navigate this essential aspect of healthcare management effectively.

Form Sample

DEPARTMENT OF HEALTH AND HUMAN SERVICES	Form Approved OMB
CENTERS FOR MEDICARE & MEDICAID SERVICES	No. 0938-1197

PATIENT’S REQUEST FOR MEDICAL PAYMENT

IMPORTANT: PLEASE READ THE ATTACHED INSTRUCTIONS PRIOR TO SUBMITTING A CLAIM TO MEDICARE

SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTOR – Include a copy of the itemized bill and any supporting documents. Make a copy of your claim submission for your records and allow at least 60 days for Medicare to receive and process your request.

Reference the Medicare Administrative Contractor Address Table for the correct address to mail your claim form.

Medicare will not process a beneficiary request for payment for diabetic test strips, Part B drugs, or for items paid for under the DMEPOS Competitive Bidding program.

Your reason for submitting this claim: (see the Instructions for additional information, check one box only)

The provider or supplier refused to file a claim for Medicare Covered Services

The provider or supplier is unable to file a claim for the Medicare Covered Services

The provider or supplier is not enrolled with Medicare

IF YOU NEED HELP, CALL 1-800-MEDICARE (1-800-633-4227). TTY USERS SHOULD CALL 1-877-486-2048.

Type of Patient’s Request (see instructions for additional information, check one box only):

Influenza/Pneumococcal Vaccination, Part B (includes physician, laboratory, imaging services), Foreign Travel (including Canada and Mexico) and/or Shipboard Services

Durable Medical Equipment, Prosthetics, Orthotics and Supplies

PLEASE TYPE OR PRINT INFORMATION

SECTION 1 - PATIENT INFORMATION

Patient’s Name as shown on Medicare Card (Last, First, Middle)

Patient’s Medicare Number exactly as it is shown on the Medicare card:	Date of Birth (mm/dd/yyyy)		Male		Female
			Male		Female

Street address (or P.O. Box - include apartment number)

City		State		Zip code

Telephone number

Form CMS-1490S (version 01/18)

SECTION 2 - INFORMATION ABOUT SERVICES FURNISHED

FOR ALL CLAIMS including Influenza and Pneumococcal Vaccinations, describe the illness or injury for which you received treatment.

Attach all supporting documentation to the form including an itemized bill with the following information:

•Date of service

•Place of service

•Description of illness or injury

•Description of each surgical or medical service or supply furnished

•Charge for each service

•The doctor’s or supplier’s name and address

•The provider or supplier’s National Provider Identifier (NPI) If known

IMPORTANT: If the itemized bill is from:

•A Clinical laboratory for ordered tests

•An independent diagnostic imaging center for ordered imaging procedures

•A supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) for ordered DMEPOS

The ordering & referring providers legal name MUST be included on the itemized bill.

Please also include the ordering & referring providers National Provider Identifier (NPI) if known.

Was the condition related to:

YesNo Employment

YesNo Auto Accident

YesNo Treatment for chronic dialysis or kidney transplant

YesNo Other Accident

SECTION 3 - INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICARE

Complete this section if you are age 65 or older and enrolled in a health insurance plan where you or your spouse are currently working and covered by any medical coverage other than Medicare.

Yes	No	Are you employed and covered under an employee health plan?

Yes	No	Is your spouse employed and are you covered under your spouse’s employee health plan?

Yes	No	Do you have any medical coverage other than Medicare, such as private insurance, MEDIGAP, employment related insurance,
		Medicaid,or the Veterans Administration (VA)?

Name of other Medical Insurance

Policy Number including Medicaid ID Number

Policyholder’s Name (Last, First, Middle)

Street Address (or P.O. Box) of other Medical Insurance

City

State

Zip code

Please attach a copy of your primary insurer’s Explanation of Benefits if Medicare is secondary.

Form CMS-1490S (version 01/18)

SECTION 4 - SIGNATURE

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Anyone who misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal law.

I authorize any holder of medical or other information about me to release it to the Centers for Medicare & Medicaid Services or its designated contractor or the Social Security Administration for this Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to me.

