DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID - PDF document

1 1 DEPARTMENT OF HEALTH AND HUMAN SERVI
1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 – IF YOU NEED HELP, CALL 1-800-MEDICARE (1-800-633-4227). TTY USERS SHOULD CALL 1-877-486-2048. ype of Patient’s Request (see instructions for additional information, check one box only): mococcal Vaccination, Part B (includes physician, laboratory, imaging services), Foreign PLEASE TYPE OR PRINT INFORMATION SECTION 1 - PATIENT INFORMATIONPatient’s Name as shown on Medicare Card Patient’s Medicare Number exactly as it is shown on the Medicare card:Street address (or P.O. Box - include apartment number) Telephone number 2 SECTION 2 - INFORMATION ABOUT SERVICES FURNISHEDFOR ALL CLAIMS including Inuenza and Pneumococcal Vaccinations, describe the illness or injury for which you received treatment. •Date of service•Place of service•Description of illness or injury•Description of each surgical or medical service or supply furnished•

2 ;Charge for each service•The doctor
;Charge for each service•The doctor’s or supplier’s name and address•The provider or supplier’s National Provider Identifier (NPI) If known •A Clinical laboratory for ordered tests•An independent diagnostic imaging center for ordered imaging procedures•A supplier of Durable Medical Cruipment, Nrosthetics, Mrthotics and Supplies (DMCNMS) for ordered DMCNMS Yes Yes Yes Yes SECTION 3 - INFORMATION ABOUT HEALTH INSURANCE OTHER THAN MEDICARE Yes No Yes Is your spouse employed and are you covered under your spouse’s employee health plan? Yes Do you have any medical coverage other than Medicare, such as private insurance, MEDIGAP, employment related insurance, Medicaid,or the Veterans Administration (VA)? 3 SECTION 4 - SIGNATUREbelow. 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 Send the completed form and supporting documentation to your Medicare contractor. do not know the address of your Medicare contractor, call 1-800-MEDICARE (1-800-633-4227). TTY users valid OMB control number. The

3 valid OMB control number for this infor
valid OMB control number for this information OT MAIL APPLICATIONS TO THIS ADDRESS. Mailing 4 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 eligibility. It is also used to decide if the services and supplies you received are covered by Medicare and to insure 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 number, would delay payment of the claim. worker’s compensation will pay for the treatment. Section 1877(a)(3) of the Social Security Act provides criminal Medicare beneciary, within one year of the date of service. To reduce your out-of-pocket expenses, Medicare beneciaries should always obtain medical care from physicians www.medicare.gov/physiciancomparecontractor. TTY users should call 1-877-486-2048.invalid information, the Medicare contractor will

4 return the claim along with a letter to
return the claim along with a letter to you clearly stating what If the Patient is deceased, please contact your Social Security ofce for instructions on how to le a claim.NOTICE: Anyone who misrepresents or falsies essential information requested by this form may upon conviction be subject to ne and imprisonment under Federal law. No Part B Medicare benets may be paid unless this form is 5 (PLEASE RETURN ONLY THE FORM AND NOT THE INSTRUCTION)Patient’s Request for Medical Payment for the Inuenza/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 Inuenza and Pneumococcal Vaccination:coinsurance amounts do not apply. Medicare does not pay for the hepatitis B vaccines. All physicians, non-physician practitioners, and suppliers who administer seasonal inuenza vaccinations must take assignment on the claim for In most situations, your physician, other practitioner or supplier will submit your claim to Medicare, if they do not, Durable Medical Eq

5 uipment, Prosthetics, Orthotics and Supp
uipment, 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 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 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. You’re traveling through Canada without unreasonable delay by the most direct route between Alaska andhospital that can treat your illness or injury. Medicare determines what qualies as “without unreasonable You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treatyour medical condition, regardless of whether it’s

6 an emergency.physician and ambulance se
an emergency.physician and ambulance services furnished in connection with that foreign inpatient hospital stay.Shipboard Services: •You have Part B benets•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 You have a medical emergency within 6 hours of departing or arriving at a U.S. port that requires2.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 benets.5.The physicias please include a copy of the ship’s itinerary. 6 Medicare may pay you directly when you complete this form and attach an itemized bill from your doctor or supplier. ou have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also A.Your Reason for submitting this ClaimB.Type of Patient’s Request Section 1 – PATIENT INFORMATION•Print your name as shown on your Medicare card (Last Name, First Name, Middle Name).•Print your Medicar

