Medicare Claim Form

A Medicare Claim Form is used by doctors and healthcare providers for the care a persons receives through Medicare. In some cases, however, such as receiving services for which Medicare is the secondary payer, patients may have to file a Medicare claim form and attach a bill for the services they received.

You may also have to file a claim if your doctor has failed to do so and the time limit (12 months) is approaching. Contact your doctor’s office or Medicare representatives to make sure the claim is filed in time.

How to File a Claim

First, download the Patient Request for Medical Payment form (CMS-1490S). Complete the form, using the instructions on the second page, and send it to your carrier. To find the correct address to send the form to, go to the downloads page at CMS.gov and download the English (or Spanish) Instructions Part B form, which shows you the correct addresses to send the form to based on where you received services.

You must file a claim within 12 months of the services, or else Medicare cannot pay for the services. Check your Medicare Summary Notice or log in to MyMedicare.gov to make sure your claims are filed on time. You need to file a claim (in the rare case your doctor’s office does not) even if you don’t expect reimbursement because you want the deductible to be credited to you. To avoid paying the total cost of services, be sure to check whether the provider you want to see accepts Medicare.

Filling Out the Form

The claim form is straightforward, requiring personal information and information about the services you received.

Print your name and Health Insurance Claim Number with the letter on the end of it exactly as they appear on your Medicare card. Then write your name, address, and phone number, and describe the illness you were treated for and check the boxes in sections 4b and 4c. Then in section 5, check the boxes and answer whether you have health insurance other than Medicare, along with your policy number under that insurer, and whether you don’t want information about this claim to be released to that insurer. Then you sign and date the form, and it will be completed.

Itemized Bill

You must attach a bill describing the services you’re filing the claim for. It must include the following information:

• Date of services
• Address and name of location where each service was received
• Doctor’s names
• Description of each service
• Costs of each service
• Diagnoses made