Signature of Patient	Date Signed (mm/dd/yyyy)

If you cannot sign your name, mark an (X) on the signature line. Have a witness sign his/her name next to the “X” and complete the section below.

If signing this form on behalf of a Medicare patient, on the ‘Signature of Patient’ line above, indicate the patient’s name followed by “By” and sign your name. Provide your name, address, and relationship to the patient with a brief explanation why the patient cannot sign.

Name of Witness (Last, First, Middle)

Street Address

City

State

Zip code

Relationship to the Patient

Signature of Witness

Date Signed (mm/dd/yyyy)

Briefly explain why the Patient cannot sign:

Send the completed form and supporting documentation to your Medicare contractor. Reference the Medicare Administrative Contractor Address table for the correct address to mail your claim form. If you still

do not know the address of your Medicare contractor, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection฀is฀0938-1197. The time required to complete this information collection is estimated฀to฀average฀15฀minutes฀per response, including the time to review instructions, search existing data

resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing.

Form CMS-1490S (version 01/18)

COLLECTION AND USE OF MEDICARE INFORMATION

We are authorized by the Centers for Medicare & Medicaid Services to ask you for information needed in the administration of the Medicare program. Authority to collect information is in section 205(a), 1872 and 1875 of the Social Security Act, as amended.

The information we obtain to complete your Medicare claim is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you received are covered by Medicare and to insure that proper payment is made.

The information may also be given to other providers of services, Medicare Administrative Contractor (MAC), medical review boards, and other organizations as necessary to administer the Medicare program. For example, it may be necessary to disclose information to a hospital or doctor about the Medicare benefits you have used.

With one exception, which is discussed below, there are no penalties under Social Security law for refusing to supply information. However, failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of the claim. Failure to furnish any other information, such as name or Medicare number, would delay payment of the claim.

It is mandatory that you tell us if you are being treated for a work related injury so we can determine whether worker’s compensation will pay for the treatment. Section 1877(a)(3) of the Social Security Act provides criminal penalties for withholding this information. If you are being treated for a work related injury be sure to check the appropriate box in Section 2 titled ‘Condition Related to’.

Physicians and other suppliers, such as clinical laboratories, imaging service suppliers, and durable medical equipment suppliers are required by law to submit a claim for Medicare covered services furnished to you, the Medicare beneficiary, within one year of the date of service.

To reduce your out-of-pocket expenses, Medicare beneficiaries should always obtain medical care from physicians and other suppliers who are enrolled in the Medicare program. If you submit a claim for covered services furnished by a physician or other supplier who is not enrolled with the Medicare program, your claim may be denied.

For a list of participating Medicare enrolled physicians in your area, please go to www.medicare.gov/physiciancompare or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If a physician or supplier furnishes Medicare covered services to you and refuses to submit a claim on your behalf for those services, please call 1-800-MEDICARE (1-800-633-4227) in order to file a complaint with the Medicare contractor. TTY users should call 1-877-486-2048.

When you submit your own claim to Medicare, complete the entire form. If the claim form has incomplete or invalid information, the Medicare contractor will return the claim along with a letter to you clearly stating what information is missing or invalid.

If the Patient is deceased, please contact your Social Security office for instructions on how to file a claim.

NOTICE: Anyone who misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal law. No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (20 CFR 422.510).

Form CMS-1490S (version 01/18)

INSTRUCTIONS

READ BEFORE SUBMITTING A CLAIM TO MEDICARE

(PLEASE RETURN ONLY THE FORM AND NOT THE INSTRUCTION)

Patient’s Request for Medical Payment for the Inﬂuenza/Pneumococcal Vaccinations, Part B Services, (includes physician, laboratory, imaging services), Durable Medical Equipment, Prosthetics, Orthotics and Supplies, Foreign Travel (including Canada and Mexico) and Shipboard Services

Inﬂuenza and Pneumococcal Vaccination:

Medicare may pay for seasonal influenza and pneumococcal vaccinations. Annual Part B deductible and coinsurance amounts do not apply. Medicare does not pay for the hepatitis B vaccines. All physicians, non-physician practitioners, and suppliers who administer seasonal influenza vaccinations must take assignment on the claim for the vaccine.