7 e Number exactly as it is shown on the M
e 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 numberSection 2 – INFORMATION ABOUT SER •Describe the illness or injury for which you received treatment•Patient’s Condition related to: Check the appropriate boxesNOTE: You must attach an itemized bill in order for Medicare to process this claim.•Date of service•Place of service•Description of illness or injury•Description of each surgical or medical •Charge for each service•The doctor’s or supplier’s name and address•The provider or supplier’s National Provider Identifier•The ordering & referring Providers Full Legal Name •It is helpful if the diagnosis is shown on the physician’s itemized bill. If not, be sure you have completed Section•Many times a bill will show the names of several doctors or suppliers. It is very important the provider who•Mark out any services on the itemized bill(s) you are attaching for which you have already led a Medicare&

8 #149;Attach a copy of your primary insur
#149;Attach a copy of your primary insurer’s Explanation of Benets notice if you are requesting Medicare Secondary•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 • Name of other Medical Insurance• Policy Number including Medicaid ID NumberPolicyholder’s Name•Street Address of other Medical Insurance•Check all boxes that apply Section 4 – SIGNATURE 7 FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)If you received a P.O. Box 100306Noridian Healthcare Solutions, LLCP.O. Box 6703Fargo, ND 58108-6703Noridian Healthcare Solutions, LLCP.O. Box 6777Fargo, ND 58108-6777Novitas Solutions, Inc.P.O. Box 3098Mechanicsburg, PA 17055-1816(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050Noridian Healthcare Solutions , LLC.O. Box 6704Fargo, ND 58108-6704California Northern (For Part B)Noridian Healthcare Solut

9 ionsP.O. Box 6774Fargo, ND 58108-6774Cal
ionsP.O. Box 6774Fargo, ND 58108-6774California Southern (For Part B)Noridian Healthcare Solutions, LLCP.O. Box 6775Fargo, ND 58108-6775P.O. Box 3107 Mechanicsburg, PA 17055-1823 following street address:Attention: Claims Department2020 Technology Parkway, Suite 100Mechanicsburg, PA 17050National Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178DelawareP.O. Box 3397Mechanicsburg, PA 17055-1842P.O. Box 3396Mechanicsburg, PA 17055-1841MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE 8 FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)If you received a First Coast Service Mptions, Gnc.N.M. Box 2009Mechanicsburg, NA 17055-0709P.O. Box 100306P.O. Box 6777Fargo, ND 58108-6777P.O. Box 6777Fargo, ND 58108-6777P.O. Box 6701Fargo, ND 58108-6701P.O. Box 6475Indianapolis, IN 46206-6475P.O. Box 8940P.O. Box 8550P.O. Box 7238P.O. Box 20019 Novitas Solutions, Inc.P.O. Box 3097Mechanicsburg, PA 17055-1815(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100Mechanicsburg, PA 17050National Government Services, Inc.

10 P.O. Box 6178Indianapolis, IN 46206-6178
P.O. Box 6178Indianapolis, IN 46206-6178MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE 9 FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)If you received a Novitas Solutions, Inc.P.O. Box 3398Mechanicsburg, PA 17055-1843(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 National Government Services, Inc. P.O. Box 6178 Indianapolis, IN 46206-6178Wisconsin Physicians ServiceP.O. Box 8987National Government Services, Inc.P.O. Box 6475Indianapolis, IN 46206-6475P.O. Box 3129Mechanicsburg, PA 17055-1834(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050Wisconsin Physicians ServiceP.O. Box 14260 Madison, WI 53708-0260P.O. Box 6735Fargo, ND 58108-6735Wisconsin Physicians ServiceP.O. Box 8667Noridian Healthcare Solutions, LLCP.O. Box 6776Fargo, ND 58108-6776National Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS

