Fill out CMS-1490S (Patient's Request for Medical Payment) online
Form CMS-1490S is used by Medicare beneficiaries to request reimbursement for medical services when the provider did not submit a claim on the beneficiary's behalf. This commonly occurs when receiving care from a non-participating provider, while traveling, or from a provider who does not accept Medicare assignment.
How to fill out CMS-1490S (Patient's Request for Medical Payment)
Enter your Medicare information
Provide your name, Medicare Beneficiary Identifier (MBI) number, date of birth, and mailing address where you want the reimbursement sent.
Describe the medical services received
Provide details about the medical service, including the date of service, the name and address of the provider, and a description of the treatment received.
Explain why you are filing the claim
Indicate why the provider did not submit the claim (e.g., non-participating provider, emergency care while traveling, provider refused to file).
Attach supporting documents and sign
Attach the itemized bill on the provider's letterhead showing the diagnosis, procedure codes, charges, and proof of payment. Sign and date the form.
About CMS-1490S (Patient's Request for Medical Payment)
Who needs this form
Medicare beneficiaries who paid out of pocket for covered medical services and need to request reimbursement from Medicare because their provider did not file a claim.
Where to submit
Mail to the Medicare Administrative Contractor (MAC) that processes claims for your area. The address can be found on your Medicare Summary Notice (MSN) or at Medicare.gov.
Source and content freshness
- Filing deadlines may shift for weekends and holidays. Verify due dates with official instructions.
Common mistakes to avoid
- Not attaching an itemized bill from the provider on their letterhead
- Missing the filing deadline (generally within one calendar year of the date of service)
- Not including proof of payment (receipt or cancelled check)
- Forgetting to include the diagnosis code from the provider
Frequently asked questions
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What documents do I need to include with CMS-1490S?
You must include an itemized bill from the provider on their letterhead showing the date of service, description of the service, diagnosis code, procedure code, and charges. You should also include proof of payment such as a receipt, cancelled check, or credit card statement. Without these documents, Medicare cannot process your claim.
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