Part B Services:

In most situations, your physician, other practitioner or supplier will submit your claim to Medicare, if they do not, you can submit a claim.

Durable Medical Equipment, Prosthetics, Orthotics and Supplies:

In most situations, your supplier of DMEPOS will submit your claim to Medicare, if they do not, you can submit a claim for an item or services furnished by this supplier.

Foreign Travel (including Canada and Mexico):

Medicare law prohibits payment for health care services furnished outside the United States (U.S.) except in certain limited circumstances. The term “outside the U.S.” means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

Services furnished on a ship in a U.S. port or within 6 hours of when the ship arrived at or departed from a U.S. port are furnished inside the U.S.

There are three situations when Medicare may pay for certain types of health care services rendered in a foreign hospital (a hospital outside the U.S.):

1.You’re in the U.S. when you have a medical emergency and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury.

2.You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as “without unreasonable delay” on a case-by-case basis.

3.You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether it’s an emergency.

In these situations, Medicare will pay for the Medicare-covered services you get in the foreign hospital and the physician and ambulance services furnished in connection with that foreign inpatient hospital stay.

Shipboard Services:

Medicare may pay for medically necessary services furnished on a ship in a U.S. port or within 6 hours of when the ship arrived at or departed from a U.S. port only if all of the following requirements are met:

•You have Part B benefits

•The physician is legally authorized to practice in the U.S.

If the ship is more than 6 hours away from a U.S. port, Medicare can pay for medically necessary services only if all of the following requirements are met:

1.You have a medical emergency within 6 hours of departing or arriving at a U.S. port that requires inpatient hospital services.

2.The nearest or most accessible hospital that can treat you is a foreign hospital rather than a U.S. hospital.

3.The services are to treat the emergency illness or injury.

4.You have Part B benefits.

5.The physician is legally authorized to practice where he or she furnished the services

For shipboard services please include a copy of the ship’s itinerary.

Form CMS-1490S (version 01/18)

THI	E WITH YOUR CLAIM

HOW TO FILL OUT THIS MEDICARE FORM

Medicare may pay you directly when you complete this form and attach an itemized bill from your doctor or supplier. Mail your completed claim form to the Medicare contractor responsible for processing your claim. If you need additional assistance, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you believe you’ve been discriminated against. Visit https://www.medicare.gov/ about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information.

FOLLOW THESE INSTRUCTIONS CAREFULLY:

A. Your Reason for submitting this Claim

Check the box that applies to this claim

B. Type of Patient’s Request

Check only one box that applies to this claim

Section 1 – PATIENT INFORMATION

•Print your name as shown on your Medicare card (Last Name, First Name, Middle Name).

•Print your Medicare Number exactly as it is shown on the Medicare card.

•Print your date of birth (mm/dd/yyyy)

•Check the appropriate box for the patient’s sex.

•Furnish your mailing address and include your telephone number

Section 2 – INFORMATION ABOUT SERVICES FURNISHED

•Describe the illness or injury for which you received treatment

•Patient’s Condition related to: Check the appropriate boxes

NOTE: You must attach an itemized bill in order for Medicare to process this claim.

Attach all supporting documentation to the form including an itemized bill with the following information:

•Date of service

•Place of service

•Description of illness or injury

•Description of each surgical or medical service or supply furnished

•Charge for each service

•The doctor’s or supplier’s name and address

•The provider or supplier’s National Provider Identifier (NPI) If known

•The ordering & referring Providers Full Legal Name and address if required as indicated in Section 2

•It is helpful if the diagnosis is shown on the physician’s itemized bill. If not, be sure you have completed Section 2 of this form.

•Many times a bill will show the names of several doctors or suppliers. It is very important the provider who treated you be identified. Simply circle his/her name on the bill.

•Mark out any services on the itemized bill(s) you are attaching for which you have already filed a Medicare claim.

•Attach a copy of your primary insurer’s Explanation of Benefits notice if you are requesting Medicare Secondary payment.

•Shipboard services please include a copy of the ship’s itinerary.

Section 3 – INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICARE

•Complete this Section if you are age 65 or older and enrolled in a health insurance plan where you or your spouse are currently working and if you have any medical coverage other than Medicare.