11 TABLE 10 FOR INFLUENZA/PNEUMOCOCCAL VA
TABLE 10 FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)If you received a P.O. Box 3030Mechanicsburg, PA 17055-1834(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 P.O. Box 3107Mechanicsburg, PA 17055-1834UPS, FedEx) for which a PO Box cannot be used,please use the following street Attention: Claims Department2020 Technology Parkway, Suite 100 National Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178Palmetto GBA, LLCMail Code: AG-600P.O. Box 100190 Columbia, SC 29202-3190Noridian Healthcare Solutions, LLCP.O. Box 6706Fargo, ND 58108-6706Northern Mariana Noridian Healthcare SolutionsP.O. Box 6777Fargo, ND 58108-6777CGS Administrators, LLCP.O. Box 20019 Nashville, TN 37202P.O. Box 3107Mechanicsburg, PA 17055-1834(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050Noridian Healthcare SolutionsP.O. Box 6702Fargo, ND 58108-6702MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE 1

12 1 FOR INFLUENZA/PNEUMOCOCCAL VACCINATI
1 FOR INFLUENZA/PNEUMOCOCCAL VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)If you received a P.O. Box 3418(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050Puerto Ric P.O. Box 2004 National Government Services, Inc. .O. Box 6178 Indianapolis, IN 46206-617Palmetto GBA, LLCMail Code: AG-600P.O. Box 100190 Columbia, SC 29202-3190Noridian Healthcare Solutions, LLCP.O. Box 6707Fargo, ND 58108-6707TennesseeP.O. Box 100306TexasP.O. Box 3108Mechanicsburg, PA 17055-1834(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 Noridian Healthcare Solutions P.O. Box 6725 Fargo, ND 58108-6725VermontNational Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178Virginia P.O. Box 3396Mechanicsburg, PA 17055-1841Palmetto GBA, LLCMail Code: AG-600P.O. Box 100190 Columbia, SC 29202-3190MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE DO NOT SEND THIS PAGE WITH YOUR CLAIM 12 FOR INFLUENZA/PNEUMOCOCCAL

13 VACCINATION, PART B (INCLUDES PHYSICIAN
VACCINATION, PART B (INCLUDES PHYSICIAN, LABORATORY, IMAGING SERVICES)If you received a Virgin Islands First Coast Service Options, Inc. WashingtonNoridian Healthcare SolutionsP.O. Box Fargo, ND 58108-6700West VirginiaPalmetto GBA, LLCMail Code: AG-600P.O. Box 100190 Columbia, SC 29202-3190 National Government Services, Inc. P.O. Box 6475 Indianapolis, IN 46206-647Noridian Healthcare SolutionsP.O. Box 6708 FOR DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES (DMEPOS) ONLYConnecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, VermontP.O. Box 6780Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, P.O. Box 20013Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, West VirginiaP.O. Box 20010Alaska, American Samoa, Arizona, California, Guam, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, P.O. Box 6727MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE 13 FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICESP.O. Bo

14 x 100306Noridian Healthcare Solutions, L
x 100306Noridian Healthcare Solutions, LLCP.O. Box 6703Fargo, ND 58108-6703Noridian Healthcare Solutions, LLCP.O. Box 6777Fargo, ND 58108-6777Novitas Solutions, Inc.P.O. Box 3098Mechanicsburg, PA 17055-1816(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050Noridian Healthcare Solutions , LLCP.O. Box 6704Fargo, ND 58108-6704California Northern (For Part B)Noridian Healthcare SolutionsP.O. Box 6774Fargo, ND 58108-6774California Southern (For Part B)Noridian Healthcare Solutions, LLCP.O. Box 6775Fargo, ND 58108-6775P.O. Box 3107 Mechanicsburg, PA 17055-1823 commercial courier (UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100Mechanicsburg, PA 17050National Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178DelawareP.O. Box 3397Mechanicsburg, PA 17055-1842P.O. Box 3396Mechanicsburg, PA 17055-1841MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE 14 FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES First Coast