•Check all boxes that apply

Section 4 – SIGNATURE

Sign your name and date the form

•Name of other Medical Insurance

•Policy Number including Medicaid ID Number

•Policyholder’s Name

•Street Address of other Medical Insurance

If the Medicare beneficiary is not able to sign his/her name, follow the instructions on the form.

Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE

FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)

If you received a	Mail your claim form, itemized bill and supporting documents to:
service in:

Alabama	Palmetto GBA, LLC
	Mail Code: AG-600
	P.O. Box 100306
	Columbia, SC 29202-3306

Alaska	Noridian Healthcare Solutions, LLC
	P.O. Box 6703
	Fargo, ND 58108-6703

American Samoa	Noridian Healthcare Solutions, LLC
	P.O. Box 6777
	Fargo, ND 58108-6777

Arkansas	Novitas Solutions, Inc.
	P.O. Box 3098
	Mechanicsburg, PA 17055-1816
	(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
	(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
	Novitas Solutions, Inc.
	Attention: Claims Department
	2020 Technology Parkway, Suite 100
	Mechanicsburg, PA 17050

Arizona	Noridian Healthcare Solutions , LLC
	P.O. Box 6704
	Fargo, ND 58108-6704

California Northern	Noridian Healthcare Solutions
(For Part B)	P.O. Box 6774
	SEND
	Fargo,	58108-6774
California Southern	Noridian Healthcare Solutions, LLC
(For Part B)	P.O. Box 6775
	Fargo, ND 58108-6775

Colorado	Novitas Solutions
	P. . Box 3107
	Mechanicsburg, PA 17055-1823
	(Address to send Medicare 1490 claims via Priority mail or through a
	commercial courier (UPS, FedEx) for which a PO Box cannot be used, please use the
	following street address:
	Novitas Solutions, Inc.
	Attention: Claims Department
	2020 Technology Parkway, Suite 100
	Mechanicsburg, PA 17050

Connecticut	National Government Services, Inc.
	P.O. Box 6178
	Indianapolis, IN 46206-6178

Delaware	Novitas Solutions
	P.O. Box 3397
	Mechanicsburg, PA 17055-1842

District of Columbia	Novitas Solutions
	P.O. Box 3396
	Mechanicsburg, PA 17055-1841

Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE

FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)

If you received a	Mail your claim form, itemized bill and supporting documents to:
service in:

Florida	First Coast Service Options, Inc.
	P.O. Box 2525
	Jacksonville, FL 32231-0019

Georgia	Palmetto GBA, LLC
	Mail Code: AG-600
	P.O. Box 100306
	Columbia, SC 29202-3306

Guam	Noridian Healthcare Solutions, LLC
	P.O. Box 6777
	Fargo, ND 58108-6777

Hawaii	Noridian Healthcare Solutions, LLC
	P.O. Box 6777
	Fargo, ND 58108-6777

Idaho	Noridian Healthcare Solutions, LLC
	P.O. Box 6701
	Fargo, ND 58108-6701

Illinois	National Government Services, Inc.
	P.O. Box 6475
	Indianapolis, IN 46206-6475

Indiana	Wisconsin Physicians Service
	P.O. Box 8940
	Madison, WI 53708-8940

Iowa	Wisconsin Physicians Service
	P.O. Box 8550
	Madison, WI 53708-8550

Kansas	Wisconsin Physicians Service
	P.O. Box 7238
	NOT
	Madison, WI 53707-7238
Kentucky	CGS Administrators, LLC
	P. . Box 20019
	Nashville, TN 37202

Louisiana	Novitas Solutions, Inc.
	P.O. Box 3097
	Mechanicsburg, PA 17055-1815
	(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
	(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
	Novitas Solutions, Inc.
	Attention: Claims Department
	2020 Technology Parkway, Suite 100
	Mechanicsburg, PA 17050

Maine	National Government Services, Inc.
	P.O. Box 6178
	Indianapolis, IN 46206-6178

Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE

FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)

If you received a	Mail your claim form, itemized bill and supporting documents to:
service in:

Maryland	Novitas Solutions, Inc.
	P.O. Box 3398
	Mechanicsburg, PA 17055-1843
	(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
	(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
	Novitas Solutions, Inc.
	Attention: Claims Department
	2020 Technology Parkway, Suite 100
	Mechanicsburg, PA 17050

Massachusetts	National Government Services, Inc.
	P.O. Box 6178
	Indianapolis, IN 46206-6178

Michigan	Wisconsin Physicians Service
	P.O. Box 8987
	Madison, WI 53708-8987

Minnesota	National Government Services, Inc.
	P.O. Box 6475
	Indianapolis, IN 46206-6475

Mississippi	Novitas Solutions
	P.O. Box 3129
	Mechanicsburg, PA 17055-1834
	(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
	(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
	Novitas Solutions, Inc.
	Attention: Claims Department
	2020 Technology Parkway, Suite 100
	Mechanicsburg, PA 17050

Missouri	Wisconsin Physicians Service
	P. . Box 14260
	Madison, WI 53708-0260

Montana	Noridian Healthcare Solutions, LLC
	P.O. Box 6735
	Fargo, ND 58108-6735

Nebraska	Wisconsin Physicians Service
	P.O. Box 8667
	Madison, WI 53708-8667

Nevada	Noridian Healthcare Solutions, LLC
	P.O. Box 6776
	Fargo, ND 58108-6776

New Hampshire	National Government Services, Inc.
	P.O. Box 6178
	Indianapolis, IN 46206-6178

Form CMS-1490S (version 01/18)

MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE

FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)

If you received a		Mail your claim form, itemized bill and supporting documents to:
service in:

New Jersey		Novitas Solutions
		P.O. Box 3030
		Mechanicsburg, PA 17055-1834
		(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
		(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
		Novitas Solutions, Inc.
		Attention: Claims Department
		2020 Technology Parkway, Suite 100
		Mechanicsburg, PA 17050

New Mexico		Novitas Solutions
		P.O. Box 3107
		Mechanicsburg, PA 17055-1834
		(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
		UPS, FedEx) for which a PO Box cannot be used,please use the following street address:
		Novitas Solutions, Inc.
		Attention: Claims Department
		2020 Technology Parkway, Suite 100
		Mechanicsburg, PA 17050

New York		National Government ervices, Inc.
		P.O. Box 6178
		Indianapolis, IN 46206-6178

North Carolina		Palmetto GBA, LLC
		Mail Code: AG-600
		P.O. Box 100190
		Columbia, SC 29202-3190

North Dakota		Noridian Healthcare Solutions, LLC
		P.O. Box 6706
		Fargo, ND 58108-6706

Northern Mariana		Noridian Healthcare Solutions
Islands	NOTP. . Box 6777
		Fargo, ND 58108-6777

Ohio		CGS Administrators, LLC
		P.O. Box 20019
		Nashville, TN 37202

Oklahoma		Novitas Solution
		P.O. Box 3107
		Mechanicsburg, PA 17055-1834
		(Address to send Medicare 1490 claims via Priority mail or through a commercial courier
		(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:
		Novitas Solutions, Inc.
		Attention: Claims Department
		2020 Technology Parkway, Suite 100
		Mechanicsburg, PA 17050

Oregon		Noridian Healthcare Solutions
		P.O. Box 6702
		Fargo, ND 58108-6702

Form CMS-1490S (version 01/18)

⇩ PDF

Document Specifications

Fact Name	Description
Form Purpose	The CMS 1490S form is used by patients to request medical payment from Medicare for services rendered.
Submission Requirement	Patients must send only the completed CMS 1490S form to their Medicare Administrative Contractor with supporting documents.
Excluded Items	This form cannot be used to claim payment for diabetic test strips, Part B drugs, or items under the DMEPOS Competitive Bidding program.
Timeframe for Processing	Medicare requires at least 60 days to receive and process requests submitted on this form.
Patient Information	Section 1 requires detailed patient information, including their Medicare number and contact details.
Supportive Documentation	An itemized bill and all necessary supporting documents must be attached when submitting the claim.
Legal Authority	The collection of information for this form is authorized under sections 205(a), 1872, and 1875 of the Social Security Act.
Filing on Behalf	If someone is filing the form on behalf of a patient, they must provide their relationship and the reason the patient cannot sign.
Assistance Contact	Patients can call 1-800-MEDICARE for assistance with the form or claims process.