15 Service Mptions, Gnc.N.M. Box 2009Mechan
Service Mptions, Gnc.N.M. Box 2009Mechanicsburg, NA 17055-0709P.O. Box 100306Noridian Healthcare Solutions, LLCP.O. Box 6777Fargo, ND 58108-6777Noridian Healthcare Solutions, LLCP.O. Box 6777Fargo, ND 58108-6777Noridian Healthcare Solutions, LLCP.O. Box 6701Fargo, ND 58108-6701National Government Services, Inc.P.O. Box 6475Indianapolis, IN 46206-6475Wisconsin Physicians ServiceP.O. Box 8940Wisconsin Physicians ServiceP.O. Box 8550Wisconsin Physicians ServiceP.O. Box 7238CGS Administrators, LLCP.O. Box 20019 Nashville, TN 37202Novitas Solutions, Inc.P.O. Box 3097Mechanicsburg, PA 17055-1815(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100Mechanicsburg, PA 17050National Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE 15 FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICESNovitas Solutions, Inc.P.O. Box 3398Mechanicsburg, PA 17055-1843(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100

16 Mechanicsburg, PA 17050 National Governm
Mechanicsburg, PA 17050 National Government Services, Inc. P.O. Box 6178 Indianapolis, IN 46206-6178Wisconsin Physicians ServiceP.O. Box 8987National Government Services, Inc.P.O. Box 6475Indianapolis, IN 46206-6475P.O. Box 3129Mechanicsburg, PA 17055-1834(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050Wisconsin Physicians ServiceMadison, WI 53708-0260Noridian Healthcare Solutions, LLCP.O. Box 6735Fargo, ND 58108-6735Wisconsin Physicians ServiceP.O. Box 8667Noridian Healthcare Solutions, LLCP.O. Box 6776Fargo, ND 58108-6776National Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE 16 FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICESP.O. Box 3030Mechanicsburg, PA 17055-1834(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 P.O. Box 3107Mechanicsburg, PA 17055-1834for which a PO Box cannot be used,please use the following street address:Attention: Claims D

17 epartment2020 Technology Parkway, Suite
epartment2020 Technology Parkway, Suite 100 National Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178Mail Code: AG-600P.O. Box 100190 Columbia, SC 29202-3190Noridian Healthcare Solutions, LLCP.O. Box 6706Fargo, ND 58108-6706Northern Mariana Noridian Healthcare SolutionsP.O. Box 6777Fargo, ND 58108-6777CGS Administrators, LLCP.O. Box 20019 Nashville, TN 37202P.O. Box 3107Mechanicsburg, PA 17055-1834(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050Noridian Healthcare SolutionsP.O. Box 6702Fargo, ND 58108-6702MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE 17 FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICESP.O. Box 3418(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 First Coast Service Options, Inc.P. O. Box 2004Mechanicsburg, PA 17055-0704National Government Services, Inc.P.O. Box 6178South CarolinaPalmetto GBA, LLCMail Code: AG-600P.O. Box 100190 Columbia, SC 29202-3190Noridian Healthcare Solution

18 s, LLCP.O. Box 6707Fargo, ND 58108-6707T
s, LLCP.O. Box 6707Fargo, ND 58108-6707TennesseeP.O. Box 100306TexasP.O. Box 3108Mechanicsburg, PA 17055-1834(UPS, FedEx) for which a PO Box cannot be used, please use the following street address:Attention: Claims Department2020 Technology Parkway, Suite 100 Mechanicsburg, PA 17050 Noridian Healthcare Solutions P.O. Box 6725 Fargo, ND 58108-6725VermontNational Government Services, Inc.P.O. Box 6178Indianapolis, IN 46206-6178Virginia P.O. Box 3396Mechanicsburg, PA 17055-1841Palmetto GBA, LLCMail Code: AG-600P.O. Box 100190 Columbia, SC 29202-3190MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE DO NOT SEND THIS PAGE WITH YOUR CLAIM 18 Virgin Islands WashingtonNoridian Healthcare SolutionsP.O. Box 6700Fargo, ND 58108-6700West VirginiaPalmetto GBA, LLCMail Code: AG-600P.O. Box 100190 Columbia, SC 29202-3190 National Government Services, Inc. P.O. Box 6475 Indianapolis, IN 46206-647Noridian Healthcare SolutionsP.O. Box 6708Fargo, ND 58108-6708MEDICARE ADMINISTRATIVE CONTRACTOR ADDRESS TABLE FOREIGN TRAVEL (INCLUDING CANADA AND MEXICO) AND SHIPBOARD SERVICES DO NOT SEND THIS PAGE WITH YOUR CLAIM DO NOT SEND THIS PAGE WITH YOUR CLAIM Form CMS-1490 (version 01/18