Steps to Filling Out Cms 1490S

Filling out the CMS 1490S form is an essential step in submitting a claim for Medicare benefits. Once the form is completed and all required documentation is gathered, it should be sent to the appropriate Medicare Administrative Contractor. This ensures that your request for payment is processed accurately and timely.

Obtain the Form: Download or print the CMS 1490S form from the official Medicare website.
Read Instructions Carefully: Make sure to review the instructions attached to the form, as they provide critical information about filling out the form and submitting it.
Fill Out Patient Information (Section 1): Enter the patient’s name, Medicare number, date of birth, gender, address, city, state, zip code, and contact number.
Describe Services (Section 2): Clearly describe the illness or injury for which treatment was received. Attach the itemized bill, ensuring it includes the date of service, place of service, services or supplies provided, and charges for each.
Conditions Related to the Treatment: Indicate whether the condition was related to employment, auto accidents, chronic dialysis, or any other accident by checking the appropriate boxes.
Complete Health Insurance Information (Section 3): If you are over 65 and have additional health insurance, provide details about your employer’s health plan, your spouse's plan, and any other medical coverage.
Review Signature Section (Section 4): Sign and date the form, affirming the accuracy of the information provided. If someone else signs on the patient’s behalf, include their relationship to the patient and an explanation of why the patient cannot sign.
Attach Supporting Documents: Include a copy of the itemized bill and any relevant explanations of benefits from other insurers.
Make a Copy: Before mailing, create a copy of the entire claim submission for your records.
Submit the Form: Send the completed form and all documents to the correct Medicare Administrative Contractor. Find the appropriate mailing address in the Medicare Administrative Contractor address table.
Allow Time for Processing: Allow at least 60 days for Medicare to receive and process your request.

More About Cms 1490S

What is the CMS 1490S form used for?

The CMS 1490S form is used to request medical payment from Medicare. It is typically submitted by patients who need reimbursement for medical services that were not billed directly to Medicare. The form allows patients to claim payment for various services, including vaccinations, Durable Medical Equipment (DME), and some healthcare services received while traveling abroad.

Who should submit the CMS 1490S form?

Patients should submit the CMS 1490S form if their healthcare provider or supplier refuses to file a claim with Medicare on their behalf, is unable to submit it, or is not enrolled in Medicare. In these situations, filing the claim personally ensures that the request for payment is made.

What documents should accompany the CMS 1490S form?

You must include an itemized bill and any supporting documents with your CMS 1490S submission. The itemized bill should detail the date of service, location, description of the treatment received, charges for each service, and the provider's name and National Provider Identifier (NPI), if known. All relevant supporting documents will help facilitate your claim's approval.

How long does it take for Medicare to process a claim submitted with the CMS 1490S form?

After submitting the form and accompanying documents, you should allow at least 60 days for Medicare to receive and process your request. Ensure that all information provided is complete and accurate to avoid delays in processing.

Can the CMS 1490S form be used for any medical services?

No, the CMS 1490S form cannot be used for diabetic test strips, Part B drugs, or items covered under the DMEPOS Competitive Bidding Program. It is critical to review the instructions attached to the form for details on eligible services.

What if I am unable to sign the CMS 1490S form?

If you cannot sign the form, you may mark an X in the signature line. A witness must then sign next to the X. If someone is signing the form on your behalf, they should indicate your name followed by "By" and sign their name. Providing the witness's information and a brief explanation for your inability to sign is also essential.

What information must I provide about other health insurance?

If you are 65 or older and have other health insurance coverage, you'll need to provide information about that insurance on the CMS 1490S form. This includes stating whether you or your spouse are employed with coverage, the name of the other insurance provider, and the policy number. If Medicare is secondary to another insurer, attaching the Explanation of Benefits (EOB) is important.

Where should I send the completed CMS 1490S form?

You should mail your completed CMS 1490S form to the address of your Medicare Administrative Contractor. This address can be found in the Medicare Administrative Contractor Address Table. If you are unsure of where to send your claim, you can call 1-800-MEDICARE for assistance.

Common mistakes

Failing to read the attached instructions before completing the form. This can lead to missing important details.
Not providing an itemized bill along with the form. Without it, the claim may be rejected.
Neglecting to check only one box in the section for reasons for submitting the claim. Multiple selections can confuse the processing.
Leaving out critical patient information such as Medicare number or date of birth. Incomplete fields can lead to delays or denials.
Not including the ordering provider’s National Provider Identifier (NPI) when required. This may complicate the claim processing.
Overlooking the section for other health insurance. Failing to complete this can result in missed coordination of benefits.
Not signing the form correctly or omitting the date signed. This could cause the claim to be deemed invalid.
Submitting the form without making a copy for personal records. This can prevent tracking the status of the submission.

Documents used along the form

The CMS 1490S form, known as the Patient’s Request for Medical Payment, is often used with several other important documents to facilitate the processing of claims for medical expenses under Medicare. Below is a list of five additional forms and documents that are frequently utilized alongside the CMS 1490S form.

Itemized Bill: This document details the specific charges associated with medical services provided. It includes dates of service, descriptions of treatments, and the costs incurred. An itemized bill is essential when submitting your claim to ensure accurate processing.
Medicare Card: A copy of the Medicare card verifies the patient's Medicare number and eligibility. It is important to include this document to authenticate the identity of the beneficiary submitting the claim.
Explanation of Benefits (EOB): If other insurance is involved, an EOB from the primary insurer provides information on what has been covered and what remains payable by Medicare. Submitting an EOB helps clarify the financial responsibility of the patient.
Attending Physician Statement (APS): This document is completed by the healthcare provider and outlines the patient's medical history, diagnosis, and treatment plan. It is particularly necessary when additional verification of the medical condition is requested.
Authorization for Release of Medical Information: This form allows healthcare providers to share necessary medical information with Medicare. It ensures that the claim can be processed without delays due to confidentiality issues regarding the patient's health information.

Utilizing the correct forms and additional supporting documents can streamline the claims process and improve the chances of successful reimbursement. Ensure that all paperwork is completed accurately and sent in accordance with Medicare's guidelines.

Similar forms

The CMS 1490S form shares similarities with the CMS 1500 form. Both forms are utilized to submit claims for medical services to Medicare. The CMS 1500 form is specifically for healthcare professionals to bill Medicare for medically necessary services provided to patients. Like the CMS 1490S, it requires detailed patient information and documentation to support the claim. However, the CMS 1500 is primarily filled out by the healthcare provider, while the CMS 1490S is used when the patient submits a claim directly, often due to the provider's inability or refusal to do so.

The UB-04 form is another document similar to the CMS 1490S. This form is used by hospitals and facilities to bill Medicare for inpatient and outpatient services. Just like the CMS 1490S, the UB-04 requires comprehensive information about the patient, the services rendered, and any associated costs. The key difference is that the UB-04 is aimed at facility billing, while the CMS 1490S is focused on individual patient claims, particularly in instances where providers do not submit claims directly to Medicare.

The DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) claim form also has similarities with the CMS 1490S. This form is specifically for claims related to durable medical equipment that patients may need. Like the CMS 1490S, it requires a clear description of the item, the need for it, and any relevant supporting documentation. The main distinction lies in that the DMEPOS claim form is intended for suppliers of equipment rather than patients submitting their claims directly.

The CMS 855 form is often compared to the CMS 1490S, as it is used for provider enrollment in Medicare. While the CMS 1490S is a request for payment after services have been rendered, the CMS 855 establishes a provider's eligibility to bill Medicare. Both forms are critical in the overall Medicare claims process but serve different purposes: one focuses on payment requests, and the other addresses enrollment and eligibility.

The HIPAA Authorization Form shares similarities with the CMS 1490S regarding patient information. Both documents require patient consent and a signature to allow the sharing of medical information. However, the HIPAA Authorization Form is primarily focused on giving permission to healthcare providers to disclose protected health information, while the CMS 1490S is intended for financial reimbursement for services received.

Lastly, the Medicaid Claim Form can resemble the CMS 1490S in its purpose of seeking payment for medical services provided to patients. Like the CMS 1490S, this form requires detailed patient information, service details, and documentation of costs. The crucial difference lies in the program—Medicaid serves those with limited income considerations, whereas the CMS 1490S is dedicated to Medicare beneficiaries, highlighting the distinctions in eligibility and coverage between the two healthcare programs.

Dos and Don'ts

When filling out the CMS 1490S form, there are important dos and don’ts to keep in mind. Following these guidelines can help ensure a smoother claim submission process and reduce the chances of delays.

Do read all instructions attached to the form before filling it out.
Do ensure that all information is accurate and matches what is on your Medicare card.
Do provide an itemized bill and any necessary supporting documents.
Do maintain a copy of your submission for your own records.
Don't forget to check only one box for the reason you are submitting the claim.
Don't submit claims for items not covered by Medicare, such as diabetic test strips or certain durable medical equipment.
Don't leave any sections of the form blank; incomplete forms can delay processing.
Don't send the instructions with the form; only the completed form should be submitted.

By adhering to these guidelines, individuals can better navigate the Medicare claim submission process, thus enhancing the likelihood of a timely resolution to their medical payments.

Misconceptions

Understanding Medicare's CMS 1490S Form is essential for individuals seeking reimbursement for medical services. However, several misconceptions about this form can lead to confusion. Below are ten common misconceptions along with clarifications.

The CMS 1490S form is only for denied claims. Many believe this form is only necessary when a claim has been denied. In reality, it can also be used when a provider refuses to submit a claim on behalf of the patient.
You cannot submit claims for medications. Individuals sometimes assume that only medical services qualify for claims. However, certain medications may be included, except for items like diabetic test strips and specific Part B drugs.
It is not necessary to attach supporting documents. Some think it's sufficient to submit the form alone. Yet, acquiring itemized bills and additional documentation is crucial for processing the claim.
CMS will automatically process all claims. There is a misconception that all claims will be automatically managed by Medicare. Patients must ensure they submit the form correctly; otherwise, Medicare may return it due to missing information.
Medicare covers all healthcare services outside the U.S. People often mistakenly believe that Medicare provides coverage for medical services rendered abroad. Coverage exists only under specific circumstances, such as emergencies when no U.S. facility is available nearby.
Submitting the form once guarantees claim approval. It is assumed that sending the CMS 1490S form alone guarantees approval. Each claim must meet Medicare's eligibility requirements and is reviewed on a case-by-case basis.
Anyone can submit claims on behalf of the patient. While someone can help, official representatives must ensure proper authorization, especially if the patient cannot sign the form themselves.
There is no deadline for submitting claims. Some believe they can submit claims at any time. However, Medicare often has specific timeframes within which claims must be filed, typically within one year from the date of service.
The CMS 1490S form cannot be used for durable medical equipment claims. This form is valid for these claims. If a DME supplier does not submit the claim, the patient can use the CMS 1490S form to get reimbursed.
Once submitted, you will immediately know the claim outcome. Many mistakenly think that results will be provided right away. Medicare processes claims over a period, and beneficiaries should allow at least 60 days for evaluation.

Awareness of these misconceptions helps ensure a smooth experience when submitting claims. Each form submission represents a vital step toward obtaining necessary reimbursements.

Key takeaways

Here are six key takeaways for filling out and using the CMS-1490S form:

Submit Only the Completed Form: When sending your claim, only include the completed CMS-1490S form. Attach an itemized bill and any necessary documents. Keep a copy for your records.
Timeframe for Processing: Allow at least 60 days for Medicare to receive and process your request. This ensures you don’t miss any critical deadlines.
Choose the Right Reason: Clearly indicate the reason you are submitting the claim. You can only select one reason from the options provided. Accuracy here is essential to avoid delays.
Include All Required Information: Fill in sections completely and accurately, especially the patient information and details of services received. Missing information can lead to your claim being returned.
Understand Coverage Limitations: Be aware that Medicare doesn't cover certain items without prior claims, such as diabetic test strips or claims made under DMEPOS Competitive Bidding. Always consult the list of eligible services.
Witness Signing: If you cannot sign the form, you may mark an “X” instead. Ensure a witness signs next to it, and provide a short explanation about your inability to sign.